Title: Clients’ expectations and experiences with providers of menstrual regulation: A
qualitative study in Bangladesh
Version: 2 Date: 20 Feb 2024
Reviewer's report:
There’s a fundamental problem with their manuscript—a disconnect between their recruitment
strategy and the arguments they’re making about clients' fears of how they will be treated, and
the way they were treated. Was there any difference in the treatment by providers based on
the location of where the service provider worked? Their sample is imbalanced to even answer
this question.  They said their recruitment strategy was determined by reaching saturation.
“Saturation” on which dimension(s)? Five interviews from one site is unlikely to result in
saturation unless their research question was very narrow, and it's not--it's broad. What’s missing
in the paper is any connection between where respondents chose to get services and their
anticipation of how they would be treated, as well as any analysis of how they were treated by
where they received services.   The conclusion does not draw out any differences.  The refusal
rate is not reported.
What was the research question they were trying to answer? They say: “In order to better
understand the MR client perspective on quality of care, with a focus on interpersonal
interactions, this study aimed to assess the knowledge and expectations clients had prior to
their MR care and explore experiences with providers during the MR process.” If they were
really setting out to explore experiences with providers, they should have had a more balanced
sample, and at the very least conducted their analysis according to where the woman obtained
services, and is a further testament to why they shouldn’t identify their quotes as “Call Center”
but according to where the woman got an abortion. Later in the paper, they go on to talk about the
“call center” as a model of care. I come away not being able to distinguish any difference in the
sample according to where the clients got their MRs, if some locations were doing a better job,
if there were factors that facilitated women having better experiences, etc. They should show a
table of type of abortion by location of recruitment.
I am aware that this is a revision. Some of these issues were not so clear in the earlier draft
because their recruitment strategy wasn't clear in the first draft with the designation of "call
center" adding a great deal of confusion; a confusion which remains in this draft.
What is the definition of person-centered care that they are using? Are they trying to make an
argument that women’s experiences in Bangladesh are shaped somehow by their context? If so,
what is that context that shapes their abortion experiences?
They slide between different naming conventions for the surgical vs. medical abortion. It would
be easier to read if they study with one. They use MMR; in Bangladesh, MRM is more commonly
understood/used.
What does it mean when something is in parenthesis inside a quote? Was it said by the respondent
or was it not said? If it was said, then it doesn’t need to be in parentheses. If it wasn’t said, then
it should be in brackets.
Data from 2014 is not an accurate representation of the current situation in Bangladesh, and the
authors should not represent it as such.
A decrease in use of services (Ref #3) cannot be interpreted to mean that fewer people know
about the services (lines 78-79). Similarly, lines 78-79: urban access to services cannot be
interpreted as fewer rural women knowing about the services. Since the study was conducted in
an urban area, the authors should specify that as a limitation as they are trying to make the point
that there is a difference in knowledge about MR between rural and urban areas.
Line 89: specify “unmarried”
Line 94: “existing literature…most of which…” is followed by only one citation. Are the authors
saying that that represents all existing literature? Reference #12 doesn’t support the point “…
measuring health outcomes such as maternal mortality and access to MR services…”
Line 118: “edited IT”
How were the respondents provided their remuneration when they were not interviewed face
to face?
No need to show marital status in Table 1 since there is no distribution.
The authors say the interviews were done after the procedure was complete but then in lines
214-215, they say, “than the one they were currently seeking”—as though the abortion was yet
to be completed.
They say in response to Reviewer #1’s comments, Q9, that they didn’t include in their analysis
fear of dirty instruments, but they did: see Line 218.
Parity would be interesting to include in the quotes.
Statements like in lines 236-238 are just not very interesting if not shown by where respondents
got abortions. How did this expectation on negative treatment relate to where respondents went
to get care? The quotes shared by women about this expectation came from women who went
to a maternity hospital, which is surprising that even though they feared negative treatment by
providers.
When do the authors use commas right before a quote, and when do they use colons or periods?
It seems arbitrary.
Line 295: “the fetus was living”—that’s odd phrasing.
Lines 306-208: No quotation marks necessary around the quote.
Line 318: “’—quotation marks facing each other.
Line 330-331: “suggestions of what to eat before taking the pills,”—what is this referring to?
Lines 33-334: the quote doesn’t add anything to the authors’ paraphrasing.
What was the origin of the pamphlet that clients were given at the public facility? Was it
mandated in some way for providers to give that pamphlet? What is the source of the information
in the pamphlet?
Lines 368-369: “At least six were explicit [ABOUT] not having an option or choice presented
to them during counseling.” Word missing.
Line 422: “Clients across the different models of care”—which are the models of care that the
authors are referring to? The quote comes from a call center respondent. Is she referring to the
facility where she was treated? The call center?
Line 433: define “Apu”
Line 435: Gratuitous closed parentheses.
Line 438, line 451, line 457, line 461, line 464, line 468, line 469, line 475-476: Why is “quite
good” only in single quotation marks? Other examples indicated by line numbers.
Line 439-440: Reword as not clearly written: “clients felt that they provided more encouraging
or supportive care.”
Line 462 & 463: Why both single and double quotation marks?
Line 472: In keeping with the formatting that the authors are using throughout, “(25 years old,
Call Center, medication MR)” should be italicized.
Line 496-497: “the misinformation”—which misinformation?
In their conclusion, they are mixing policy recommendations in throughout their summary
statements. It would be cleaner to pull the policy recommendations into a paragraph that are just
about policy recommendations.
Line 505: “Previous qualitative studies”—and then there’s only one citation.
Why didn’t the authors try to validate a person-centered abortion care scale, such as was done
in Kenya? Can they do this retrospectively?
Line 536: “Clients rely heavily of” – of is incorrect. It should be “on.”
Why is “Consent for Publication” “Not applicable”? Do the authors need to specify if
respondents agreed for the results to be published when they provided consent?
Line 580: ASQ?
REF #6 looks strange. Department of Population Sciences, University of Dhaka, is an author
+ publisher?
REF #9: The fact sheet is based on another publication—cite the publication and not the fact
sheet.