Reviewer ’s report  
 
Title:  Sowing the seeds of transformative practice to actualize women's rights to respectful 
maternity care: reflections from Kenya using the consolidated framework for implementation 
research  
 
Version: 1 Date: 03 Aug 2016 
 
Reviewer:  Ana Langer  
 
Reviewer’s report:  
 
Thank you for the opportunity to review this very good manuscript on an essential topic, 
wom en's rights to respectful maternity care in Kenya. The authors describe and discuss the 
comprehensive and original work of the Heshima project, in the context of a relevant conceptual 
framework, the Consolidated Framework for Implementation Research (CFIR) . This paper 
complements other articles mostly focused on the empirical results of the project. This detailed 
description of process will be of great value to other maternal health experts interested in 
replicating and scaling up the interventions tested i n Kenya.  Above, I say that the paper did not 
include the necessary controls, because there was no option to say that controls were not needed. 
Regarding the conclusions, where I also said "no", some of them are better supported by the 
evidence in the pape r than others, but a more nuanced option was not offered for this question.  
 
 
From my perspective, the article could be strengthened by making some changes to it:  
 
1) The paper is very long and sometimes provides too much detail. I think that the key 
message s would be more effective if some sections of the paper were more succinct and to the 
point.  
 
2) In the Background section, first sentence, I recommend the authors to add a reference to 
the rights dimension (i.e., D&A is not only a problem because it negati vely influences women's 
decision to seek obstetric care in facilities, but also because it violates women's rights). In the 
following sentence (p. 4, 63 -67), it would be good to mention financial schemes as very common 
interventions, in addition to those f ocused on improving perceptions of quality of care.  
 
3) In this paper, it is not clear how interventions were evaluated and on what evidence were 
the conclusions on successes and limitations of each of them based  (e.g., page 17, 365 -369). 
While the author s include the references to other papers where methods and findings are 
described (page 8; 156 -159), adding a summary (narrative or table) here would be most helpful.  
 
4) The narrative in the results section does not follow the tables and figures, nor does  
describe them in an orderly fashion. Using them as "organizing principles" would help readers 
navigate a complex text.  
 
5) Also, sometimes in the text there are references to the tables but the consistency between 
text and table is not clear (e.g., "see ta ble 3" in line 253 refers to a list of stakeholders that are not 
the same ones listed in the table). Furthermore, the drivers of disrespect and abuse are included 
in one of the figures, but no allusion to them is included in the text. Maybe a short overall  
description of that figure would help. Or a simplified graph that only includes the elements that 
are most relevant to this paper (i.e., the final package of RMC interventions.)  
 
6) The results and discussion sections are not clearly separated; some text i n the Discussion 
section seems to belong to the results section and vice versa (e.g., page 26, 577 -581 would be 
better in the Discussion section). This distinction would help the readers fully appreciate the 
points you are trying to make.   
 
7) Some stateme nts are not clear. For example, p.9, 194 -196, "The rigor of this 
approach….knowledge", or the quote on page 24 531 -537 that emphasizes that monitoring and 
evaluation would ensure sustainability. How? The authors may want to add a few lines to clarify 
the m echanism or choose a different quote. One last example is the last part of the sentence on 
page 31, 685 -687: …"and the flexibility to accommodate real world settings accommodated local 
and national priorities"…This is not clear.  
 
8) From my perspective, the  discussion should start with reflections on CFIR, the main 
focus of this paper. I strongly recommend the authors to move the discussion on the framework 
they currently have at the end of this section (page 38, 838 -852) to the beginning.  It would also 
be helpful to understand why some components of CFIR are discussed and others are not.  
 
9) In the section on "Free maternal policy" (page 23, 509 -522) the authors could discuss in 
more detail the impact of financial and other incentives to institutional delive ry on quality of 
care, especially disrespect and abuse,  
 
10)  Some of the interventions were more successful than others, but the authors seem to be 
oversimplifying when they say that implementation was a success in Kenya (page 31, 678 -679). 
This does not reflect the more nuanced description in other sections of the paper.  
 
11)  Some recommendations address limitations of common approaches, but do not offer 
solutions that, from the authors' perspective, would be better. For instance, on page 37, "RMC 
trainin g" explains that adding it to EMONC skills training does not work, but does no alternative 
approaches are mentioned.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
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 manuscri pt or would you recommend an 
additional statistical review?  
If an additional statistical 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  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an org anisation that may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursem ents, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to thi s paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy o f the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be i ncluded in my named report can be included as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal