Socio-Cultural Barriers Influencing Unplanned Pregnancy in Mugombwa Refugee Camp, Rwanda: Female Adolescents’ Perspectives

Round 1

Reviewer 1 Report

A very well written paper, on an important and under-researched area, with a hard to reach research sample. My main concern is the with the lack of discussion and context of child sexual abuse, including institutional child sexual abuse. I have elaborated on this point below as well as made some suggestions to enhance the paper below.

Introduction:

Line 37: 'Adolescents, defined between the ages of 10-19', who defines adolescents as this age range? A reference is needed here. It would also be helpful to provide a justification for why this definition was used over other definitions (ie. different age ranges are provided in different definitions of adolescence. 

Data analysis:

This section feels very underdone. The research is described as qualitative and that the method of data analysis was inductive thematic analysis (the reader only knows this from the abstract, this is not included in the data analysis section). How did the two investigators work together? what is the positionality of the researchers? Was there any paradigm, theory or methodology guiding the design and/or methods? Have the authors considered including any references in this section? 

Line 154 & 156: Expand and justify how themes emerged.  

Results:

Line 159: This sentence is redundant and information is provided in the sentence that follows. How many of the 16 had had consensual sex? How many of the children had been sexuallly abused? How many of the 16 children had been pregnant? A limitation of the study would appear to be sampling from schools, when the literature review identifies that adolescents who have an unplanned pregnancy are at increased risk of not continuing with school. 

Figure 1: Unclear what 'fear of side effects' means? Would be good to describe the theme in full or provide note to Figure, so that the Figure is understandable without referring to body of the article. 

Line 184: quotes refer to prostitution. Have the authors considered reflecting/commenting on these quotes, acknowledging there is no such thing as child prostitution and in fact what is being described is child sexual abuse. 

Line 325: 'Adolescents between the ages of 10-14 are not often thought of as being sexually active, but participants explained that some in the camp are...' Have the authors considered providing context here around the age people can legally consent to sex and the definition of child sexual abuse? 

While this paper is about unplanned pregnancy, in fact much of what is being discussed is child sexual abuse without any discussion or context about child sexual abuse in the paper. It would be helpful if the authors included a discussion on why this approach was taken. 

Discussion about sexual health education but no commentary about the need for education around consent, exploitation, coercion and child sexual abuse. No discussion about what education and intervention adolescent men and men in general need to ensure adolescent women are safe from child sexual abuse. 

Limitations

By only including adolescent females in the study risks overstating the control and power they have in decision-making. Have the authors considered discussing this in the article?

No discussion about who it is that is raping, sexually coercing the female adolescents, same age peers, older men, family members, men in positions of power and authority. Discussion of this could help provide much needed context to rich data generated from the focus groups. 

lack of recommendations around child sexual abuse education, prevention, early intervention and therepeutic healing opportunities. 

An interesting area for the Discussion would be what role do organisation in charge of refugee camp take to ensure it is a child-safe place and to prevent institutional child sexual abuse.

Author Response

Please see the attachment

Author Response File: Author Response.docx

Reviewer 2 Report

Changes to your title: Socio-Cultural Barriers ... and change to plural, Female Adolescents' Perspectives. 

Inconsistent wording, line 107 purpose was to identify socio-cultural factors that underpin unplanned pregnancy.  In line 136, you switch to socio-cultural barriers.  Changing to the word barriers, narrows the focus of the study before it started.  Factors is a more neutral word that allows for exploration of socio-cultural facilitators/strengths and barriers.  The word in both lines should be the same.  In this paper, you could change line 107 to barriers to be in concert with your results.  The results include barriers.  Strengths are not described.  One thing that could be a strength, choosing to not have sex, was presented as a barrier. 

I think that understanding the barriers young people face is important.   Strengths were largely not acknowledged in this paper.  The discussion also lists the barriers and recommendations are for what to do to address barriers. 

Line 127 - specify a qualitative design.  I think qualitative description is appropriate. 

LIne 137-138, can you provide information about the study guide?  In general what type of information did the questions elicit?  Only barriers? Were there any questions about strengths or socio-cultural factors that were helpful to promote SRH?  

Results 

Pg 156 - can you add any more description to tell us about the participants?  Such as their ethnicity, parity, their language (monolingual, bilingual), or how long they have been in the camp?

Limitations: Add that strengths were not described, only barriers. 

Authors list language barriers as limitations.  In the methods, tell us more about the focus groups.  What language were they conducted in?  Were they recorded and transcribed?  If transcribed in Kinyarwanda, were they translated into English? 

Author Response

Please see the attachment

Author Response File: Author Response.docx

Reviewer 3 Report

Manuscript review

I appreciate the opportunity to review this manuscript which reflects the identification of sociocultural factors influencing unintended pregnancy in a refugee camp in Rwanda.

The issue is very interesting and worrisome in many countries where unscheduled pregnancy is a public health problem.

It is necessary to mention in the manuscript whether the adolescents lived with their sexual partner (married or cohabiting), or all lived with their parents.

Likewise, it is important to show the interview guide, since it is striking that the issue of sexual violence and marriage with girls was not a topic of sociocultural importance in unwanted pregnancy in adolescents.

Furthermore, it is necessary to argue why male adolescents were not included in the recommendations.

The selection of the participants is a very important bias, since after reading the manuscript it appears that the problem of unwanted pregnancy is a problem only for the adolescent, her parents and the health services. He considered that the problem is much more complex, especially in an environment as hostile as a refugee camp, so this fact must be noted in the limitations of the study.

It is necessary to specify in material and methods the reasons why the group of adolescents was divided into two.

In the abstract

Too many keywords are used.

In line 43

When an abbreviation is used for the first time, it must be defined (STI, HIV).

In line 55

What does UNHCR mean? Whenever an abbreviation is used for the first time, it must be described.

In material and methods

It is important to show the interview guide in additional material

In line 142

It is necessary to specify the time used for interviewer training, since half a day is very imprecise.

In line 235

What does the abbreviation IUD stand for?

In line 553

What are the strengths of the study?

In line 563

Why don't the recommendations take into account the participation of adolescents' sexual partners?

Author Response

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Author Response File: Author Response.docx

Reviewer 4 Report

Dear Authors, 

my comments.

This article could be interesting. I am satisfied of contents of this article.

Lines 77-78 in itroductom- the sentence is not finished.

Please perform one more time English editing.

Why the number of the participants is so small?

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Round 2

Reviewer 3 Report

The manuscript currently meets the requirements for publication.

Reviewer 4 Report

Dear Authors,

I accept your reply.