Title: “I still don’t know how someone gets pregnant”: Determinants of poor reproductive health
among young female refugees in South Africa
Version: 1 Date: 07 Nov 2023
Reviewer's report:
The manuscript entitled "“I still don’t know how someone gets pregnant”: Determinants of
poor reproductive health among young female refugees in South Africa" was very interesting. It
explores an under-studied issue in the South African context and for the most part, the manuscript
was easy to read and coherent. There were, however, a few issues identified, that if corrected,
could improve the manuscript:
1. Typographical and vocabulary-related errors:
Line 19- typo, 'focused' not 'focussed'.
Line 23 - add comma between 'rights' and 'needs'
Abstract from line 31 - The section of the 'Results' starting from "Participants..." must be checked
for grammatical mistakes.
Line 38 - perhaps use 'Desire for' rather than 'Need for'
Line 42- remove 'more'
Line 49 - remove 'a'
Line 66 - SRHR abbreviated, but should be in full in first use
Line 83 - 'populations'
Line 88 - add ages of 'young people'
Line 95 -SRHR should be abbreviated since first use
Line 158 - 'component' instead of 'part'
Line 335 - 'non contraceptive use' or 'lack of contraceptive use?'
Line 368 - should be 'abortifacients'
Line 461 - 'led' not 'lead'
2. The 'Results' section requires further nuance between the different nationalities of participants.
As it is, it is very Congolese-heavy, owing to the fact that 30/ 35 of the participants were
from the DRC. Despite this, the perspectives of participants from Ghana and Burundi should
be incorporated, where relevant. If not relevant, then a point about this should be made in a
'Limitations' section. I have noted that a 'Limitations' section is altogether absent, however. Some
additional points include:
-Further analysis and elaboration is required in the 'Results' section, particularly in lines 189
and 197.  For instance, line 197 refers to "cultural silences around sex" but after the excerpt, the
authors do not pick up on this and elaborate further on how this is related to menarche and lack
of knowledge about conception. Instead, there is a quick transition to financial constraints. This
point about "cultural silences" could be presented more slowly.
-The excerpts presented from lines 259 and 270 also reflect the participants' shame at becoming
pregnant out of marriage and at so young an age. This should be incorporated into the point of
'avoidance of stigma'.
-Line 312 -An explanation of what is meant by 'tenuous sexual relationships' should be  included
-The findings in the 'cross-cultural positionality...' section are very Congolese heavy. Where
possible, an incorporation of insights from the participants from Burundi and Ghana would help
to balance this out.
-Line 310 - participants identifiers should be consistent. While line 304 mentions this participant
is Congolese, the identifier should include this too, as done for all other IDs.
-I would like to suggest that the authors put the findings section on 'prevention and termination
of unintended pregnancies' before the section on 'consequences'.  This would make the results
section flow better.
-Line 344 - an explanation of 'traditional methods' is missing
-The excerpts provided from line 380 require a conclusive paragraph.
3. The 'Discussion' section was well-written and integrated relevant literature. Some points made
in the 'Results' section, such as "cultural silences around sex" could however, be incorporated
more explicitly, as they signify important cultural issues.
-The claim that girls "help parents by working" should be presented as a finding somewhere in
the results section. Otherwise, this point reads as though it was added without any evidence to
back up the claim.
-The point made by Metusela et al should perhaps come after the claim that "poor SRH
knowledge may extend beyond our asylum seeker and refugee participants in the South African
setting". Either that, or this section of the Discussion needs to be slightly reframed.
-Line 447 - a brief explanation of what is meant by a more "open" climate of South Africa should
be added.
Overall, this manuscript presented an interesting exploration of determinants of poor
reproductive health among young female refugees which is both a relevant and important topic.