Title: Syrian refugee women’s access to family planning services and modern contraception
during overlapping crises in Bekaa, Lebanon
Version: 2 Date: 14 Jun 2023
Reviewer's report:
This is an interesting study looking at how crises impact FP access and use.  The paper seems to
focus on contraceptive services rather than on reproductive health services broadly. References
to services other than FP are rare, so I would recommend revising the paper (and title) to say that
it is about access to FP services rather than using RH services and FP services interchangeably,
when you seem to primarily mean FP services.
• RHS is not a commonly used acronym. I’ve seen RH services, but only very rarely RHS. I
would recommend not using RHS, but leave this to the authors’ discretion.
• Lines 116-121: when you describe where/how refugees receive health care, could you expand
a bit on this? Is care subsidized at the PHCs? Free at the PHCs? What about the outreach services
– what are these and are they free or with a cost? Later you reference their preference for private
care – is that different from these? Explaining a bit more how refugees accessed health care
before the pandemic would make it easier to understand your results.
• Lines 131-132: I’m not sure what you mean by this phrase in this sentence ‘While the results
of previous studies on refugees’ access to and use of FP services are comprehensive,’?
• Line 201-204: the description of the 3rd group of women is a little confusing. It is clear that
they are women over 35 years old. The rest is a little unclear: Are all of them mothers or mothers-
in-law of daughters? Are they mothers or mothers-in-law of girls who married before age 18?
• Table 1: would you please be consistent with % and either include or exclude 1 decimal place
for all %?
• Table 1: For the older women, you have NA for ‘no children’, but in line 201-204, you say you
recruited women over 35 who were ‘often’ mothers or mothers-in-law. If an inclusion criteria
was that they were the mother or mother in law of a married girl, then please state that.
• Line 309: you have 3.3.3 here in the heading, but no numbering in the previous headings. Title
here should refer to Outreach contraceptive services, not RHS. It may be useful to add a sentence
describing what these outreach services are, perhaps earlier in the Background section when you
describe how Syrian refugees receive health care (lines 116-121). Are FP services different (eg
free or subsidized compared to other health services)?
• Line 312: when you say outreach services were disrupted, do you mean they ended? stopped
temporarily and re-started?
• Lines 342-343: you talk here about preference for private doctors – is that different from the
PHCs you mention in the background?
• Line 474: you say that “It appears that some health facilities maintained their pre-crises
provision of RHS and contraception methods," – do you have a reference for this because this
doesn’t seem to come from your data?
• Figure 3: seems like the crises exacerbated (or made worse) all of the existing barriers refugee
women already faced, rather than introduced new barriers.
• Lines 503-513: I believe mHealth would be more than providing information. In this situation,
for example, could women receive a consultation for contraceptives via mHealth and then need
to pick up a prescription for pills in person to avoid the long wait at the facility.
• In the Discussion, you have a long section on giving women more info on Covid, but that
didn’t seem to be the main problem. However, other issues such as that they believed Lebanese
women were served first, cost of transport and services, security, etc. seemed more important
barriers for the women than Covid regulations. Women also seemed to know about FP, so lack
of information isn’t the problem – lack of access to services is.
• Lines 516-524: You suggest increasing LARC access, but several women said they requested
a LARC (IUD) and were denied or told to go elsewhere. That should be addressed as well as
figuring out how to ensure continued LARC access during a crisis. Also, generally injectables
are not considered LARC (implants and IUDs are) since they are only for 3 months.
• Line 530: this is first use of SRHS acronym.
• Generally, the Discussion could use a bit more analysis. In many places, it seems as if the
authors are simply repeating the results (for example, lines 461-463). It might work better to
group things according to the 4 domains in Figure 3, or by theme (such as Covid regulations) that
had both demand-side and supply-side impacts rather than organize the Discussion by theme
in the Results.
• Line 545: might be good to write ‘Syrian refugee women’s access’ rather than just ‘women’s
access’ since refugees are not mentioned at all in the Conclusion.
• In the conclusion you refer to solutions you presented that have worked elsewhere – I think it
would be useful to add references for where the solutions you proposed have worked.
• The abstract will require revision based on comments above.