Title: Partner involvement in abortion trajectories and subsequent abortion safety in Nigeria
and Côte d’Ivoire
Version: 1 Date: 17 Feb 2022
Reviewer:  Erin Pearson
Reviewer's report:
Thank you for the opportunity to review this manuscript, which is very well done and discusses
the important topic of partner involvement in abortion and abortion safety. My overarching
comment is about the way you have defined “most unsafe” abortions. I understand that this is
based on the current WHO definition of safe abortion, which includes abortion using WHO-
approved methods by a trained provider in a safe environment, but I think it’s important to
recognize where the field has moved on the definition of safe abortion (and where WHO
will soon be moving) given the safety of MA with mife and/or miso, regardless of provider
or environment. Based on growing recognition that many people worldwide are having safe
abortions with mife and/or miso in out of facility settings (see for example recent paper from
Heidi Moseson in Lancet Global Health), WHO will soon be coming out with new safe abortion
guidance that includes pharmacist provision of mife and/or miso as well as lay health worker
and self-administration of these drugs due to their safety. I would strongly encourage you to
either remove mife and/or miso from your definition of “most unsafe” abortion or rename this
category to avoid a judgment on safety, for example “out of facility abortion or abortion with
methods that are not WHO-approved”. I also have some more minor comments, which I will
outline below by section.
Background
• You have nicely covered the partner involvement literature, but I think it would help to bring
in some of the reproductive coercion (RC) literature to better describe why some people who
have abortions do not want to involve their partner. See Ann Moore’s 2010 paper on RC among
people having abortion and Sam Rowlands’ work on this topic.
• Line 109, helpful if you can provide more information on why secrecy limits access to safe
abortion. This is entangled in the definition of unsafe abortion you are using, but in general, it
is possible to have a safe abortion with MA that is also secret. I think it would be more accurate
to say that secrecy limits access to facility-based abortion.
• Line 125, write out safe abortion care (SAC) at first use.
Methods
• Helpful if you can give more information on classification of method of abortion. In Table 2,
mife/miso reporting is very low. I am wondering if many of the “other pill” reports are actually
miso due to its widespread availability with PPMVs (I’m less familiar with OTC availability
in Cote d’Ivoire). We often find that people do not know the technical names of the pills they
take, and I am wondering what procedures PMA used to try to sort this out. As mentioned
above, the mife/miso category really should be considered “safe”, so it’s important to be able to
disentangle these drugs from others. Also helpful if you can give examples of what’s classified
under each method, especially surgery (mainly D&C?), other pills, injection, and traditional
methods (herbal teas? uterine massage?).
• I also wanted to mention that it will be important to clarify the definition of your “most unsafe”
category throughout. In many places you say “non-recommended method, by a non-clinical
provider” which I at first thought considered pharmacist provision of mife/miso as safe because
it is a WHO-recommended method by a non-clinical provider, but it becomes clear that you are
actually defining it as a “using a non-recommended method OR by a non-clinical provider”.
Results
• Helpful if you could add average time since abortion since you are including people who ever
had an abortion – some could have had abortions 20 years before. You mention in the limitations
that some report on abortions decades ago – helpful if you can provide more data on this in the
Results so that the reader can assess the impact of recall bias on the details of the abortion and
the impact of the changing abortion landscape over time.
• Helpful if Table 2 could be reconstructed to show the combination of source and method. Right
now it is unclear why public and private facilities are included in the most unsafe category – I
assume this is where most of the surgeries took place, and you would also need to provide more
info on the surgery. Were these D&Cs rather than MVAs?
Discussion
• Here, too, it’s important to bring in the RC literature to discuss why some people having
abortions will not want to include their partners. Currently, the paper sets up partner involvement
as a net positive that we should encourage to improve safety of abortion. I think it’s important
to recognize that mife/miso is very safe regardless of who is administering it, and for many
people having abortions, excluding their partner from the decision is the safest outcome for them
physically and emotionally. Research from other contexts has shown that people experiencing
intimate partner violence are more likely to abort outside the health system and to use MA
(Pearson et al., 2017), and the goal should be making sure they are having the safest abortion they
can, which typically means access to mife/miso in out of clinic and community-based settings.
• Need to further justify why involvement in the abortion decision would be associated with
“most unsafe” abortion. Involvement in the source/method is obviously the most proximal
determinant of “most unsafe” abortion. To me, this is true partner involvement in the positive
sense in which you are describing it – partners helping identify the safest way to have a needed
abortion in a restrictive context. For involvement in the abortion decision, you are likely picking
up partners who are rejecting the pregnancy (as you mention) and people who do not want to
tell their partners about the pregnancy because they know their partner would not agree with
their decision to abort. It is likely that women whose partners aren’t involved are getting mife/
miso from pharmacists/PPMVs because it is more easily accessible and discreet than facility-
based abortion, especially in these restrictive contexts. This is a good and safe option for people
who are experiencing reproductive coercion or otherwise do not want their partner involved in
their abortion.
• Limitations – need to mention self-report of abortion method and possibility of
misclassification (especially that “other pills” could include some mife/miso).
• Lines 524-526 – also important to mention changes in abortion over the years as mife/miso
have become more widely available over the counter (and hence, abortions have become safer).