Title: Barriers to using postpartum family planning among women in Zanzibar, Tanzania
Version: 1 Date: 13 Dec 2022
Reviewer's report:
Overall
This study addresses an important knowledge gap by seeking to understand the barriers to FP
use among postpartum women in Zanzibar. Zanzibar is often overlooked by researchers, leading
to misinformation or anecdotal evidence being used to inform policy and practice. This study
therefore makes a meaningful contribution to the literature. However, to warrant publication
several changes are needed to improve the reporting of the methods and results, and additional
information is needed in the presentation of the background to anchor the study in the existing
literature.
Background
1. The societal benefits of FP on girls and families are mentioned; however, the relevance of
these benefits to Zanzibar’s context is not clear. Could the relevance to the local context be
explained in the background?
2. The global and national figures mentioned in the background relate to FP in general. Very little
information is provided around postpartum FP specifically. Could the global, Tanzanian and
Zanzibari prevalence or unmet need for postpartum FP be included in the background section?
3. The background mentions that ‘all kinds of postpartum FP’ are provided in government
facilities. There are important differences in the availability and quality of health services, and
indeed FP services and methods, across the different levels of the health system in Zanzibar
(e.g., LARCs and permanent methods are not provided everywhere). This should be explained
and an idea of the specific FP methods that are available at each level should be provided to
contextualise the findings and improve their transferability to other settings.
4. The knowledge gap relating to Zanzibar is mentioned in the background section; however,
there is no mention about the literature on postpartum FP use (and the barriers to use) from
similar settings in SSA. The lessons learned from other contexts should be explained in the
background section.
Methods
1. In the study setting section it says that “Attendance at antenatal visits is low, and only 43%
of all mothers attend the recommended postnatal visits within 42 days after childbirth”. It needs
to be specified whether this relates to the studied hospital or the entirety of Zanzibar. The rest
of the paragraph speaks about the specific hospital, which causes some confusion.
2. The age of participants is not mentioned when presenting the inclusion criteria. Were women
of any age eligible for inclusion? This should be specified.
3. The recruitment approach and procedure are not sufficiently explained. Was a convenience
or random sampling? This should be explained.
4. What procedures were used to ensure that ethical standards were met in the recruitment, data
management, data analysis, and reporting? There is only mention of ethical considerations in
the form of consenting procedures.
5. Was ethical approval granted outside of Zanzibar for researchers affiliated with international
institutions? The information shared in the manuscript seems to suggest that no ethical approval
was sought outside of Zanzibar. This is concerning and the reasons for opting not to seek
additional approvals should be mentioned.
6. The anonymity of the respondents may be compromised given the amount of information that
is reported in the article. For anyone with basic knowledge of the health system in Zanzibar, it is
easy to identify the name of the hospital where the FGDs took place. In light of this and given that
the exact data collection dates (March 2-22, 2022) are reported, the anonymity of respondents
could be compromised. As such, it would be good to avoid reporting the dates. Perhaps the
authors could mention that the FGDs took place during the first quarter of 2022, instead.
7. I am not familiar with the term ‘meaning units’. I do not believe that this term will be familiar
to the average reader. Can this term either be defined, or can more standardised language be
used such as ‘themes’ (assuming this term accurately represents what was done)?
8. In table 2 the first example of a woman ‘needing to involve the husband’ isn’t clear. In
reading the quote in this example, the reader is left wondering if the woman really means that
she ‘needs’ to involve her husband as is seemingly interpreted by the authors, or whether this is
her preference. This raises questions about the level of attention that was given to these nuances
in the data analysis. Perhaps the example chosen could be improved to ensure that these doubts
are avoided?
9. What quality assurance measures were put in place in the transcription and translation of
interviews?
10. What quality assurance measures were put in place in the analysis of data?
11. The use of guidelines for reporting qualitative results would help ensure that reporting
standards are met (e.g., COREQ or SRQR checklist).
Results
1. There seem to be 4 overarching barriers presented in the results: 1) perceived usefulness
on modern contraceptive methods, 2) perceived risks of modern contraceptive methods, 3)
autonomy among women to make FP decisions, and 4) support from husbands/male partners.
These are all distinct and important. I recommend restructuring the results section to make these
4 barriers clearer.
2. The ‘insufficient FP services’ subcategory label could be improved for clarity. What is
insufficient? Is it the availability, accessibility, quality? The example provided suggests that it
is the quality of counselling that may be lacking.
3. The sub-category relating to ‘traditional medicine’ would be clearer if divided into two
separate categories ‘beliefs in natural FP methods’ and ‘beliefs in traditional medicine’. There is
a crucial distinction between these two categories and presenting them as one is problematic. The
calendar method is a natural FP method, which is not the same as ‘trusting god’ or ‘swallowing
black seeds’ – it is very important to make this distinction when presenting the results.
4. One of the 3 research questions posed by this study is ‘how can the needs of postpartum women
be met’. The suggestions made by women on how their needs could be met (e.g., husbands
should be invited to the ANC clinic) should be presented as a separate section in the article
to make these important findings clear. This should then also be discussed more fully in the
discussion section.
5. It would be helpful to include more quotes from the data in the results section to substantiate
the findings from the analysis.
Discussion
1. It is not clear what an ‘interview study’ refers to. Is this in lieu of a ‘qualitative study’? Perhaps
it would be clearer to call it a qualitative study as this is what was done.
2. The authors mention that their findings are “in line with findings from other studies performed
in low- and middle-income countries”, however they do not explain or provide examples of
this. Can further information be added to explain what findings aligned or differed from other
research carried out prior to this study?
3. The authors speak of ‘access’ as a barrier in the discussion, but there is no reference to access
in their findings (unless the reader is meant to understand the limited support from husbands
as an access barrier). If access to services was found to be an issue according to the data, this
should be explained in detail in the results section.
4. The discussion around women’s decision-making power could be strengthened. Hoyt et al.
have written on this topic with respect to postpartum women and Karp et al’s work provides
important insights into women’s decision making and agency that could be incorporated to
strengthen the discussion.
5. It is not clear why male involvement and education is a ‘clinically’ relevant finding, nor why
it would be more important than other findings such as the lack of quality of FP counselling. If
this was found to be ‘most’ important based on the data that was collected and analysed, this
should be explained in the results.
6. Nearly half of the women interviewed were between 25 and 29 and yet differences in the
views of younger and older respondents are not discussed. Was consideration given to these
differences in the analysis? Could this be presented in the results and then discussed?
7. The findings are based on a very small sample of women. Although rich qualitative findings
can be produced from a few FGDs, it is important to note the limitations imposed by a small
sample. These should be added to the discussion.
8. Biases, such as a selection bias (related to interviewing women who chose to give birth in
a referral hospital instead of in a health center, district hospital or at home) and the inherent
limitations of FGDs (compared to in-depth interviews for example) should also be acknowledged
in the discussion.