Title: Self-assessment of attitudes towards conditions to provide safe abortion among new
medical graduates in Thailand, 2018: an application of cross-sectional survey with factor
analysis
Version: 1 Date: 24 Mar 2021
Reviewer:  Sarah Raifman
Reviewer's report:
Thank you for the opportunity to review this interesting and well-written paper. The aims of
this study are to explore attitudes towards abortion among new medical graduates in Thailand
and to identify factors associated with those attitudes. Understanding medical provider attitudes
about abortion is important in Thailand given that doctors are permitted (though not required) to
provide safe abortion for certain indications and access to abortion is often left to the discretion
of the provider. Overall, I think this is a useful and relevant exploration of an understudied topic.
The paper would be greatly improved with attention to some of the comments below.
Background:
3rd paragraph – it would be helpful if the authors could clarify the current law on the books
regarding abortion. I assume the law mentioned in the paragraph before was the 1956 law, and
that the 2016 law is broader with regard to the indications for abortion that are allowed.
Does the inclusion of abortion in the Thai main public health insurance scheme in 2017 mean
that currently the cost of abortion is covered by the state? That might be helpful to clarify given
that many present with socioeconomic motivations for seeking abortion.
4th paragraph – I appreciate the authors’ statement about the role of medical providers’ discretion
in who can access safe abortion in Thailand. Studies from around the world have shown that
women are denied care at clinics in countries where abortion is legal, for various reasons. It
might be helpful to cite some of this literature from outside of Thailand, including the findings
from the Turnaway studies around the world:
• Gerdts et al: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4501171/
• Nepal: http://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-015-0241-y
• Bangldesh: http://reproductive-health-journal.biomedcentral.com/articles/10.1186/
s12978-016-0199-8
• South Africa: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4371847/
• Tunisia: http://www.ncbi.nlm.nih.gov/pubmed/26684189
• Colombia: https://www.ncbi.nlm.nih.gov/pubmed/29058629
5th paragraph – The authors mention that the only relevant past study in Thailand was conducted
in 2003, but the authors do not summarize the findings from this study. It may be helpful to
include a brief summary of what this study found in order to place the current study’s findings
in context. I see that the authors explain some of these studies findings in the discussion (lines
245-248); I think this could be moved to the background, including reference to the other study
by Sanitya et al 2017. And then in the discussion you can clarify that your findings support those
of these previous studies.
In addition, there have been studies of provider attitudes about abortion (and abortion denial)
outside of Thailand, which may be worth referencing. For example Baba et al. studied
medical and midwifery student attitudes about abortion morality and legality following
the decriminalization of abortion in Chile, which may be particularly relevant (https://
www.sciencedirect.com/science/article/abs/pii/S1877575619302861). Another study in Nepal
surveyed providers about their perspectives on abortion denial (https://reproductive-health-
journal.biomedcentral.com/articles/10.1186/s12978-018-0619-z).
The authors mention that the medical graduating system has changed massively in the last 2
decades. It seems like the main changes have been the volume of people graduating from the
system. Have there also been changes in the type of education provided, particularly with regard
to women’s health?
For the background section, it may be helpful to comment on geographical variation in
Thailand with regard to access to abortion or prevalence of unsafe abortion, if there is literature
on this. I suspect there may be regional or geographical differences in the rates of unsafe
abortion throughout the country, which may mirror or correlate with where CPRID graduates
work? Regardless, it would be helpful context to include somewhere, particularly because the
comparison between CPRID and normal track seems like the focus of the study.
It also may help to clarify which types of providers can provide abortion in Thailand (which
specialties and levels).
Methods:
Do you know what proportion of all medical graduates in Thailand attend the forum where
participants were recruited (ie “those who declined to work in public facilities and were subject
to fines”)?
Were all medical graduates invited to this forum, including all specialties (OB-GYN and others)?
In other words, was the intent to ask only OB-GYNs (those presumably trained to provide
abortion) about their attitudes or was the aim to ask all providers in Thailand?
Can you clarify how forum attendees were asked to participate in the survey? Where was the
QR code (for example was it on a flyer that was handed out to all attendees or did you have
research staff walking up to attendees and inviting them to participate? etc). Were they told
at recruitment that the survey was about abortion attitudes, or did that come later during the
informed consent process?
If providers said “no” they did not intend to continue further training to be an OB-GYN, did you
ask what specialty they intended to pursue?
Were the 14 conditions developed for the survey based on the meetings of experts previously
mentioned? If they were based on other guidelines or policies it would be helpful to cite these.
3rd paragraph under Data analysis – how were independent variables selected for the model?
Results
May be interesting to present the conditions which received the lowest mean scores overall,
just as you’ve presented those that received scores over 4. In the discussion, you mention “non-
marital pregnancy and pregnancy in children and teenagers (either aged below 15 years or aged
15-20 years)". It's important to make sure this finding is highlighted in the results as well.
End of page 11 – may be helpful to provide the factor scores for both groups for pregnancy with
maternal and fetal life threatening conditions, even though they were not significantly different.
I’m curious if both were positive.
I’m not sure I understand the comparison group (“females”) in this sentence: “Respondents
with high confidence levels of ANC and CPIRD graduates were less agreeable than females
to performing abortion under the condition of pregnancy with socioeconomic and well-being
problems”. I believe this may be an error. Please clarify the reference groups for each of these
variables (high vs low confidence levels of ANC and CPIRD vs normal track).
Again, in order to understand the reference group for intention to become an OB-GYN doctor,
it would be helpful to know what those with “no intention” do plan to do… what kind of doctor
do they become?
In the sentence (“For conditions of pregnancy with maternal and fetal life threatening conditions,
there was no significant difference of the factor score between CPIRD and normal track doctors”)
it might be helpful to clarify that none of the independent variables significantly predicted the
factor score for this condition, including CPIRD vs normal track.
Discussion
Spell out GPs in the discussion when referencing the Ireland study.
In 3rd paragraph, may be helpful to reference other articles (beyond Ireland study) that show
that providers denial abortion care even in contexts where abortion is legal and for the specific
indication requested.
4th paragraph –
The finding that more than half of respondents agreed to offer abortion services for pregnancy
women upon reasonable request after adequate counseling was also not highlighted in the results
section. If you’d like to include in the discussion, it would be helpful to include in the results
section.
Please add a reference for this sentence “Note that a few studies from abroad suggested that
most of medical students believed that it was acceptable to provide abortion service upon request
from the women regardless of the medical reasons."
5th paragraph – this sentence seems important and I think would be helpful to clarify further:
“The environment in this context is not just equipment and medical supplies but it means
the whole health service system that makes physicians more comfortable to deal with women
requiring a termination of pregnancy."
More context/discussion is needed for the finding that male doctors were more “agreeable” than
female doctors to provide abortion. I see the sentence and reference in the discussion, but think
it would benefit for elaboration and deeper thinking around this: “A study by Myran et al also
supported our findings, by suggesting that male doctors were more agreeable than female doctors
to performing abortion services as men tended to have a broader social perspective on abortion
compared with women [23].”
Do you have any theories as to why those with high confidence in ANC appear less agreeable to
provide abortions for women with socioeconomic problems? I agree qualitative research would
be helpful, but wonder if the authors have any theories to provide (is there any prior literature
on this?). Revisiting why the authors included ANC confidence as a variable in the model in the
first place, and how ANC confidence may relate to the unmeasured factors the authors list in the
limitations (religion, legal knowledge, etc) may be helpful.
Methodological discussion
The lack of inclusion of private sector providers in this survey is interesting. Is there any prior
evidence as to abortion access in public vs private sector in Thailand? Do women end up seeking
care in the private sector after being denied in the public sector for example? It may be helpful
to comment on this.
With regard to the authors’ comment about limitations to causal inference – I agree in general,
but also recognize that at least some of the independent variables selected for the analysis (male
vs female, CPIRD vs normal track, age) are likely not subject to reverse causality (abortion
attitudes does not affect one’s age or sex). The temporal relationship between confidence in
providing ANC and intention to become an OB-GYN and the outcome (abortion attitudes) may
be more complicated.
Finally, I presume the authors chose to focus on new providers because they are much easier
to sample effectively (at the forum). If there are other reasons, it may be helpful to articulate
those in the background/aims. In addition, the authors may consider adding to the limitations
that these results are not generalizable to more experienced providers. Depending on the medical
hierarchy in Thailand, more experienced providers may actually have more influence than new
providers regarding whether an abortion service is offered at a given clinic or whether women
are denied care.