Reviewer’s report
Title: Investigating the quality of family planning counselling as part of routine antenatal care and
its effect on intended postpartum contraceptive method choice among women in Nepal
Version: 0 Date: 19 Nov 2019
Reviewer: Anne Pfitzer
Reviewer's report:
BMC Women's Health - review BMWH-D-19-00536
This paper describes pregnant women's qualitative experience with antenatal care in several tertiary 
hospitals in Nepal, with a focus on postpartum family planning counseling. This article is linked to a 
separate published report on NESOG and FIGO efforts to integrate postpartum IUD services within the
immediate postpartum maternity care at these hospitals. This paper will provide a useful complement to
that other publication in that it provides rich description for the lack of high coverage in prenatal PPFP 
counseling and awareness of PPIUD. The methodological approach for this study is strong. From the 
perspectives of someone working in PPFP programs, the results are not particularly surprising; but this 
paper will provide more rigorous evidence for such observations. It also highlights the important 
finding that women are eager to be given more information, not just about PPFP, but about how to care 
for themselves during pregnancy and prepare for the arrival of the child. The paper is well written, the 
use of the Bruce-Jain framework to organize the content very appropriate. I have few suggestions for 
improvement.
 
General observation on wording and definitions: the word counseling is used throughout the 
manuscript but often time the interaction described hardly qualifies as counseling. Perhaps, it should be
described more as giving information, without an opportunity to probe a woman's wishes or plans. The 
authors might include a sentence in the methods section to define what they mean by "counseling" - 
and to clarify their use of the term is in terms of what is expected, and differentiating what was reported
as practiced from what proper counseling should be.
Also, in Table 2 and line 445, there is a reference to group counseling. What occurs in group settings is 
usually better described as group education, as counseling implies two way interaction which is more 
complex in a group. The authors could perhaps refer to information shared in a group setting as "group 
education" on PPFP.
Introduction
Line 80- 82 - the implication here is that PPFP counseling is not well integrated into postpartum check-
ups. However, the authors may want to cite data on the proportion of women who return for postnatal 
care, and clarify that waiting until these visits to initiate PPFP conversations would miss large segments
of the childbearing women. 
Line 81 - the authors should specify what they mean by "the survey"
Results
Section on technical competence. Lines 344 onwards describes that satisfaction was high in Group 2 
hospitals. In the discussion, the authors note that one (or all?) of these hospitals recruited a dedicated 
counselor. Is it possible for the authors to review quotes of that site to see whether they specific 
whether the counselor or the ANC provider was the one that spoke to them about PPFP?
Table 2 shows that women reported being counseled by students. Are there any qualitatively data about 
whether students are well accepted or not? Whether they too rush through the process? Whether their 
counseling is supervised?
Line 429 through to end of quote on line 434 - The authors should not whether that quote is from the 
same Group 2 hospital(s) with a dedicated counselor. And whether the larger context of the quote 
clarifies who "they" are. 
Under interpersonal interactions - are there any quotes that suggests that sometimes women themselves 
felt empowered enough to (insist) ask for PPFP information during their visits? Despite providers not 
asking if they have questions and rushing through giving of information. There were initiatives in the 
early aughts to empower clients and prompt them to prepare FP related questions (not in postpartum 
settings) - for example Kim, YM, F. Putjuk, E. Basuki, A. Kols, "Increasing patient participation in 
reproductive health consultations: an evaluation of ''Smart Patient'' coaching in Indonesia". Patient 
Education and Counseling, 2003 and Young Mi Kim, Eva Bazant, J. Douglas Storey. Smart Patient, 
Smart Community: Improving client participation in FP consultations through a community education 
&amp; mass media program in Indonesia. International Quarterly of Community Health Education, 
2017. Also interesting paper on client-centered communication and satisfaction here: Nahla Abdel-
Tawab &amp; Debra Roter. The relevance of client-centered communication to FP settings in 
developing countries: Lessons from the Egyptian experience.  Social Science &amp; Medicine, 2002
Discussion
Line 468-469 - "Poor quality of care was often attributed …" - It is not clear who is making this 
attribution. Is it the authors or the study participants? 
Paragraph starting with line 475. The point about structural changes is well taken. Related to the idea of
booking appointments, the authors could also mention (perhaps in a separate paragraph) that there is a 
movement to reinvent ANC, including by providing group ANC. There is some recent literature on this 
(see for example: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0222177 and Lori 
JR, Ofosu-Darkwah H, Boyd CJ, Banerjee T, Adanu RMK. Improving health literacy through group 
antenatal care: a prospective cohort study. BMC Pregnancy Childbirth. 2017; 17:228. pmid:28705179), 
which shows positive results including for intention to use PPFP. (But then the point about the role of 
doctors would be separate). 
Same para as above and the next one starting on line 490 - the data is clear that women value the advice
of doctors, which is quite rational given their more extensive training. However, I wonder if the authors
could temper that with the fact that doctors are typically the least able to devote considerable time on 
ANC counseling (and often are not the best communicators as compared to other cadres and even lay 
providers). Given skilled health workforce shortages and this study's own experience in one Group 2 
hospital, a separate discussion on who are the most appropriate counselors might be appropriate. In 
India as with that hospital, the government has recruited social work graduates as RMNCAH 
counselors the relieve ANC and L&amp;D nurses and midwives. The danger then is that nurses and 
midwives no longer see PPFP counseling as their mandate at all, as opposed to sharing the task. Is there
anything more in your qualitative data about how roles were shared in that hospital? 
Related to dedicated counselors, the authors have not made any specific policy recommendations about
their role (perhaps because the number of sites is too small to derive valid conclusions). However, they 
offered a recommendation on health system infrastructure (including provider availability), and it 
would be interesting to know whether the authors think policy-makers should weigh the role of 
dedicated counselors to address the issue in hospitals. 
The recommendations do not explicitly speak to make care more client-centered but I would argue that 
this is more important than going through "the pros and cons of each choice". 
Tables
Table 1 - I find it a bit confusing that "Janajati" is added to both the description of "relatively 
advantaged indigenous group" and "disadvantaged plain indigenous group". Also the text, but not the 
table, refers to the Terai... Maybe the authors could align table and text and a table footnote could 
clarify the "janajati" term? Also should it be "plains" to avoid confusion.
Table 1 - "Joint Family" is not a term I recognize. Perhaps the authors could use the word "Extended 
Family" to mean that uncles and aunts and grandparents may share the same household or compound?
Table 2 - Type of provider who counseled was often indicated as Sister. For an international readership,
the authors might specify if this is a nurse or counselor. From this table, it seems that clients may not be
able to differentiate whether their counselor is a nurse or a dedicated counselor. Is that correct? This 
may be worth mentioning in the text, when dedicated counselors are discussed.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
No
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Yes
Are you able to assess any statistics in the manuscript or would you recommend an
additional statistical review?
If an additional statistical review is recommended, please specify what aspects require further
assessment in your comments to the editors.
Not relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
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