Reviewer ’s report  
 
Title: “Regardless, you are not the first woman”: An illustrative case study of contextual risk 
factors impacting sexual and reproductive health and rights in Nicaragua  
 
Version: 1 Date: 02 Aug 2018  
 
Reviewer: Francine Coeytaux  
 
Reviewer's report:  
 
This is a very good article that merits wide distribut ion. I have a few comments and 
recommended edits that I believe will strengthen the paper.  
line 7 - add to the methods the fact that you conducted ten in -depth interviews with women ages 
16 - 23 in Ocotal, an   isolated city in North Central Nicaragua, fr om June to July 2014. Then say 
this paper focuses on the case study of Ana Maria...  
line 9 - move the this sentence to the Results section:  
 
Results: The case of Ana Maria highlights unique challenges related to the fulfillment of sexual 
and reproductive  rights due to the Nicaraguan total ban on abortion, rampant machismo, and 
violence against women and provides a useful lens through which to examine individual sexual 
and reproductive health experiences and identify missed opportunities for public health 
intervention.  
 line 43 and 49   please spell out sexual and reproductive health and violence against women 
throughout the document. Please limit acronyms to the names of organizations and agreements 
(WHO, UN, CEDWA)  
 line 60 does states refer to countri es? if yes, please consistently  use the word countries 
through out document  
 line 87 change word "among" to "in" (among implies complicity) violent acts like rape were 
endemic in Nicaragua and occurred most frequently in young women ages 15 -24. 
 line 106 -108  change order of sentence to highlight fact that there is already low usage of these 
contraceptives: Due to a lack of sexual education, Nicaraguan adolescents, if they use 
contraceptives like male condoms or oral contraceptive pills, do so inconsisten tly or incorrectly.  
 line 113   why mention just LARCS?  better would be simply to mention using contraception. 
The way you have done it here looks like you are just paying lip service to the push for LARCS.  
 line 142  Make clear that is the gov that doe s not view abortion as a human right -   While the 
Government may not view abortion as a human right per se,.....  
line 145  Needs an introductory sentence here - Criminalizing abortion also increases stigma and 
significantly reduces the willingness to spea k about the problem...  
 line 150  spell out IDI throughout - in many places can just use word interviews (pg 10 line 55 
and line 161)  
 line 158 maybe explain on what basis study was exempt from full review?  
 
pg 12 Section on social norms - I expected to see more discussion about the impact of the 
isolation - the fact that she did not feel she could tell anyone impacted her decisions - and the 
fact that when she did tell her brother, he got her care. The isolat ion due to stigma and shame, 
especially in cases of rape, is an important driving factor and merits discussion  
line 314 or 318  Again, worth mentioning that the silence due to stigma and criminalization 
endangers - impedes getting help  
line 346 -349 this is what I would have liked to have seen better explored above under social 
norms  
Thank you for doing this.  I look forward to seeing the article published. And apologies for 
taking so long to review this.  
Are the methods appropriate and well described?  
If not, please specify what is r equired 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.  
 
Yes 
 
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 req uire further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of co mpeting interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either n ow or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents rela ting to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interest s? 
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests.  
 
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