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Research Article | DOI: https://doi.org/10.31579/2693-4779/221
1Masters of nursing Science, Post Graduate Diploma in Clinical nursing education, Namibia.
2Bachelors of Nursing Science, University of Namibia.
*Corresponding Author: Joseph Galukeni Kadhila, Masters of nursing Science, Post Graduate Diploma in Clinical nursing education, Namibia.
Citation: Joseph G. Kadhila, Lucia Ileka, (2024), Factors Influencing Woman Towards Family Planning at A Public Hospital, Clinical Research and Clinical Trials, 10(4); DOI:10.31579/2693-4779/221
Copyright: © 2024, Joseph Galukeni Kadhila. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 22 July 2024 | Accepted: 08 August 2024 | Published: 02 September 2024
Keywords: contraceptives; family planning; woman
The aim of the study was to investigates factors influencing women at Intermediate Hospital Katutura towards family planning, Khomas region, Namibia. Family planning has become an important element of not only preventing unwanted pregnancy but also ensuring only to have children when ready and economically able to take care of them. The study utilized a qualitative approach with data collected through interviews from a population of all the female patients who were visiting the Ante-natal Clinic.The researcher utilised purposive sampling to select participants, data saturated at 22 respondents. The study found that factors that influenced the attitudes of women towards family planning included the side effects of the various options which ranged from physical, emotional and health wise. Themes were developed based on the analysis of the data with discussions made under them also in relation and comparison to other studies that have been published by other authors. It can be concluded that there are various factors that influence the attitudes of women towards family planning need to be addressed if women are to be able to have children when they are ready and able to take care of them.
Family planning (FP) is defined by Amarin, (2018) as a preventative service that allows married couples to have the number of children they want and to space their pregnancies according to their economic opportunities and personal preferences, as well as to ensure that births occur at appropriate intervals for the mother and child's health. Family planning helps couples and individuals to avoid unintended pregnancies, it reduces the spread of sexually transmitted diseases (STD’s), prevents maternal mortality and helps reduce rates of infertility by addressing the problem of sexually transmitted diseases (STD’s) (World Health Organization, 2020).
Despite the clear contribution of family planning to important public health goals, the public varies widely in its attitudes toward family planning and contraceptives. About 86 per cent of the American public support family planning services as part of health care for low-income women, however not everyone believes in birth control as some believe that it should be available for married couples only and not for unmarried individuals and not for teenagers as contraceptives and family planning methods encourage sexual activities. Some religions, like the Roman Catholic Church, oppose certain methods of contraceptives (National Academy Press, 2019). A similar study from Turkey by Ayaz, (2020) revealed that the attitude of women towards family planning was at a good level, nearly half of the women were using an effective family planning method. However, despite the substantial benefits of family planning services, the researcher has observed that utilization remains low in Namibia (HIS IHK, 2022). This has led to a high incidence of unintended pregnancies, unexpected deliveries, unsafe abortions, and maternal mortality throughout Namibia.
The objectives of the study were to explore the factors that influence the attitudes of women towards family planning in a public hospital, Khomas region, Namibia.
This study followed a pragmatic research paradigm, applying a case study research design. The study has employed a qualitative research approach because it provided a better or deeper understanding of the subjective experiences of the participants of a study. A total of 22 out of 250 female clients who visited the Ante-Natal Clinic for family planning from 01 September to 01 October 2023 were recruited for this study and data was determined saturation, using purposeful sampling.
The researcher designed a data collection tool in English with one central question: What are your perceptions and views regarding Family planning. Followed by a probing question: Is there something else you want to tell me regarding family planning? Moreover, a tape recorder and field notes were also used to collect data. The researcher received an ethical clearance from the University and permission letter from the Ministry of Health and Social Services, permission from the Hospitals matron and written informed consent from the participants. Data was collected from September to October 2023.Data was analyzed and coded manually.
The four principles required to guide research included, respect of persons, beneficence, non-maleficence and justice. Permission to carry out this study was obtained from the University School of Nursing Ethical Committee 20/2023, Ministry of Health and Social Services, hospital management and written informed consent from the participants.
| Participants | Gender | Age | Number of children | Period of using family planning |
| M1 | Female | 34 | 3 children | 1st time |
| M2 | Female | 29 years | 2 children | 2 years |
| M3 | Female | 27 years | 1 child | 1st time |
| M4 | Female | 19 years | 2 children | 1 year |
| M5 | Female | 21 years | 1 child | 1st time |
| M6 | Female | 26 years | 2 children | 3 years |
| M7 | Female | 18 years | 2 children | 1st time |
| M8 | Female | 24 years | 1 child | 2 years |
| M9 | Female | 23 years | 1 child | 2 years |
| M10 | Female | 40 years | 5 children | 5 years |
| M11 | Female | 26 years | 2 children | 4 years |
| M12 | Female | 30 years | 2 children | 2 years |
| M13 | Female | 33 years | 2 children | 1 year |
| M14 | Female | 26 years | 2 children | 5 years |
| M15 | Female | 26 years | 2 children | 1 year |
| M16 | Female | 37 years | 2 children | 2 years |
| M17 | Female | 42 years | 4 children | 3 years |
| M18 | Female | 23 years | 2 children | 6 months |
| M19 | Female | 34 years | 3 children | 3 years |
| M20 | Female | 28 years | 3 children | 1st time |
| M21 | Female | 40 years | 3 children | 2 years |
| M22 | Female | 38 years | 1 child | 1st time |
Table 1: Demographic characteristics
As shown on table 1 all the participants were female. Additionally, the majority of the respondents 7 were between the ages of 18-24 while 6 were between the ages of 25-29. A total of 4 were aged between 30-34 years while 3 were between 35-39 and 2 between 40 and 44. Majority of the participants 15 had 2-3 children while 5 had 1 child and only 2 have 4 or more. For a majority of 10 it was the first time they were using family planning.
A total of four themes and twenty sub-themes were presented in this study and are as shown in the table 2 below:
| Themes | Sub-themes |
| Theme 1: Perception and views of mothers regarding family planning |
|
| Theme 2: Preferred type and methods of family planning |
|
| Theme 3: Side effects of family planning |
|
| Theme 4: Recommendations |
|
Table 2: Themes
This theme presented the understanding of mothers regarding family planning methods. The theme was important in the overall context of the study as an understanding of family planning meant the participants would also have an idea of the other aspects of family planning. Most mothers understood family planning as a way of preventing unwanted pregnancy however the perceptions or reasons for using it differed in most cases. These are presented below.
Sub-theme 1: Healthy timing and spacing of pregnancy
Most of the participants highlighted how they believed that family planning was a way of ensuring a woman spaces their pregnancies therefore avoiding having children within short periods of time or one after another after giving birth while also ensuring to stay healthy through avoiding this. This was articulated by participant who stated the following
"Family planning helps with spacing of births and helps the mother to stay healthy". M2
"Family planning gives a chance for children to grow before the next one and prevent competition among siblings". M17
"Family planning helps with spacing of birth and you only get a child when you want and when you are ready". M12
It is clear from the above responses that these participants were of the belief that family planning helps with child spacing, ensuring that one has a child when they are ready and the mother’s health is not compromised by consecutively having babies.
Sub-theme 2: Prevent unwanted pregnancy
Most of the participants highlighted that family planning was a way of preventing unwanted pregnancy. Diverse reasons were given for this. Participants stated the following:
"Family planning helps prevent unwanted pregnancy and give the baby a chance to grow". M4
“Family planning is a method of keeping someone waiting until they are ready to have children”. M21
It is clear from the above that the participants see family planning as a way of preventing unwanted pregnancy thereby enabling them to give recently born babies time to grow without focus being shifted to another baby as well as ensuring one gives birth when they are ready.
Subtheme 3: Completion of personal goals
Another element that was highlighted about family planning is how it is a way of ensuring that one is able to achieve certain goals without getting pregnant such as finishing their studies. This was highlighted by participant who stated the following:
"Family planning is a good thing as it helps girls to finish their education. Like me, I have been using family planning since I became sexually active until I was ready to have my baby". M8
Subtheme 4: For specific groups of people
There were participants who also perceived family planning to be more relevant or applicable to other groups of people such as married people and unmarried people. Participant stated the following:
"Family planning is supposed to be used by married people to plan their families". M7
"Family planning is supposed to be for unmarried people but married people should give birth because it is their obligation". M8
The above views show the differences in the perceptions with regards to family planning and who it is meant for among married and unmarried groups.
Subtheme 5: Population control
One participant also stated that family planning was meant to control the population through preventing people from giving birth as they please due to especially the economic situation. This was highlighted by participant M20 who stated the following:
“Family planning is a method of controlling the population in Namibia because imagine how much we are in this country but no jobs and food is expensive". M20
Theme 2: Preferred type and methods of family planning
Beyond identifying which types and methods the participants knew, it was important to also identify which ones they preferred. It was found that the most preferred were the implant, injection as well as pills. Although there were a few that also mentioned the IUD and condoms.
Subtheme 1: Implant
Most of the participants stated that they had the implant as their preferred method of family planning. The reasons for this revolved around not requiring follow ups after, effective, safe, stays longer and does not cause physical body changes. The following are responses various participants gave in relation to this. Participant stated the following
"I prefer the implant because I will not be going for a follow up". M1
"I prefer implant because there was a time when I was using pills and I used to forget to drink them". M5
“I prefer implants because it works for many years and there is no need for follow up". M6
The above shows the various reasons why participant used the implant. Additionally, these other participants mentioned the implant to be more effective and safer compared to others such as the injection as well as staying longer in the body without one getting pregnant. Some of the participants also had reservations with the other family methods making them lose weight which was not the case with the implant.
Subtheme 2: Injection
Other participants preferred using the injection method for family planning. Most of the participants highlighted that this was because they have never experienced side effects, no knowledge of modern methods like IUCD, likelihood of forgetting to take pills and longer periods before follow up. Participant stated the following in this regard:
"I prefer the injection because I have never experienced any side-effects with it". M8
"I prefer Depo Provera because it is very effective for me and never caused problems. M12
"I prefer the injection because I have no knowledge of these modern things like implant and IUCD". M13
Subtheme 3: Pills
Some of the participants highlighted that they preferred pills. The reason for this among all the participants who chose this method was because they do not have any side effects. This was high by participant who stated the following:
"I prefer pills because it has no side effects". M2
Subtheme 4: Intrauterine Copper Device (IUCD)
Two participants mentioned that they preferred the IUCD. The reasons given were that it does not have hormones as well as is the best method for women who have been operated on. Participant stated the following:
"I prefer IUCD because it does not have any hormones". M3
"IUCD because I know it is a method that is good for operated women”. M20
Subtheme 5: Condoms
One participant mentioned that they preferred the use of Condoms for family planning because unlike the other methods, they go beyond just preventing unwanted babies but also diseases. Participant stated the following:
"Condoms because it prevents both unwanted pregnancy and STI (Sexually Transmitted Diseases)" M4
Subthemes 6: BTL
One of the participants also highlighted that they preferred BTL especially if one never wants to give birth again. This was highlighted by participant who stated the following:
"BTL because if you don't want to fall pregnant ever again". M10
The researcher also sought to identify the side effects of family planning that the participants experienced or had knowledge of. This was important as side effects also tend to have an influence on the choice of family planning that someone chooses. These side effects ranged between menstrual cycle changes, physical changes, emotional changes, and health issues.
Subtheme1: Menstrual cycle changes
Most of the participants highlighted that one of the major changes that come with family planning are the changes in menstruation cycle and volume of bleeding. Participant stated the following:
"Family planning can cause heavy bleeding during menstruation and spotting". M1
"Family planning causes prolonged menstruation and missing of periods making them irregular". M13
Subtheme 2: Physical changes
Some of the participants also highlighted that family planning causes various physical changes to the body in ways that do not sit well with the participants. For instance, participant stated the following:
"I was using depo Provera before it was losing my hair (in my head) and not interested in sexual activities even". M14
It is clear from the above that there are various physical side effects that can occur due to family planning that make participants take seriously the type they use as some don't want to lose or gain weight, lose hair, have struggles breastfeeding or lose interest in various activities.
Subtheme 3: Emotion changes
A few of the participants also mentioned that one of the side effects of family planning is mood swings. Participant stated the following:
"Family planning gave me mood swings”. M 14
Subtheme 4: Health issues
The participants also mentioned that there are a number of health issues that come with using family planning. These include heart palpitations, illness, heartburn, headaches, dizziness and vomiting. Additionally, others believe some cause cancer as well as infertility. Participant stated the following:
"Family planning leads to heart palpitations." M8
"You can get an illness after BTL".
"For me it caused heartburn and headaches". M2
"If one uses Depo Provera for long it can cause infertility". M19
This theme was introduced by the researcher to obtain recommendations that the participants may have had with regards to family planning. The comments covered a wide range including the need for education on family planning, family planning advice, issues with side effects, availability as well as conflict in using it.
Subtheme1: Education
The participants highlighted that there was a need for education on family planning to ensure that people were aware of the options as well as the side effects that come with the various options. Participant stated the following:
"Family planning is good for preventing unplanned pregnancy but education on side effects should be given". M9
"Most of the time we are not educated on the advantages and disadvantages of family planning all you are being told is that it prevents unwanted pregnancy but not the side effects". M4
"I used to hear about family planning at school but didn't have the knowledge of using it until I fell pregnant. Only after health education I got the knowledge of how to use family planning". M7
The above responses show a clear need for education as derived from the participants especially in relation to the side effects as well general knowledge especially at school level and at home.
Subtheme 2: Advice
The participants also offered various advice that was based on their experiences with family planning. Participants stated the following:
"It is best for the mother to wait at least 18 months in-between before getting pregnant or giving birth again so that when they fall pregnant again the baby is a year and a half old you can even get enough time for the wound to recover especially when you are operated and your baby will breastfeed for long”. M1
"If you miss your follow up and don't take pills regularly (everyday) you can fall pregnant". M20
"I was already 40 years with 4 children when I found out that I was pregnant with my last-born baby I was so sad because I didn’t plan on falling pregnant or having children again. I was using depo- Provera and was not getting my period so I stopped for a while I just get flu one day I went to the hospital and had a pregnancy test done and it was positive". M10
Subtheme 3: Availability of family planning
Some of the participants highlighted that family planning was available and free of charge in Namibia while others mentioned that there were issues with regards to accessibility when it came to family planning. Such that the various options were not always available at all hospitals which then complicated the getting them easily. These issues revolve around a lack of adequate stock, long queues, lack of preferred methods and high costs. For instance, participant stated the following:
"Family planning is free of charge in Namibia and is available and accessible at every clinic and hospital". M5
“Most of the time you will go to the clinic for this method of family planning but you will be told it is only being offered at another hospital which you have wasted your taxi money and you will have to get another taxi to go to the hospital”. M6
Subtheme 4: lack of support
One participant also added that they had a lack of support from the spouse that then made them not get family planning. Participant stated the following:
"At times you want to be on family planning but your husband do not want especially these uneducated husbands who just want you to have a lot of children without considering our pockets". M12
"Sometimes we are just too shy to ask our parents and teachers about family planning. You will find yourself having a boyfriend but no idea how to use a condom even or you don't even know what type of family planning method to use". 9
From the responses above it is clear that the participants hold a significant amount of views on family planning, the education required, lack of support and availability etc.
The study found that family planning refers to methods used to prevent unwanted pregnancy, ensure child spacing and keep the mother healthy. This is similar to the definition provided by Amarin, (2018) who stated that family planning is a preventative service that allows married couples to have the number of children they want and to space their pregnancies according to their economic opportunities and personal preferences, as well as to ensure that births occur at appropriate intervals for the mother and child's health.
Additionally, the study found that FP is pivotal in ensuring women meet their career goals such as finishing school. This is a finding that was emphasized by Sonfield, (2018) who highlighted that a number of studies have found that the use of family planning prevents pregnancy for women in school or chasing their careers therefore ensuring pregnancy does not affect their progress.
The study also found that people had varying perceptions of family planning with others saying it is for married people and others saying it is for unmarried people while other perceptions were that those that are Christians must not use it as it goes against their values. This is a finding that was echoed by the National Academy Press, (2019) which stated that not everyone believes in birth control as some believe that it should be available for married couples only and not for unmarried individuals and not for teenagers as contraceptives and family planning methods encourage sexual activities.
Moreover, the authors state that some religions like the Roman Catholic Church oppose certain methods of contraceptives (National Academy Press, 2019). The study also found that FP is utilized for population control as influenced by the perception of harsh economic times and that it enables people to engage in sexual activities without any worries. Grant, (2016) also highlighted this stating that family helps couples engage in a sexual relationship without having to worry about the woman getting pregnant.
Theme 2: Preferred type and methods of family planning
The study found that the most common preferred FP method was the implant due to reasons such as that it does not require numerous follow-ups, other methods less suitable and because it has worked well for a long time when used. Contrary to this study, Tibaijuka et al., (2017) found that there was low intake of long-acting reversible contraceptive (LARC) methods (i.e., intrauterine devices and hormonal implants) even though they were highly effective and lasted longer.
The study also found that injections were highly preferred due to not causing much problems, lack of knowledge of other options and having long periods such as 3 months before follow-ups. This is backed by Taapopi, (2019) who highlighted that most women are not aware of modern family planning methods like intra- uterine copper device (IUCD) but they have knowledge and understanding of injectables and pills that's why they end up opting for those. The study found that other preferred methods were pills because they did not have side effects.
The Intrauterine Copper Device (IUCD) because it does not have any hormones and is suitable in the case of operations. Similar WHO, (2021) highlights that IUCD has been growing in popularity mostly because it does not have any hormones. Additionally, this method is regarded as 95
It was concluded that factors such as side effects, irregular menstrual cycle, getting mood swings, headaches, feeling dizzy and vomiting played a significant role in influencing the attitudes of women towards family planning. Other factors included such as spousal refusal, economic status as well as women's views about having more children played a role in influencing their attitudes towards wanting to adopt family planning. It was clear from the study that women face a significant number of issues relating to the availability of their preferred family planning methods as well as their high cost at private hospitals if not available at state hospitals. This leads to women either choosing not to take what is available or enduring through the ones that are available but developing a negative attitude towards them. It is clear that there is a need to identify strategies to ensure the change of attitudes through dealing directly with the contributing factors.
Joseph G Kadhila was responsible for study design, data analysis, study supervision, manuscript writing and critical revision. Lucia Ileka was responsible for study design and data collection.
No funding was received for this study.
The authors declared no conflict of interest.
Data may be available on request from the corresponding author Mr Joseph Galukeni Kadhila, jkadhila@unam.na. (University of Namibia)
We would like to thank all the mothers that availed themselves to take part in our study from the Intermediate Hospital Katutura, Khomas region Namibia.
Family planning helps couples and individuals to avoid unintended pregnancies, it reduces the spread of sexually transmitted diseases (STD’s), prevents maternal mortality and helps reduce rates of infertility by addressing the problem of sexually transmitted diseases. Women face a significant number of issues relating to the availability of their preferred family planning methods as well as their high cost at private hospitals if not available at state hospitals.
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Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
