Reviewer’s report
Title: 
“I did not plan to have a baby. This is the outcome of our work” -a
qualitative study exploring unintended pregnancy among female sex workers
Version: 
1 
Date: 
17 Aug 2020
Reviewer's report:
General:
This study has a very clear rationale, based in a country where FSWs run a high
risk of unintended pregnancy but the law permits only "life-saving" abortions.
There is a clear need for tailored SRH services for FSWs. I believe that this
study, which shows that stigma and gender-related factors impede FSWs access
to and use of contraceptives, adds value to the existing literature and would be
suitable for publication after taking into account the below suggestions. 
Introduction:
Page 4, lines 43-45: the author states that a number of studies have shown the
factors associated with contraceptive use among FSWs but there are no
supporting citations. 
Page 4, lines 46-47: again here the author does not cite literature to support their
statement that "FSWs experience more unintended pregnancy than women in the
general public". It would also be useful to know whether the author is referring
to FSWs all around the world or FSWs in Tanzania specifically. 
Methods:
This section is missing a sub-section on "services offered". The reader would
like to know what type of healthcare services the FSWs received during the
PrEPVacc study. Were they tested for STIs? How often were they tested for
HIV? Were participants offered long-acting reversible contraceptives during the
study? If so, which kinds? Knowing this information will give more context to
the study findings.
Table 1: did the authors collect information on drug and alcohol use among study
participants? If so, that information will be useful to show in this table,
especially because alcohol and drug use were factors cited in the results as being
associated with skipping pills. 
Page 8, lines 1&2: the author states, very briefly, that the health belief model
informed their interview guide. At this point, the authors should add more detail
about which component of the health belief model (perceived susceptibility,
perceived severity, perceived benefits, perceived barriers, self efficacy) the
themes/questions from their interview guide corresponded to. 
Discussion:
Page 13, line 45: the author states that FSWs "failed to negotiate consistent
condom use". This statement, although not the author's intention, may come
across as victim blaming- perhaps the author could complement that phrase by
stating, as they have in other parts of the manuscript, that this inability to
negotiate condom use is due to gender-based power differentials between FSWs
and their male clients. 
Page 14, line 17: this paragraph tackles the inconvenient clinic hours and the
reluctance of healthcare workers to provide care to FSWs. Here, the reader
would appreciate some discussion about potential solutions to surmount these
barriers. Could there be trainings for healthcare workers on destigmatising
practices? Are there other possible approaches to better meeting the reproductive
health needs of FSWs? 
Page 15, lines 1-2: the author commendably states that linking HIV and SRH
services for sex workers will improve contraceptive outcomes. However, the
author does not discuss the potential difficulty of doing so in a context where sex
work is illegal and healthcare workers stigmatise FSW. How can tailored
services for FSWs in Tanzania be implemented while protecting FSWs' safety
and ensuring access to these services?
Page 15, lines 18-23: 
Here the author restates information that has already been
covered in the methods section. I suggest deleting the following phrase: "In this
study, we sampled informants on the basis of their pregnancy test, demographic
data, and reproductive health information in the PrEPVacc database. Although
an allowable sample size was roughly estimated beforehand for logistic planning
purposes, selection of informants was informed by preceding interviews and
stopped when no new aspects were emerging, i.e. saturation reached."
Page 16, Lines 1-13: Once again the following information is very descriptive
and seems more appropriate for the methods section under "design and data
collection" rather than the discussion; "DF and PM were part of the PrEPVacc
study team involved in enrollment and follow-up interviews of participants in
the cohort study. Data collected in these interviews included questions on the use
and preference of contraceptives. This provided a chance to explore
contraceptive use among sex workers other than those already participating in the
qualitative interviews. Again, DF and PM took part in delivering pregnancy test
results to the women as part of the study visit procedure. This provided a first-
hand experience on how women reacted to a positive pregnancy test result
because the majority of them had not intended to become pregnant. In all these
encounters, personal notes were taken on observations relating to the study
question and later used in the analysis process. DF is female medical doctor from
Dar es Salaam. She holds a master's degree in epidemiology and currently
pursues a doctoral degree focusing on HIV risks, sexual and reproductive health
needs among females"
Conclusion:
Page 17, line 6: the author mentions "good contraceptive behaviour" being
difficult to achieve for FSWs. I would appreciate more detail about what the
author defines as good contraceptive behaviour. Could that mean dual
contraceptive use or the use of long-acting reversible contraceptives? 
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
No
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Yes
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Yes
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from apparent manipulation?
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