Reviewer ’s report  
 
Title: Partici patory action research to identify a package of interventions to promote postpartum 
family planning in Burkina Faso and the Democratic Republic of Congo  
 
Version: 3 Date: 09 Feb 2018  
 
Reviewer: Anne Pfitzer  
 
Reviewer's report:  
 
General comment:  
Thanks for the opportunity to review this paper.  
I have been thinking about how to craf t my review of this paper. On the one hand, it is a well -
researched, well -written paper on an important set of studies. There is definite value to 
publishing reports on the formative stage of research. But I also admit to disappointment for lack 
of convinc ing or ground -breaking insights from this paper. In particular, I was reflecting that I 
was not convinced that a more abbreviated assessment phase would not have resulted in the same 
or similar interventions being selected. The budgetary constraints clearl y played a big role in the 
ultimate selection of interventions. Also, I feel the reader is not given the full information (more 
on the specifics of that below) that fed into the selection. Leaving me to ask the question so 
what? I don't think the statement  that "the package does not promote any modern contraceptive 
method over another, but prioritizes the women's right to information and choice regarding 
postpartum fertility options" is a valid conclusion or answer to the so what question. Obviously, 
the 20 15 revision of the MEC made a huge contribution in expanding choice in the early 
postpartum period. I doubt there are many programs out there that seek to prioritize one method 
over another, so this is hardly earth -shattering. And whether the interventions  described will 
result in implementing a fully -rights based approach is wide open for debate. Easier said than 
done. The fact that multiple interventions are better than single interventions is not new. That 
supply, demand and health system factors are par t of the package is clearly an established best 
practice, so again the outcome of the process is hardly a surprise or generating new knowledge or 
insights. What I came to understand is that this is likely one of a suite of papers from the study. 
And that t his paper is likely adding detail that the other papers don't have the space to include. 
But together, they should help describe the genesis of the studies and aid in the interpretation of 
final results. There is a gap in the literature in terms of describ ing processes that lead to research 
outcomes making independent interpretations more difficult. That is to say, that I can see the 
value of publishing this as one within a suite of papers. However, whether to recommend 
publication of this paper as it stand s alone is a more difficult one to make as it is quite thin on 
data or generalizable knowledge on its own.  
 
Ways that this could be addressed:  
1. The results section of the paper describe decisions made based on the results of field 
assessments by the resea rch team. However the methods for those assessments are missing 
from the methods section. Furthermore, a textbox that summarizes the findings of those field 
observations would add interest.  
 
2. The methods section describes the focus group discussions held with a) women who were 
pregnant or delivered within 12 months, b) men whose partners were pregnant or recently 
gave birth and c) service providers. The methods describe in detail how these data were 
analyzed However, the results completely passes over the results from this population, and 
gives more (although not comprehensive) results of the IDI with clinic managers, policy 
makers. Community influential IDIs are described, but also seem to be absent from any of 
the results. I don't know if this is because those results are the object of another paper (if so 
this should be stated more clearly). Nevertheless a table or text box should give some 
summary or a way of presenting the overarching results of this process as it fed into the 
process of selecting inter vention. Otherwise, the reader is blinded to what seems like 
important inputs into the decision -making process that this paper is purported to describe as 
its main objective.  
 
3. Reshape the discussion and conclusion to be more convincing as to why this pro cess is of 
interest to a general public health or reproductive health audience. Avoid the sanctimonious 
tone that the result is more rights -based unless you can demonstrate how participants 
committed to a rights based agenda (beyond sitting through a prese ntation) and thought they 
could influence the attitudes of providers and CHWs around this agenda and empowering 
women and their partners to freely make these choices.  
 
Specific comments:  
1. Background is well -written, citations all seem appropriate.  
 
Meth ods 
2. P7, lines 154 -157. The age cut offs for the different subgroups of women are interesting. 
The age 20 cut off makes sense in the context of the WHO definition of adolescences. But 
the choice of 40 as a cut off is less obvious, given that additional o bstetric risk for advanced 
maternal age is usually at earlier age cutoffs. The authors could explain the rationale for this 
choice.  
 
3. Page 9, lines 196 -199. The authors should note that the pilots in Burkina at least cited in ref 
21 (less sure about DRC) started prior to 2015 and the revised MEC. Even then and as the 
reference clearly indicates, the counseling aspects always mentioned all methods. Since the 
2015 MEC, I believe programs in both countries offer counseling on all methods and 
support pre -disch arge insertions of both LARCs. The authors may want to rephrase the 
inaccurate implications that donors are pushing one method. To the contrary.  
 
4. P9, line 208 - the mention of the presentation of results from FGDs and IDIs is made, 
without any specifics for the reader. Links to the general point 2 above.  
 
5. P9, line 211, the authors refer to a list of possible interventions. Could they not offer that list 
for readers as well? Again a text box or table would be nice.  
 
Results  
6. PPFP refresher training sec tion. The quotes from the DRC policy maker might suggest an 
alternative and perhaps more sustainable intervention would be to strengthen the pre -service 
education of auxiliary midwives and midwives. While this would be an intervention that is 
broad rather than targeted to study sites, the authors might have thought to include advocacy 
for this to happen as a larger policy intervention? This raises the question of who benefits 
from final package of interventions. Should a different list include interventions  not selected 
as part of the study design, but of merit to scale and institutionalize PPFP in the countries?  
 
7. Multiple lines - results of field observations listed, when not clearly described in methods.  
 
8. P13 counseling tool section. The authors specify that the counseling tool would be used in 
the ANC third trimester visits. Why limit to the third trimester? Especially if women need to 
buck up their courage to initiate conversations with their partners or share an invitation letter 
and often feel they need the blessing of their spouses, is there evidence to support waiting to 
the third trimester?  Does that leave enough time for couple counseling and decision 
making?  
 
Discussion  
9. P16. Line 366. "More a ppropriate" than what?  
 
10. P16, line 371. There are missing references for "earlier studies" that focus on a single 
method or single programmatic strategy. Note that some studies may be trying to answer a 
specific question about a method, without them bei ng focused on offering a specific method. 
They may exclude women who chose other methods from the study, but this does not 
constitute a denial of services or a single minded strategy.  
 
11. P16, line 372 -378. The authors should make a clearer argument of how  the circular 
reflective approach enhanced the "rights based" attributes of the interventions. For example, 
did they include ways to hold providers accountable as duty -bearers to international rights 
covenants? If so, explain. As described, it is not convi ncing.  
 
12. P17. The implications section. The authors say "we faced the possibility of developing 
multiple sets of interventions for different settings. Yet our formative research shows 
challenges and opportunities related to PPFP uptake in Burkina Faso an d the DRC were far 
from being dissimilar…" Again, there is not enough evidence presented in this paper to 
support this assertion. Nor that the package you did decide on is not "one -size-fits-all" and 
"cost -effective", in the first sentence. This section sh ould be entirely rethought and re -
written.  
 
13. P17 Conclusions. Same as above. The conclusion statement as written is not satisfactory.  
Are the methods appropriate and well described?  
If not, please specif y what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional s tatistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
Decla ration of competing interests  
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