Reviewer’s report
Title: The Loss of Dignity: social experience and coping of women with Obstetric Fistula, in northwest  
Ethiopia
Version: 0 Date: 27 Oct 2018
Reviewer: Karin Hammarberg
Reviewer's report:
Thank you for asking me to review this paper which reports findings from interviews with women in  
Ethiopia who had suffered obstetric fistula and were waiting for surgical repair. Research that promotes  
better  understanding  of  the  significant  emotional,  physical,  social  and  financial  consequences  of  
obstetric fistula is important and this paper contributes to the limited existing evidence about this,  
particularly from the perspective of women who are in this predicament. I have the following questions  
and comments: 
1)I acknowledge and appreciate the significant difficulties in writing in a foreign language. While  
the authors show capacity to write in English, the paper needs substantial English expression  
and grammar editing to be of academic standard. If possible, it would be helpful if this could be  
done by a native English speaker.   
2)I think that the background section should start with an explanation of what obstetric fistula is,  
why it happens (and how it can be avoided), and what the prevalence is in Ethiopia and other  
places in Africa, followed by the physical, emotional, social and financial consequences of this  
birth complication (some of this content is already there but could be better organized). Then it  
would be helpful to have contextual information about the health care system in Ethiopia  
including what proportion of births occur in health care settings, how health care is funded (do  
patients pay?), who can access to obstetric care, and barriers for obstetric care (including  
traditional beliefs about childbirth) etc. 
3)In the Study setting section it would be helpful to know if there are costs to the individual  
associated with care at the Fistula Treatment Centre, whether there is a waiting list for fistula  
repair, how long the average stay is, and what the success rate is in terms of women being  
continent after the surgery.  
4)Under data analysis, please provide a reference for the Open Code software. 
5)In  the  Background  of  respondents  section  please  provide  the  total  number  of  women  
interviewed. Please also provide the range of time women lived with the condition (I presume  
that the seven years mentioned is the average?). In the second last line in this section is says  
'nearly eight' which should be corrected and there is a 'The' at the end which should be removed.  
It might actually be better to show the characteristics of participants in a table which could  
include age, current relationship status, education, years living with obstetric fistula, number of  
children born and number of live children, in which pregnancy the fistula occurred. This would  
give readers an overview of the diversity of participants. 
6)It would be easier for the reader if the quotes were separated from the rest of the text and  
appeared  as  indented  sections.  I  also  think  it  would  be  helpful  to  have  some  of  the  
characteristics of the women whose quotes are used appear after the quote, e.g. (Age 23, lived  
with fistula for 3 years, one live child, separated). 
7)In the discussion percentage is used in the third paragraph, this should be removed. I would also  
like  to  see  some  discussion  about  whether  there  are  preventative  strategies  to  reduce  the  
incidence of obstetric fistula in Ethiopia. I know that at the Hamlin Fistula Hospital in Addis  
Ababa there is now a school of midwifery which was established some years ago to increase  
access to obstetric care in remote areas. Has this helped reduce the number of women who  
experience obstetric fistula?
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.
Unable to assess
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:
Not suitable for publication unless extensively edited
Declaration of competing interests
Please complete a declaration of competing 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 now 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  relating  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 interests?
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 have no competing interests to declare.
I agree to the open peer review policy of the journal. I understand that my name will be included on my  
report to the authors and, if the manuscript is accepted for publication, my named report including any 
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be included in my named report can be included as confidential comments to the editors, which will not  
be published.
I agree to the open peer review policy of the journal