Reviewer's report
Title:Perceived stress and emotional social support among women who are
denied or receive abortions in the United States: a prospective cohort study
Version:3Date:4 April 2014
Reviewer: Kelli Hall
Reviewer's report:
This article describes findings from a national prospective cohort study of women
who were provided or denied an abortion. The researchers build upon their
previous reports and ongoing work about the health and social consequences of
abortion versus unwanted childbearing and here focus on the outcomes of stress
and social support immediately following abortion-seeking and then over a 30
month period. Overall, I felt that this manuscript was extremely well-written, clear
and focused, and provided new and interesting findings which offer a unique
contribution to the broader literature on mental health and wellbeing and
abortion. I think the methods used are appropriate and rigorous and the results
are clearly presented. Overall, the majority of my comments and suggestions are
minor. Two larger issues may need to be addressed – 1) a more in-depth
discussion and reference to the literature in a few important places in the
discussion section (which I describe below) and, 2) presentation of covariate
point estimates in Table 2 and 3 and in the text, along with a mention of those
that were significantly associated with stress and social support in the discussion.
The latter is important given the limited generalizability of this sample and would
help readers contextualize these findings better. Specific
comments/suggestions/questions are as follows.
Abstract:
Is “trajectories” in the abstract an accurate usage (since it doesn’t appear that
latent curve models were used or that trajectories were formally analyzed)? I
would be more specific (i.e. social support scores did not differ between groups
initially or over time). Same comment applies for the last results paragraph in
text.
While I fully agree and am familiar with the literature on stress and pregnancy
outcomes, these results don’t seem to support the last abstract conclusion
statement given that similar stress scores were noted among women denied
abortion. I would consider removing from abstract and add to the text where
more reference to the literature and how these findings fit within can be made
and would be useful.
Background:
The introductory paragraph could benefit from a few specific details, for instance,
that “abortion is harmful to a women’s wellbeing” – I would specify outcomes
here (i.e. depression, anxiety, suicide, etc). Additionally, this first important
paragraph doesn’t read as cohesive to me. I think the problem is with trying to tie
in the line about facility gestational limits and abortion restrictions (I understand
this is relevant to the larger study but doesn’t seem necessary to set the stage
here and so I found it a bit jarring and disruptive).
Perceived stress paragraph – I would give some specific examples of the health
consequences.
Methods:
The paragraph describing stressor and stressful life events is a bit confusing. At
first I thought that the stressors comprised the “final variable stressful life events”
but following the description that doesn’t seem to be the case. I would
recommend trying to better distinguish between the two different indicators (if
they are in fact different) and how they were used in analyses.
Results:
The retention and follow-up paragraph seems a bit long and wordy, and I’m not
sure whether that level of detail is needed for this particular manuscript. I would
consider summarizing (assuming that it has been presented elsewhere) or
presenting in a figure.
Tables:
The time variables are difficult to interpret in the table. I think these are the
interaction terms, which are described in the text but not clear when looking at
the tables alone, perhaps because the same symbol is used for interaction and
p-value significance. I would change the symbol and add in a footnote.
I would have liked to see full presentation of the covariate estimates in tables 2
and 3, so that readers can put the findings into context. Were all controls
significantly associated in models? Do the main point estimates represent full
models or reduced models where these covariates were selected because they
were the only ones significant? Some greater detail in the both text and tables for
these results would be helpful. Additionally, a comment regarding significant
covariates and their relationship with stress and social support is needed in the
discussion.
Discussion:
The idea of resilience that is mentioned in the last sentence of the paragraph at
the bottom of page 12/top of 13 is very interesting and a potentially strong and
unique contribution of this study. Thus, it deserves more attention, drawing upon
other literature on resilience and childbearing, etc.
It seems that the last limitations paragraph is an extremely important one that is
directly related to the social support commentary. I would suggest adding some
comments that these data did not permit an assessment of social support and
stress before the abortion seeking and that the moment at which this study
“interjected” into these women’s lives may represent a peak in stress or low-point
in social support, which would help explain why they both improve over time. I
would also recommend moving that limitations paragraph up in that section.
The first two implications paragraphs about clinical interventions do not seem
directly supported by this research. It might help to condense them into a single
paragraph focused on the immediate findings (that stress was at it worse
immediately around the time of abortion seeking (for turnaways and second
trimesters), and abortion clinics are a unique and understudied context for
stress-related interventions. Even standard abortion counseling does not often
deal with stress management and coping, which appears to be reflected as a
potential clinical need within these data. Overall, perhaps a more careful
commentary about clinical implications is warranted. Also, more clear mention
that stress experienced by women receiving late term abortion is also needed
throughout (i.e. it wasn’t just turnaways).
Figures – I like the idea of the figures but I’m not certain how helpful they are
given the little variance in outcomes. The authors may wish to consider removing
them (particularly the social support figure).
Level of interest: An article of outstanding merit and interest in its field
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
None to report