Reviewer’s report
Title: 
Barriers to seeking post-abortion care in Paktika Province, Afghanistan: a
qualitative study of clients and community members
Version: 
0 
Date: 
25 Nov 2020
Reviewer's report:
Very good to see research coming out of Afghanistan. Unfortunately, the authors
do not present information on how having the research conducted in Afghanistan
in fact influenced the results. In its current form, it could just as easily be an
article written for **many** parts of the world. What is new in this work that we
didn't know before? How does the fact that Afghanistan is a country that is
fragile influence abortion preferences, access to safe(r) services, and ability to
access PAC care? This is the only sentence that acknowledges the specifics of
the situation in Afghanistan: "Communities living in areas controlled by armed
opposition groups may experience additional barriers." 
Additional primary weaknesses: 
* The way that the authors using the two qualitative methods together doesn't
account for the fact that the IDIs took place in private and related personal
information, while the FGDs took place in a public setting and talked about
social norms. How are they differentiating the meaning of those data? An
example of how this is inadequately accounted for is, "In many of the IDIs and a
few FGDs, respondents reported negative impressions of the care provided at the
hospital…" This does not differentiate between personal experience and hearsay.
o The authors present statements such as, "Many of the FGD participants
discussed disapproval and stigma towards induced abortion and women who
have them." FGDs are not a reasonable place to get anything besides social
norms. It's not likely anyone would speak up with a different attitude in this
peer-filled setting. This is one reason why I don't think the FDGs add much to
this paper. 
o If the authors felt that they had to use FGDs, it would be valuable for them to
explain why.
* Throughout, the authors inadequately distinguish between seeking care for a
spontaneous abortion and seeking care for an induced abortion. The IDI
respondents are presumably relating their experience of seeking care for a self-
reported spontaneous abortion, while the FDG respondents are presumably
speaking about the experience of seeking care for induced abortion. By not
distinguishing the respondents' responses on this important domain means that it
can lead the authors to incorrect conclusions such as: "In practice, many of the
PAC clients in the IDIs expressed positive personal experiences with the health
facility…It could be helpful to engage with the community to dispel rumors of
poor quality." But in fact this finding could be because women coming with
spontaneous abortions are treated well whereas women coming in for care for
complications for induced abortions are treated poorly so that isn't not about
"dispelling rumors" but in fact working with health care providers to improve the
care they provide to all PAC patients. 
o It very much muddies the waters to write, "When discussing barriers to care-
seeking for either induced or spontaneous abortions, some participants
mentioned that women may be ashamed to seek PAC…" 
o Do the authors find it strange that 8 women with first trimester self-reported
spontaneous abortions required PAC under the circumstances described? Do they
think that the women in fact may have induced the abortion?
o Even though the IDI respondents all said they had spontaneous abortions, the
language used by the authors refers to those events as abortions. Is it because
they don't believe the respondents? Or they mean to imply "spontaneous
abortion"? 
The 
sample size of the IDIs is small; it sounds like they had more to choose
from, but only selected 10. They write that these women were "purposively
selected"—based on what? Did they reach saturation? How were the FGD
respondents identified? Did they know one another? If they did, that is not good
FGD practice. And no vignettes were introduced? 
Making statements such as "many other IDI respondents" or "more than half" is
unwarranted given that the total number or IDI respondents = 10. 
The authors should describe how they are defining "quality of care." They talk
about confidentiality, privacy and pain management—is that because that is how
women were answering questions about quality of care or because they were
specifically probing on confidentiality and privacy? 
Did the interviewers come with any previous experience? And were they queried
on their attitudes towards abortion? Is there any evidence that they were
introducing bias into the data collection through their own attitudes?
"The English transcripts…were clarified with the Afghan members." Clarified?
In the next line "for each method" refers to what? 
The authors say that the guides were adapted from what they used elsewhere; the
article would be stronger if the authors compared their results in Afghanistan to
results from other countries where similar data have been collected. 
How big is the catchment area on which Sharana draws? What does "far away"
mean? How far is far away?
The titles of Table 1 and 2 shouldn't be "Afghanistan, 2018" but something more
specific like, "Sharana Hospital, 2018"
When quotes are intended, they do not also need quotation marks around them. 
"clients' seeking PAC" - the word clients should not be possessive here.
There's no need to designate the IDI respondents as "PAC clients" because all of
them are.
When the authors cite costs (i.e. "two or three thousand"), those should be
presented in an intelligible way to the reader without having to go look up the
currency in Afghanistan and the conversion rate at the time the study was
conducted. 
"expressed initial reservations regarding induced abortion"—is a strange phrase.
It would be rare to find people anywhere in the world who do not have some
opinion about induced abortion. 
I do not understand this quote: "She would complain a lot that I want to abort it
and that I can't bear it, but the doctors and clergymen told her that you are
committing a murder. God has granted it to you and now bear it." (Woman aged
25-45) 
This quote is not about care-seeking: "Most of the women are like this, if they
abort her child by their own desire. Later on, they couldn't tell to their husband
due to fear or any other family pressure."
This quote is missing a "]" so it's not possible to tell how much the authors have
inserted: "If someone find[s] out about it then they do not [allow her to die, they
help her at that moment." And I don't understand in the same quote, "to the
doctor that she got like this."
To present this statement, "Male participants also discussed their support for
PAC in order to avoid additional costs: related to more severe complications or
of marrying a new wife if their current wife were to die of complications"
without further commentary is shocking.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
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