Title: Partner involvement in abortion trajectories and subsequent abortion safety in Nigeria
and Côte d’Ivoire
Version: 1 Date: 29 Jan 2022
Reviewer's report:
This study summarizes the relationship between partner involvement in abortion decision-
making and selecting the source/method and the level of safety of abortion in Nigeria and Côte
d’Ivoire. This study adds important information to the literature related to partner involvement
and abortion safety in settings where access to abortion is generally restricted. However, I have
some comments and suggestions that I think will improve the clarity of the findings and better
contextualize the findings in the existing literature.
Background:
-In Line 94, Line 107 and Line 471 in the Discussion: the use of “variety of settings” or “multiple
settings” is not completely clear. Do the authors mean a variety of country settings? Or different
contexts of abortion legality? It might be helpful to be more specific or narrow the focus to
literature from sub-Saharan Africa to the extent that it is available.
-Line 100 – is the existing research mostly from the US/Europe? Or also sub-Saharan Africa?
Or both?
-It is helpful that the authors cognitively grouped the junctures at which the partner might be
involved with the abortion process. Since the focus of this analysis seems to be on the 2nd and
3rd junctures, I could see cutting down some of the text describing the first, and subsequently
returning to these groupings in the Discussion section.
-Line 123 – I was surprised at the statement: “Partner involvement is not necessarily the
predominant experience at this stage.” I wonder if the authors need to qualify this to lower
income settings, or restricted access settings. I imagine a lot of people may at the very least get
financial support from a partner to obtain abortion (see my additional comments below).
-Lines 128-130: These findings from Zambia don’t seem to provide support for the 3rd juncture
which is related to identifying a method/provider. This seems more about the first – disclosing
to partner and the repercussions.
-Line 133: what is meant by “partner support” here? And just because it was associated with
earlier abortions, what is the link to safety? Same comment about the Nepali study. Are men
helping to facilitate access to legal abortion in health facilities vs. in more unsafe settings/with
unsafe methods? It would greatly strengthen this paragraph if the authors were more explicit
about how these findings are related to safety. Same with the Altshuler paper: while partner
accompaniment is associated with greater subjective well-being – that’s not the same as safety.
Maybe move some of these references to a different paragraph?
-The paragraph that begins at Line 121 seems the weakest, especially given that I imagine
partners may help financially with abortion seeking at the very least, which might be related to
trying to access care in a legitimate facility, and therefore with safety. Through a very quick
review of the literature, I identified some additional relevant information (some in articles the
authors have already cited):
• “Seven (21%) of the partners made the decisions, made the arrangements, accompanied their
girlfriends and paid to have the unsafe abortion procedure done.” Dahlbäck, Elisabeth, et al.
"Pregnancy loss: spontaneous and induced abortions among young women in Lusaka, Zambia."
Culture, health & sexuality 12.3 (2010): 247-262.
• Additional information on men providing financial assistance and accompaniment in Freeman,
Emily, Ernestina Coast, and Susan F. Murray. "Men's roles in women's abortion trajectories in
urban Zambia." International perspectives on sexual and reproductive health 43.2 (2017): 89-98.
• “If the girl's parents and/or partner were involved in the decision, they usually took the girl
to a hospital, health worker or doctor in a private clinic, where services are generally more
expensive” Koster-Oyekan, Winny. "Why resort to illegal abortion in Zambia? Findings of
a community-based study in Western Province." Social Science & Medicine 46.10 (1998):
1303-1312.
• “In most cases, the young women will ask older relatives (and the partner, even if he is not
privy to the secret) for money using a fabricated excuse. Financial emergencies are common in
Burkina Faso, and any illness is likely to create this kind of demand. Young men also collect
money from their close friends on the basis of a reciprocal obligation to help in return when the
friend is in need.” Rossier, Clémentine. "Abortion: an open secret? Abortion and social network
involvement in Burkina Faso." Reproductive health matters 15.30 (2007): 230-238.
Methods:
-For defining abortion history and the subsequent dependent variable, it seems from my reading
that participants were asked if they ever did something to remove a pregnancy or bring back a
period, but not whether the abortion was completed. So they could possibly have needed post-
abortion care. Is this correct?
-For the paragraph that starts on Line 199, are the full text of the questions from the abortion
follow-up survey available anywhere? If not, could they be made available, perhaps in a
Supplemental File?
-Line 228: Here and on line 301 in Results - consider using “procedural” rather than surgical and/
or clarify if “surgical” abortion refers to those abortion performed using MVA and/or another
method like D&C.
-Line 230: It’s interesting that the authors classified pharmacies as “non-clinical” sources,
considering the extensive literature on availability of medication abortion through pharmacies
and completion rates particularly with accompaniment (see: Moseson, Heidi, et al.
"Effectiveness of self-managed medication abortion with accompaniment support in Argentina
and Nigeria (SAFE): a prospective, observational cohort study and non-inferiority analysis with
historical controls." The Lancet Global Health 10.1 (2022): e105-e113.) The authors might
consider doing a sensitivity analysis grouping those who got a procedure through a pharmacy
in “safe” abortion.
-Is religion available as a co-variate? I was curious if it might also be associated with stigma,
not discussing with partner, or seeking a more unsafe abortion.
-I think it was very important to look at the analysis separately by the type of partner involvement
(involved in decision and involved in selecting source/method). However, I was a little confused
about why both of those binary indicator variables were put in the same regression model (Table
6). Couldn’t it be the case that someone’s partner could be involved in both the decision and
selecting the source/method? If so, it seems that including both variables in the same model
might attenuate their individual effects.
Results:
-Paragraph starting at Line 332: There is a lot of information in this paragraph and some refers
to Table 3 and some to Table 4. I recommend referencing the Tables when switching between
them in the text so readers know where to find this information.
-For example, Lines 342-344: This sentence is slightly unclear: “In Nigeria, those who
experienced a most unsafe abortion were equally likely to have experienced or not to have
experienced partner involvement.” Perhaps rephrase to say something like “In Nigeria, those
who experienced a most unsafe abortion were equally likely to have experienced partner
involvement in one or more ways as not to have experienced partner involvement” – again,
would add (Table 4) in text here for reference.
-Table 4: Not entirely clear on how some of the bivariate results are reported and how they sum.
For example, out of a total 585 “most unsafe” abortions in Nigeria, 277 had partners involved in
discussing decision and 170 in selecting source. I imagine that there was not complete overlap,
but 288 were not involved in any way? I wonder if it’s worth adding an additional row for clarity,
so the categories are “Discussed decision only”, “Selecting method and/or source only”, “Both
discussed decision and selecting method/source”.
Discussion:
-Lines 411-412: this is not clear in the Results, but I think would be helped by the suggestion
I made above for an additional row in Table 4.
-Line 439: Not entirely sure what is meant by the statement “which generally aligns with
documented disparities in abortion access.” – is it referring to all background characteristics?
Or marriage/age/parity specifically?
-The paragraph that starts on Line 454 seems less strong and a little off-topic from the main
findings. One might hypothesize that having support from friends/family might also lead to a
safer pregnancy, and maybe more so than from a partner if it’s an unintended pregnancy.
-Line 534: Does “(relative to most abortion research)” refer to abortion research in an African/
restricted access context? The authors do mention low-resource settings at the end of the
sentence, so considering that there is lots of quantitative research on abortion I think this aside
can be deleted.
-Overall the Discussion is quite long and can be shortened/tightened in places to focus on the
most novel and impactful findings.
Minor comments:
Abstract:
-In Background section, can separate first sentence into two for readability.
Background:
-Though I imagine that relevant citations are included in the following paragraphs, lines 93-98
could use some citations to support the statements.
-Line 115: a word may be missing here:  responsibility “for” the pregnancy?
-Line 119: incomplete citation
-Line 122: an “abortion” method and an “abortion” provider?
-Line 125 – spell out acronyms (SAC and PAC) when used for the first time
- Lines 151-152 seem to be a repeat of line 132 but line 132 doesn’t seem to be a good topic
sentence for that paragraph.
Methods:
-Line 175 – perhaps edit, as when reading “these most unsafe abortions” it seems like the authors
are referring to the previous sentence where they discuss the conditions under which abortion is
permitted in these contexts. Also could just remove the qualifier and start with “Annual abortion
incidences….”
-Line 177 – missing decimal place: CI 33.3-“48.1”
-Line 248: traditional health “provider”?
Results:
-Table 2: perhaps add a note that there could be multiple responses to “Who spoke to about
decision to terminate pregnancy” and therefore the columns may not total 100%.
-Line 336: the p-values in the text do not match those shown in Table 3.