Reviewer ’s report  
 
Title: "The sun keeps rising but darkness surrounds us": a quali tative exploration of the lived 
experiences of women with obstetric fistula in Ethiopia  
 
Version: 3 Date: 20 Nov 2017  
 
Reviewer: Alison El Ayadi  
 
Reviewer's report:  
 
Please include all comments for the authors in this box rather than uploading your report as an 
attachment. Please only upload as attachments annotated versions of manuscripts, graphs, 
supporting materials or other aspects of your rep ort which cannot be included in a text format.  
 
 
Thank you so much for the opportunity to review this important manuscript. This qualitative 
study reports on women's perceptions on the cause of their obstetric fistula and their experiences 
living with fistu la. There is a substantial amount of data here, and given the neglected nature of 
this condition, there is a lot of potential for this manuscript. However, as currently written, the 
manuscript lacks focus. In particular, it is not clear what the overall ai m is and what can be 
achieved through this more nuanced understanding of the conditions of women living with 
fistula in Ethiopia. I recommend that the authors work to streamline this manuscript, focusing 
less broadly, and pulling out important recommendati ons for prevention and intervention. 
Furthermore, the language will need heavy editing for publication in an English language journal 
and the document needs to be reviewed for spacing, capitalization, and other errors.  
 
 
Some specific revision requests foll ow:  
 
Background  
 
1. Page 2, Line 43: More descriptive than 'problem' would improve this sentence. 
Furthermore, the first and second sentences here are stating much of the same thing and 
can be combined.  
 
 
2. Page 3, Lines 17+: Please make it clear that this data are from Ethiopia. Additionally, the 
cited DHS data are from 2005 whereas there has been a 2016 DHS in Ethiopia with the 
fistula module, which would be a better source for contextualizing this.  
 
 
3. Page 3, Lines 38: Please include more detail on the p urpose of understanding the lived 
experiences of women with obstetric fistula. What does this bring to the evidence base 
that is unique?  
 
Methodology  
 
1. Page 4, line 57: You indicate purposive sampling was conducted, but the strategy used is 
not clear. Wha t characteristics were you selecting women based on and why?  
 
 
2. Page 5, line 47: Please describe how the preliminary code list was developed.  
 
 
Results  
 
1. The summaries of the themes and subthemes are inadequate. More detail would be useful 
here to describe the main findings before including the quotations.  
 
 
2. The data provided in the manuscript is quite broad and I think that reducing the focus of 
the results section to a more detailed exploration of certain themes and subthemes would 
be more effective.  
 
 
Discussion  
 
1. Please revise the conclusions section to exclude presentation of data. This should be in 
the results and discussion of it within the discu ssion section.  
 
 
2. Please discuss how these results can inform public health practice.  
 
 
3. Short on references and discussion to other contexts . 
 
 
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.  
 
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 manus cript or would you recommend an 
additi onal statistical review?  
If an additional statistical review is recommended, please speci fy 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 l anguage 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 reim bursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly 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 fro m 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 declare that I have no competing interests . 
 
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