Title: Why do women walk away from maternal health services in Southwest  Ethiopia? A
qualitative study of caregivers' and clients' perspectives.
Version: 2 Date: 02 Dec 2022
Reviewer's report:
Rivewer comment
This study assessed provider, administrator, and user perspectives on barriers to the continuum
of care (COC) in maternal health services in Ethiopia using a qualitative method. The collected
interview data were analyzed and organized into three main themes of barriers to COC: system-
level, community-level, and individual-level.
The continuum of care (COC) in maternal health services (antenatal care, delivery, and postnatal
services) is important to reduce existing high maternal mortality in low-income countries. In
agreement with the author’s clam, in low-income countries huge difference reported between
utilization of antenatal care service, facility based childbirth, and postnatal care services.
However, the background of the manuscript lack reasonable argument with evidence that show
need for research on the topic. Based on these observations, I am recommending this article for
publication with major revisions.
My recommendations are presented below and are classified into major and minor comments.
INTRODUCTION
1. Major : The authors did a good job of discussing why COC is an important topic, but they did
not summarize key studies on the topic. I advise the authors to use more contemporary studies
to support their arguments to persuade readers on the significance of this study. There are many
studies in low-income countries, including Ethiopia on the barriers to utilization of maternal
health services, particularly ANC and institutional delivery,. I advise the authors to have a closer
look more recent writing on the topic and write how their study adds to it.
2. Major : The author need to revise and check for errors on citations and use up-to-date citation
# Major:  Page 4 Line number 96 - 97, Reference 21 (is qualitative phenomenological study
in Ethiopia) . However The author noted “this study shows that more than three-fifths of
pregnant women receive at least one ANC follow-up, but only one-fifth give birth in a health
facility” (check for error ) . In addition this example does not show the recent report in Ethiopia.
Recently in Ethiopia 48% of women give birth at health care facilities (EDHS, 2019 key
indicator).
# Major:  Page 4 Lines 97- 98, the citations to support their arguments is not recent and have an
error (22 published 2005)   and reference 23 (conducted in Pakistan 2006)    .   Authors noted
that "in Oromia, where the study was conducted, ANC4+ is 22.1%, SBA is 19.7%, and PNC
within the first two days is only 9%" (22, 23). According to recent reports, the ANC-4 pulse
in Oromia is 40.6%, deliveries by skilled birth attendants are 43.7%, institutional deliveries are
40.9%, and postnatal care is 21.1% (EDHS 2019).
METHOD
Method and material section
• Minor :  use study setting as a subtitle
• Minor : the study setting not consistent throughout the manuscript. Example page 5 Line
104, the author noted “study took place at selected health facilities” this appears the study was
conducted only in health care facilities such as health centers and hospital. . However in the
abstract the (Line 36,-38) participants included  from “from woreda health departments, head of
the health facilities, midwives  and women attending the MCH clinic”
• Minor : Please add two separate sub title page 5 ( Line 122 study design that describe study
design and study participants
• Major: research design Page 5, line 113 the authors described the research design however not
it justified.  For example a description for :  Why the authors selected  qualitative design
• Major: The sampling strategy is not justified. For example, the method of sampling for
participants and the setting were not adequately described
Comment on participant’s selection
• Major: The authors included the most useful rang of participants relevant to the research
question. However, the characteristics of the participants has not been well defined. For example
the authors stated page 5 Line  117    “ all purposefully selected study participant
•  Major: Some established criteria are not differentiated for different groups of participants;
for example, on page 5, line 118, the criteria "nearness to the activity" are listed as criteria for
whom ,? Rewrite it in a more understandable manner. Line 118.   The author uses “experience” as
a criterion for selecting participants (providers, administrators, and users). The criteria are open
to different interpretations (work experience , experience in health care facility )   . Similarly,
authors need to revise the remaining selection criteria’s
• Minor:  Some parts of method sections of the manuscript lack consistency and clarity. For
example, in the abstract (method section), line 39, the authors stated" key informant interview
guide was used”.  However, on page 5, lines 119-120, the sentence “midwives who have been
rendering maternal health services were selected as key informants” it is interpreted as only
midwives selected as key informants. Author need to make this long and complex sentence in
to short and simple sentence.
• Major: There is the possibility of inducing selection bias; for example, the authors wanted to
learn about users' perspectives on COC barriers. The authors, on the other hand, included women
who attend maternal health services at the facility (women who are using and present in health
care facilities during data collection). This selection criteria must be justified by the authors in
the method section and must be noted in the limitation section of the manuscript. Do you think
using this  participants as  key informant appropriate
• Minor: there is unnecessary repetition of some phrases and words, for example, "purposefully
selected study participants" (lines 116, 120, and 127).
• Minor: The authors state   page 5 Line 128-129 “saturation approach” The authors need to
describe data saturation for potential readers.
Comment on data collection
• Minor : Data collection (page 5 Line 130) data collection selection section, needs an
independent subheading in the method section.
• Major: The method used for data collection is documented page 6 , Line 132  but not fully
described. For example, 132, the description is not explicit. Who conducted the interview? The
data collectors' expertise in qualitative data collection; the length of the interview is not specified.
Methods of data collection, such as audio recording and field notes, are scarcely described.
• Major : The author does not explicitly described the interview guide used for their data
collection. Did the author use a topic guide for interview?? For example in data collection section
of the manuscript  the author noted numerous topics Page 6 Line 133-134   “ To gain an in-
depth understanding of social and economic context in which continuum of care for maternal
health care takes place, women’s autonomy , social relationships, health care-seeking behaviors,
socio cultural barriers to existing health services; perceptions towards maternal health care and
acceptance of care providers the data were collected”  this is your topic  for interviews  ??  How
authors use this topic during interview. Do you use structure or unstructured guide?  The content
of the interview topic needs to be explicitly described in the data collection section or under
separate subheading.
• Minor: Line 137 , the word “insider perspective” who take the in sider perspectives ??
• Major : Line 133–135, did the data collection follow a theme? Or do you use a key informant
interview guide. I recommend include it as an additional file for revision with the manuscript?
•  Major: Line 143    ”our data consist largely interview and expanded field notes."  I realized
your study did not have observational data. What is the expansion of field note in this sentence?
What is the content of your field notes?  Furthermore, when you say "largely," it appears that
you have another form of data; rewrite this paragraph in a more understandable manner to limit
misunderstanding.
DATA ANALYSIS
• Major :   Line 141-148. The method, and process of data analysis, is not clear. For example, the
authors did not explain how the themes and sub-themes were derived from the data (inductively
or deductively) in the manuscript. The description of the researchers who conducted the analysis
(qualification in relation to research design) is lacking. There no description on number of
researchers participated in the data analysis or how they resolved differences in interpretation
of findings during the data analysis. Furthermore, the manuscript  not show  the way of
data management, whether the data was analyzed manually or using qualitative data analysis
software.
Data quality
• Major: Lines 150–157, there is no evidence in the manuscript that shows the data quality
is being maintained in line with the study design. Training of data collectors is not sufficient
to maintain quality in qualitative research. How authors maintained the trustworthiness of the
findings? For example, describe how you maintained the conformability of your findings. What
other methods did the authors employ to demonstrate the trustworthiness of their findings?
Result
The authors included supporting quotes for each theme, but their interpretation is missing.
Furthermore, some example quotes do not support the interpretations of the researchers, or the
given example quote does not fit with the researcher's description of themes.
• Major. In consistent use of themes and sub-themes in different parts of the manuscript,
for example, on page 7 line 181, the author uses “erroneous concept of responsibility and
accountability” as a sub-theme for the main theme "health system-related factor." In page 8, line
207, the author uses the phrase” responsibility and accountability" to describe the same theme.
In qualitative research design, the use of words plays a significant role, so the author needs to
maintain consistency in the words and phrases used throughout the manuscript.
• Major: some to sample participant quote not feet with the researcher interpretation for example
Theme “  shortfall in supplies and infrastructure”  Page 8 Line 191-192, example  quote state
“we have no infrastructure   , however the supporting sentence describe about lack of supplies
in health care facilities.
• Major:  Example quote for short fall in supplies and infrastructure 200-205: this quote
describes the consequences of poor infrastructure on women's lives. This quote does not mention
infrastructure as a barrier to COC. You should include another quote to support for this theme.
In such case, I recommend further analysis of your data.
•  Major: Page 9, Line 215- 224 in this quote, the respondent not describe about   responsibility
or accountability as barrier for CoC. Instead, the respondent described about inappropriate
motivation style used in their facility.
• Major: Similarly, the author must double-check the example quote's fit with themes and
the researcher's interpretation of themes. The richness of the finding across the participant
(source), or difference in the occurrence of themes across the study participant characteristic
not   described.
• Major: A thick description, which one would anticipate in a qualitative study, is missing. The
authors' findings mostly consist of descriptive information with little interpretation.
Discussion
• Minor: The authors, summarized the main findings and try to compare the findings with
existing work, however. Contextualizing the findings within previous research is limited.
•  Minor : Implication of finding not describe
• Major:   The manuscript lacks information about the study's limitations and strengths.
• When submitting the revised version, I recommend that the author include the code book with
the code description that you used during analysis.