Reviewer’s report
Title: 
Barriers to seeking post-abortion care in Paktika Province, Afghanistan: a
qualitative study of clients and community members
Version: 
2 
Date: 
12 Jun 2021
Reviewer's report:
The authors do not always have a space before the reference number. They
should double check this. 
Comma not needed pg. 3, line 13 after "quality"
Pg. 3: "In a 2010 cross-sectional study…" should come before "In 2017…"
Pg. 3: "Average knowledge…" should read instead, "Average knowledge scores
among providers for treating complications of incomplete abortion and what
information to give PAC clients was 60% or lower - lower than knowledge
scores on any other EmONC service." They cite reference 18 for that, but are
relating it to the findings from reference 17. They need to specify that those
findings come from two different studies; and how their samples differ. 
How is IMC building the capacity of community members? On what? (see pg. 3,
line 49)
The authors specify all respondents are married, but it would be valuable to
know how many are in a monogamous marriage vs. how many are in a
polygamous marriage? Polygamous marriages may indicate more conservative,
traditional values in general, including related to pregnancy loss. 
Because the study was done in a location where an intervention was conducted,
how is this location likely to be different than other locations in its PAC
provision? 
I can imagine recruitment was extremely difficult—how many respondents were
contacted but declined to be interviewed? 
Is US$25-40 really "low cost"? Can the authors contextualize this in relation to,
for example, an average monthly or yearly salary in Pathika province? 
Quotations within a quotation only need single quotation marks. 
From the quote: "…If someone find[s] out about it then they do not [allow her to
die], they help her at that moment. Later, after her recovery they don't behave
well with her...They take her to the hospital. (Woman aged 25-45)" What does
the respondent mean—take her to the hospital after she's recovered to
institutionalize her or something else? 
The discussion of a woman's life indicates very little value is placed on her life:
"Male participants also discussed their support for PAC in order to avoid
additional costs related to treatment of more severe complications. A few groups
mentioned the high costs of marrying a new wife if their current wife was
perceived as incapable of producing children as a result of the abortion or, as one
mentioned, if she was to die of complications." This deserves acknowledgement
by the authors. Male accompaniment as a requirement for care is a human rights
violation and should be named as such. 
"The findings from this study suggest that while the barriers to access and use of
services are not necessarily directly due to the conflict and some are not unique
to PAC, others, especially those related to stigma around abortion, may be
specific to PAC." The first half of the sentence suggests that there were some
findings related to the conflict when in fact they present no information in the
transcript that any behavior they captured was related to conflict. Furthermore,
for clarity, they should separate out these two points: what health behavior is
related to the conflict and what health behavior is related to PAC. 
Pg. 18, line 25-27: "Evidence…shows"
Can the authors cite the statement, "Out-of-pocket spending on health in
Afghanistan in high"? And also quantify what is meant by "high"? 
Pg. 18, line 47: which findings are the authors referring to when they say "These
findings" as they have just been discussing others' work? 
Pg. 18, line 51: "Reducing service delivery fees…" but services are supposed to
be free. So what service delivery fees are they referring to? 
Pg. 18, line 58: what are "health financing strategies"? Are they referring to
health insurance or greater funding of health facilities? 
Care-seeking should be hyphenated. 
It's very strange that the authors continue to equate abortion stigma with a
willingness to let women die (see last sentence of the conclusion, "However, it is
important to remember that despite the barriers and negative perceptions of
abortion in this community, community members expressed a strong desire for
women to receive PAC so they do not die from abortion.") The idea that abortion
stigma is so strong that women should die if they have had an abortion is not a
rational thing to connect to abortion stigma--stigma can be expressed in many
ways. An expression of stigma doesn't mean a willingness to let the person die.
They present this as a "finding" when it's a spurious idea even to begin with. 
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