Title: Women leaders perceived barriers and consequences of safe abortion in Rwanda: A
qualitative Study
Version: 7 Date: 08 Mar 2022
Reviewer:  Felix Sayinzoga
Reviewer's report:
Congratulations to the authors as the subject is very pertinent especially in the context of Rwanda
with the recent changes in the laws , There is a need to understand perceptions of different
stakeholders and adapt the program accordingly with specific interventions .
I have some suggestion to improve the manuscript :
Background
Pg 3: line 27-28 : legal safe abortion is considering five circumstances and not 4 (please cross
check again the penal code)
Pg 3: line 28-29: the authors say that despite the new penal code and the ministerial
instructions (they were adopted in 2019) , 24,000 women need emergency treatment for medical
complications resulting from unsafe abortion, and 30% of these women were not receiving any
treatment from complications due to fear of arrest in 2010.
He provided as reference a study that was published in 2012 and yet the reforms were done in
2019. I am suggesting considering new data or not link the two events.
Methods
The number KIIs is not consistent: in method section (pg 6 line 16, it is indicated 8 KIIs while
in abstract pg2 line 8, it is mentioned 7
The selection of districts: the study was performed only in city of Kigali: Is this representative?
I wonder if the title cannot be changed and instead of saying in Rwanda, chage it to City of
Kigali. This is because probably the women leaders in Kigali they are in contact with a different
category of women as their counterpart out of the city with different behavior and wealth status.
In the methodology, it is not clear how they choose participants to be in the FGD or to be
interviewed? What were the criteria for assigning them for FGD or interview?
How were participants selected among many other women leaders? Were they selected randomly
form a list? A narrative with details about their selection will give more insight for readers.
Findings:
Were the responses provided considered only for what is accepted under the Rwandan law or in
general for safe abortion not considering exemptions under the Rwandan penal code?
It is not clear how culture and religious beliefs are differentiated in the response of participants.
A question also on characteristics of participants in terms of religion beliefs, what was the
proportion of Christian , Muslims,…. Were ideas different according to the religious beliefs? (It
would be better if this information was captured, be shared by readers)
Discussions
The comparison of the results is more with findings from non leaders women and mostly
adolescents and findings are not similar. In ghanian study they are talking about poor access to
safe abortion services while Rwanda participants in the study they are fearing that the law will
make the service more accessible even to those are not eligible.
The Nepal study is comparing incidence of unsafe abortion in rural and urban area but the current
study was not about the incidence but rather the perceived among women leaders
Conclusion
“CHWs and social affairs workers had little or zero knowledge of the grounds on which one
would seek a safe abortion, and no awareness at all of the removal of the court order before
seeking a safe abortion.” This was not discussed in the findings but came in the conclusion. It
would be better if in the analysis there was an assessment of knowledge about the law to add it .
“There is a need for a paradigm shift in the current mindset of women leaders in relation to
safe abortion. This can be achieved through using mass media to raise awareness about legal
safe abortion in accordance”. Mass media may be practical to the general population, I think
specific intervention targeting women leaders like using forum gathering women leaders and
using political leaders will be a good option
“Integrating safe abortion services into health centers and giving CSOs a role to play will be
essential”. I did not see any discussion around service provision, not sure if integration of safe
abortion services into health centers will respond to change the mindsets of women leaders.