Reviewer's report
Title:Obstetric and psychological characteristics of women seeking multiple
abortions in the region of Monastir (Tunisia): Results of a cross-sectional study
Version:2Date:18 February 2015
Reviewer: David Reardon
Reviewer's report:
1. Is the question posed by the authors well defined?
No. The control group is not properly defined.
Every woman who has a second abortion previously had a first abortion.
Therefore, the characteristics of repeat aborters can only be understood in the
context of first time aborters which itself requires comparison to women without a
history of abortion. Also, there is literature indicating that negative psychological
reactions to a first abortion contribute to the risk of repeat abortions and even
further negative psychological reactions.
>>MAJOR COMPULSORY REVISION<<
This study requires a control group of women without a history of abortion. I
recommend that the Reproductive Health Center should collect reproductive
history and common mental disorder (CMD) data on at least 500 women seeking
non-abortion related services, such as family planning. This would include history
of any abortions and births, with time since last abortion (if any). This would
serve as a baseline for comparing CMD rates at the 2-3 weeks post-abortion
which were presented in this paper.
This baseline group would be segregated into at least three groups: (1) women
without a history of abortion, the main control group; (2) women with a history of
one abortion; and (3) women with a history of multiple abortions. CMD rates
should be calculated for each group and should also be shown as adjusted for
age and time since last abortion.
Now, you would finally be in a position to show how the results reported in this
study (CMD rates at 2-3 weeks post-abortion) compare to (a) the CMD rates
among reproductive age women seeking reproductive health care without a
history of abortion and (b) CMD rates in the short term (2-3 weeks after the
abortion) compared to CMD rates many months or years after one or more
abortions (as revealed in the age and time since last abortion adjusted rates.)
The latter is very important, as it will indicate whether CMD rates tend to increase
or decline as time passes.
2. Are the methods appropriate and well described?
As indicated above, the method fails to provide for adequate comparisons to
provide meaningful insights. But the methods are adequately described.
3. Are the data sound?
Given the limitations described above, there is no reason to believe that the data
collected is inaccurate
4. Do the figures appear to be genuine, i.e. without evidence of manipulation?
Yes.
5. Does the manuscript adhere to the relevant standards for reporting and data
deposition?
Reasonably well. However, the results of CMD are merely lumped into a single
percentage. While such a summary statistic is useful, the results should be
reported separately for both anxiety and depression. Also, I noted that the
methods describe that data was collected about sleep disturbances, but I don't
see this reported in the results.
Speaking of which, an important study for the background or discussion relevant
to sleep and abortion is: Reardon DC, Coleman PK. Relative treatment rates for
sleep disorders and sleep disturbances following abortion and childbirth: a
prospective record-based study. Sleep. 2006 Jan;29(1):105-6.
6. Are the discussion and conclusions well balanced and adequately supported
by the data?
In regard to the introduction, the literature review is too thin and the studies cited
do not adequately support the summary statements being made.
The conclusion that repeat abortions reflect the "way of life" of some women is
not supported by the data. There is evidence that many women have unwanted
abortion at the behest of a male partner or family members. These women are
may experience profound grief and loss which they may seek to "fill the hole" by
becoming pregnant again, often within a short period of time, at which point they
still face pressure from male partners or family to undergo another abortion.
Having submitted to an unwanted abortion once, they are likely to do so again.
Rapid repeat pregnancies are indirect evidence of this problem. See, for
example, "Contraceptive discontinuation and repeat unintended pregnancy within
1 year after an abortion." by Upadhyay UD, Brown BA, Sokoloff A, Raine
TR.Contraception. 2012 Jan;85(1):56-62, in which it was reported that "Women
who had a recent abortion or previous abortion were 60% more likely to have
another pregnancy during the next 12 months than women who never had an
abortion (AHR=1.63, 95% CI =1.21-2.20, and AHR=1.66, 95% CI=1.18-2.33,
respectively)."
The fact that many women may want to carry to term, but feel forced to have
unwanted abortions, also puts a different spin on interpreting the data regarding
knowledge of birth control. Women may claim lack of knowledge of birth control
and may not seek or practice birth control if they are consciously or
unconsciously seeking to become pregnant and are hoping that their male
partner and/or family will be supportive once the pregnancy is announced. That
these hopes are often misplaced does not change the fact that many
pregnancies that are "unplanned" are also actually wanted, at least by the
woman, even if they are eventually aborted in light of the lack of support from
significant others.
The discussion also suggests that "repeaters have less stable family relations
compared to first time abortion seekers." This may be true, but it may, at least in
part, be a consequence of exposure to the first abortion. A single abortion that
negatively impacts mental health and contributes to other problems such as
substance use, sexual dysfunction, and resentments within relationships may
contribute to broken relationships and increase the risk of separation, divorce,
being a single parent, and other problems which increase the risk of abortion of
subsequent pregnancies.
7. Are limitations of the work clearly stated?
Could be better.
8. Do the authors clearly acknowledge any work upon which they are building,
both published and unpublished?
Reasonably well.
9. Do the title and abstract accurately convey what has been found?
Reasonably well.
10. Is the writing acceptable?
There are a number of grammatical errors that would need to be fixed by the
authors or an editor
11. Is publication recommended?
No. Additional data should be collected and shown in the analysis as described
previously.
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests