Reviewer’s report
Title: 
Barriers to seeking post-abortion care in Paktika Province, Afghanistan: a
qualitative study of clients and community members
Version: 
1 
Date: 
14 Feb 2021
Reviewer's report:
The current draft reads betterand the revisions have made the manuscript
stronger, but there are still problems with the writing. All line numbers below are
from the "Manuscript_Clean" version. 
Was there a reason that the age groupings were not parallel between men and
women? The authors should report why or at least acknowledge this. And why
were there two IDIs of unknown age, but no FGD respondents of unknown age? 
Language such as "several IDI respondents"…"many other IDI respondents"
suggest that the number they are dealing with is larger than 10. What constitutes
"many" when you have a sample of 10? 
"hospital" should always be capitalized when naming "Sharana Hospital" 
The authors mistakenly believe that they still need quotation marks around
indented text. I would encourage them to consult a style manual to correct this
persistent misunderstanding. They should also add clarity to their quotes by
indicating when the respondent is quoting someone else by adding in quotations
around that text. Punctuation in the quotes still needs to be improved: see line
275 as an example. 
Isn't being charged $25-40 for care that was supposed to be free (line 231) a
demonstration that there is corruption in the system and that that is unacceptable
and needs to be called out? 
Lines 237-238: "but later admitted the cost was worth the end result of her health
and recovery" is an unacceptable interpretation. Of course staying alive is
priceless, but it doesn't ameliorate the fact that this respondent had to borrow
money which might compromise her and her family's financial stability in the
future. It's fair to point out that that was the respondent's interpretation; the use of
the words "but" and "admitted" suggests that the authors are approving of that
interpretation. 
The end of the section on "Cost of PAC Services" that begins on line 258 is
about the barrier of the cost of services preventing individuals from getting care
which is very different substantively than the IDI respondents' descriptions of the
actual amount that PAC services cost. I would recommend that the authors adjust
their wording as not getting care for fear of the costs is very different than
getting care and relating what those costs are. Such writing in this article speaks
to the fact that the authors are still struggling with how to use these two data
sources meaningfully. 
Line 272: "many women discussed what they had heard about the health facility
before coming for care…" What is "the health facility" referring to, Sharana
Hospital or is it more general than that? Line 290: "in local health facilities"—is
this Sharana Hospital or again a more general comment? If it's a more general
comment, does it belong in this paper? 
Lines 294-295: why are men being allowed to speak about what women's
motivations, without any contextualization that this is men's perception about
women's behavior? This is not a good use of information from men. Why didn't
the FGDs focus on men's attitudes and behaviors, rather than draw on men's
perceptions of women's behaviors when women can speak for themselves?
Perhaps what this text means is that lack of female health workers is a barrier for
men to take their female relatives there. Is that what this quote is really getting
at? This text should be treated simply as an perception, given greater
contextualization, or should not be included at all since it's not strong data. 
The quote in line 303-304 should include in brackets what "it" is. 
In the section on "Perceptions of quality of care received," when the respondent
spoke about something that happened to her recently, was she speaking about the
PAC she received or another time she visited the hospital for another procedure?
The quote reads as though she's speaking about another experience but the text is
written setting up this section to be about respondents' perceptions of the quality
of PAC care received. If the data captured the respondents' experiences with the
quality of care in that facility overall, that greatly weakens the value of this text
because we know from other research that women getting care for abortion
complications are often treated poorly—and differently—than women coming in
for other services, as the authors themselves write in lines 478-479. 
RE: their interpretation of quality of care, they should specify that they are using
another definition of quality of care than the respondents are. (In their response
to reviewers, they specified which dimensions of quality of care they are
considering in this analysis; they would do well to include that information in the
manuscript.) Women are satisfied with their quality of care, but then report lack
of privacy, not getting adequate information about the treatment, etc. There is a
fundamental disjuncture there that the authors fail to address. 
Quotes such as those included in lines 336-337 add noting; the authors would do
well to include more surrounding text from the quotes to provide additional
insights from the respondents' words than what their paraphrasing can convey.
And if that's not possible, then not include the quote at all. 
The quote in lines 338-391 belongs more appropriately under "Male
accompaniment." 
What lead the authors to hypothesize, "It is possible that transportation costs are
elevated in areas affected by insecurity"? Furthermore, elevated relative to what,
the costs of transportation before insecurity occurred or compared to other
locations that have never had insecurity? 
Lines 493-495: The authors are writing as though they believe that 100% of their
IDI respondents had spontaneous abortions. In lines 518-519, they suggest that
their respondents may not have represented the situation truthfully. So in lines
493-395, do they mean "as women who say that they induced" or "as women
who are known to have induced"?
The use of the phrase "negative stigma" is redundant because all stigma is
negative.
There is stigma around abortion in **all** parts of the world, not just "many
parts of the world" (line 497). 
There is no contradiction between community disapproval towards abortion and
support for PAC; without support for PAC, the implication would be respondents
believe that women deserve to die from having had an abortion. That is a very
extreme stance. There's a difference between not supporting abortion but not
wanting women to die from an abortion, and that's not contradictory. 
Line 513: "reduce stigma…to PAC"? Or do they mean reduce stigma to
abortion? 
Line 524: It is problematic to look for "truth." Contradictory attitudes can
accurately represent a person's feelings. 
What's still missing:
* The authors write, "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." Did the authors try to ask about how conflict
affected women's access to safe(r) abortion or health care? If they tried and it
didn't work, they should include that in the limitations. 
* The authors clarified in their response that "far away" is 20kms, but they didn't
include that in the text; it would be critical for them to do so to make that text
interpretable to future readers. 
* The quote on lines 245-246 is too little—it doesn't explain enough about the
cost implications of a delay for care or receiving care overall. And why would
they need to pay for blood? That doesn't make sense. How did this woman know
that she needed a blood transfusion? Does a blood transfusion cost money? If so,
that must be explained. 
Minor observations: 
Why was Sharana Hospital chosen as the site from which to recruit respondents?
How did this bias the results? The sentence, "Sharana is a public hospital and
services are supposed to be provided at no cost to the patient" shouldn't appear
for the first time in lines 228-229 but should come in the Background. 
Rather than say "2-3 months preceding data collection," what about just saying
"3 months preceding data collection"? 
Who did the transcription and translation? 
"no names were included in transcripts"—when were the names stripped out? 
How was consent obtained for minors as presumably, an adult needed to give
consent? 
It's not necessary to specify "married…" in Table 2 because the preceding
sentence specifies that all respondents were married. 
Were respondents remunerated for their participation? 
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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?
Yes
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
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Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
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