Reviewer ’s report  
 
Title: What Contraception Do Women Use After Experienci ng Complications From Abortion? 
An Analysis of Cohort Records of 18,688 Postabortion Care Clients in Tanzania  
 
Version: 1 Date: 20 Nov 2017  
 
Reviewer: Diana Foster  
 
Reviewer's report:  
 
Contraception after PAC in Tanzania  
 
This paper documents the promotion of post abortion care in prim ary care centers in four regions 
where it used to be available predominately in hospitals. The spread of postabortion care to new 
facilities seems much more interesting that contraceptive use, especially given that the authors 
can't report whether all meth ods were actually available.  
 
 
I find that much of the language in the title and introduction suggest that abortion is more 
dangerous than it actual is. The word "surviving" in the title is misleading.  Most women are at 
no risk of dying from complications. A more scientifically accurate, less inflammatory title 
would be "Contraceptive use after post abortion care in Tanzania"  
 
 
I would like some background about the level of complications women are experiencing.  I 
would have expected that many women would hav e used misoprostol to induce an abortion and 
their seeking of postabortion care is to check that the abortion is complete.  Is this not the case?  
Relatedly, I don't believe that the end of the first background paragraph is correct. 2/5 "suffer" 
complicatio ns without receiving "necessary" treatment.  It is not known whether women who 
don't come in actually need treatment. Many abortions are illegal but not unsafe and need little 
care.  The citation for this is based on facility treatments for women who did n eed care. I don't 
think we can presume that women who don't come in have the same level of complications.  
The "advised" delay of 6 months after an abortion is not evidence based.  The citations 4 -6 have 
nothing to do with recommended pregnancy intervals.  The latest review of this topic (published 
in Human Reproduction in 2017)  disputes these recommendations. 
https://www.ncbi.nlm.nih.gov/pubmed/27864302  
What is the availability of medication abortion in Tanzania? Why are PAC services not using 
misoprostol?  
 
 
And, why are nearly 100% of women in PAC receiving a uterine evacuation? This must 
represent vast over -treatment, unless you only define a woman to be receiving postabortion care 
if she did have a uterine evacuation (in which case you need to say this and also report how 
many women didn't get a uterine evacuation). The levels of medical intervention you are 
reporting here seem alarming.  
Not knowing whether all methods are available at all sites is a major limitation.  At a minimum, 
your models should be adj usting for clustered data by site - so that if hospitals don't offer short 
acting methods, or primary care clinics don't offer LARC, you are not attributing the 
shortcomings of the facility to the characteristics of their patients.  
 
 
The paper needs to be ed ited. We don't typically talk about hospitals being decongested. The 
whole discussion needs to be rewritten for clarity. "family Planning" is a euphemism and it 
doesn't just mean contraceptives.  Some people consider any method to plan to have a child, to 
avoid a pregnancy or avoid birth after pregnancy to be family planning methods. What you mean 
is contraceptive services.  You can retain "Family planning" but you need to explain that you 
only mean contraceptive services.  
 
 
The finding that MVA has become mo re common than sharp curettage is a wonderful finding.  
This is more important than the contraceptive use findings.  Where is postabortion care with 
misoprostol in the mix?  
 
 
The section on trends in decentralization seems important but I don't understand it .  What does 
the sentence "however, the decentralization.. never resulted in significant changes in care seeking 
for PAC services" mean? it seems like there was a huge increase in patients.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specif y what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being publishe d 
 
 
 
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