Title: Why do women walk away from maternal health services in Southwest  Ethiopia? A
qualitative study of caregivers' and clients' perspectives.
Version: 3 Date: 29 Dec 2022
Reviewer's report:
Reviewer 2.
Most comments were corrected by the authors based on the suggestions; however, some
comments, particularly in the method section, were not corrected.
Comments after reviewing the revised manuscript
I. Method section
Major comment: page 5  The participants' selection criteria’s not explicit
1. Comment: The authors used criteria based on purposive sampling; however, the participants'
selection criteria for  (both providers and clients)  is not explicit. In a qualitative study, the logic
and power of purposeful sampling lie in selecting information rich study participants.
• For example, the authors used “position” as a criterion: CEO, medical director, matron, being
in charge of maternity department, and nurse..etc  are all positions.   Simply stating “position”
as a study criterion does not make the criteria explicit.
• For example “Experience” as criteria is not explicitly stated in the manuscript. First, experience
as criteria is interpreted as “work experience” of the health care provider or experience of clients
(women) in health care facilities. When it comes to providers' work experience, “one month
of experience” is an experience similarly, ”ten years of work experience" is also considered an
experience.
• For example, authors used “available in facilities” as criteria; usually in maternal health
services, women (service users) may present for ANC, PNC, family planning, or post-natal
care.”
# The question is whether you used additional criteria to select diverse participants who you
considered key informants based on your research question?, or did the researchers  used a
convenient sampling method.
# If it is purposeful, as the authors stated in the manuscript, it needs to have an explicit description
because doing so enhances the trustworthiness of your findings.
2. "Who conducted the selection and how were participants chosen?"
3. Do you have any individuals excluded based on your criteria?
Suggestion:
• Authors need to make the selection criteria explicit and describe health care provider and client
selection criteria separately.
Comments:  Page 5 ; Use separated subtitle for data collection and data analysis
Major comment:  for data collection section:
# Describe the content of key informant interview guide in the method section
# Did the authors used the same key informant interview guide for both participants (health care
providers and clients (women)
Data collection section
# Major comment: the venue for data collection is not described: The interview setting is
important in qualitative research, particularly when the interview is conducted in a health care
facility to  maintain privacy, to encourage participants to express their views freely etc… . For
participant (providers and clients).
# Major: The duration (time)  of interviews needs to be documented in the data collection section
of the manuscript.
Data analysis section
• Major: How many researchers were involved in data analysis? If the analysis was conducted
by more than one person, it should be described in the method section. Furthermore, how they
handle discrepancies during analysis must be described. If one researcher analyzed the data
make it  clear.
• Major: Were the themes derived from the data inductively or formulated in advance?? Author
need to be clear here in the analysis section by describing how the themes were developed from
the data or not.
Major:
•  How did the author organize the data (using software or manual methods)?
• What theoretical approach did the authors take in analyzing the data? And what data analysis
method did you employ?
• Even if you use interpretative rather than descriptive analysis, how did the theme evolve? What
specific method do you use: thematic analysis, content analysis, narrative analysis,, grounded
theory, etc.? Or even if you use interpretative analysis, what method do you use?
• I recommend the authors to make data analysis method explicit.
Page 6
Data quality section, , In qualitative research, the researcher is an instrument. What is your role
during data collection?
1. The author need to describe how they made triangulation of the data?
• For example: authors state data triangulation:  Page 6 : : How  was  your data triangulated?
Authors only have one method of data collection, “interview” you cannot triangulate based on
data collection method. Did you triangulate your data based on the participant characteristics
or other method?
2.   In this manuscript the researcher’s position not explicitly described, how you maintain
reflexivity?  page 6  data quality section
II. Result
Page 7
• Major: Comment : table one not clear describe the respondent characteristic such as
demographic characteristic, and work related characteristics , instead table 1 , column 1 and 2
used as  selection criteria in the method section
•  Table 1:  need to be replaced with another table that contain characteristics of participants
(both demographic and work-related) that you identified during data collection; for example,
participant age, and work experience for the provider, and other characteristics….
Page 8
• Comment.  Sub-theme under health system related factor main theme: The theme “miss
concept of responsibility and accountability” is not in line with the description of the theme in
the other section of the manuscript. It is understood as the participant reported the concept of
“responsibility and accountability” as a barrier for COC. However, the authors described this
theme in another section of the manuscript as “responsibility and accountability in practice,"
not as a "concept.” Therefore, the authors need to review this theme ( page 8)  based on this
suggestion.
• Comment:  on the overall result section: the author presented the finding with an example of
participant quotation; however,, the report lacks the researcher's interpretation of the finding.
III. Discussion
Limitation section
Page 20.  Some limitations of the findings are not fully addressed,
• For example, authors described generalizability as a limitation; it is a limitation for all
qualitative research designs; besides, the authors must describe the limitations related to
participant selection, data analysis, transferability.. etc ...
• I recommend that the author need to describe other potential limitations of this study.
Genera comment
• The revisions; that authors will make  in the method and result section need to be  included
in the abstract of the revised manuscript
• Word choice : such as ” care taker” need revision based on the comment given in manuscript
with track change
•  If the authors have a code book with code names and definitions, please provide as an additional
file with the revised manuscript.