Title: Post-abortion care services in Zambian health facilities: a qualitative study of users'
experiences and perceptions
Version: 2 Date: 03 Nov 2023
Reviewer's report:
An interesting manuscript on an important issue, and findings have important policy
implications.
1. In general, it seems like you are glazing over the findings and don’t go deep enough. Unless
there is a consensus in a response to a specific question, you need to present all opinions. It is not
enough to say that most participants felt a certain way – if even one participant felt differently
you need to specify it, and add the relevant quote, and you don’t always do that.
2. I am not crazy about the structure.  You bring the AAAQ framework only in the discussing,
introducing new concept, and not really linking them to your findings.  I think all that should
be part of the introduction section.  The discussion should focus on your own findings – and
yes, you should link them back to the literature, but not introduce new concept as you currently
do. You don’t need to repeat your findings in the discussion, but you should link them back
to the framework (for example, ‘accessibility means X, but we found that Y or some such).
More importantly, in the discussion section you should specify what your results mean, and
programmatic implications.
3. The way you present quotes is confusing – whether tell us who the respondent is before the
quote (a 17 year old said), or after in parenthesis. I, myself, am a fan of the latter, but it’s up
to you. You need to be consistent – and see my comment below on what you should say about
the respondent on each quote.
4. Please read the full manuscript with an eye to fixing remaining typos, and the few places
where the text is a bit awkward.
Abstract
5. In the method section, rather than say that you had 15 interviews with women, you should say
that you interviewed 15 women – the way it’s currently stated suggests that you may have had
fewer women and they were interviewed more than once. It’s a minor linguistic issue, obviously,
but got me a touch confused.
6. In the results section, the first two sentences (3.5 lines) should be part of the background,
not part of the results.
7. Also in the results section, you say you present according to the framework, but this is not
evident in your presentation of the results. You should structure the results part of the abstract
according to the four concepts of the framework
Background
8. I think the order of the first few paragraphs does not flow.  The currently first paragraph,
should be the third.  So first present the problem, then say that every woman has a right to care
to solve the problem.
9. You are using too many acronyms, in my opinion. It would be easier to follow with fewer.
For example, you have both SRH and SRHR.  You only use SRHR four times. Why not just
say SRH rights? Also CAC is not a commonly used acronym outside of your specific field. I
think you can just spell it out.
10. P.5 line 8 -- you say that Zambia has made… Did you mean to say the government of Zambia?
11. P. 5 line 15 – the first word of the paragraph should be ‘Despite’ not ‘Although’.
Methods
12. P. 6 line 17 – what do you mean ‘up to 9’ – did you include 9 facilities or fewer?
13. P. 7 line 3 – so all the participants were either 17 or 45 (this is how it reads), or were they
between the ages of 17 and 45?
14. Table 1 is confusing.  There is no need to provide details on every participant individually.
Instead, you should have a table showing the percent married, distribution into age categories,
distribution by type of abortion, etc.  Also, add to it distribution by facility, as you have 15
respondents form 9 facilities, so different number of respondents per facility.
15. Table 1 shows that the one 17 years old was unmarried.  What is the legal age of consent in
Zambia? In most countries it is 18.  If that is the case in Zambia, then to include an unmarried
minor in the study you would need not only her ascent, but also the consent of her parent or
legal guardian. Did you obtain that? If not, then you may be in an ethical conundrum, and may
need to remove her data from the analysis. Obviously if the age of consent in Zambia is younger,
then this point is moot.
16. P. 8 line 3 – no need for the authors’ initials. Just say ‘by three of the authors’. It’s confusing
otherwise. As I reviewed, I found myself  wondering what these acronyms were, and it took me
a moment to realize they were authors initials.
Results
17. When you identify quotes – don’t use the participant number (especially if you follow my
recommendation for a simpler participant-profile table).  Instead, this is the time to give details
– age and type of abortion should do.  No need for more than that.  The way you have it now,
with the table of individual participants and reference to their number after a quote, would make
the reader interrupt the reading to go look at the table.
18. I find myself not always clear of whether you talk about spontaneous or induced abortion.
Please go through the entire results section and make sure this is always clear (it should be easy
to add the word ‘spontaneous’ or ‘induced’ before the work abortion. Or you can have sub-
sections – currently you go back and forth, which is why it is confusing. As I continue reading,
I see that there are three categories, not two – spontaneous, induced at home, safe abortion.
19. P. 12, paragraph on cost – first, are the services supposed to be free of charge, or is there a
listed cost, and does that vary by type of hospital? Then you talk about different types of cost.
There are tests (such as ultrasound and lab tests), there are drugs, and there are consumables.
You may want to go into more details on these, as each would have different programmatic
implications.
20. You report that many participants didn’t realize that abortion was legal in the country.  And
yet they all came to the facility for postabortion care.  How do these facts reconcile?
Discussion
21. See my comment above about the overall structure of the manuscript, as the discussion
section is key.
22. In the strength and limitation – you said that you had a smaller number than planned. You
need to explain (in the method section)v what was your target sample, and why you ended up
with a smaller sample.  And with this smaller sample size, do you feel that you got saturation?
Another limitation, is that your findings are limited to those women who actually made it to the
facility for post abortion care. It is likely that there are many others who deal with abortion-
related morbidity (or even mortality) who don’t come to the facility, for all the reasons you
discuss.