Title: Evaluating women’s acceptability of treatment of incomplete second trimester abortion
using misoprostol provided by midwives compared with physicians: a mixed methods study
Version: 1 Date: 11 Jul 2022
Reviewer's report:
The findings from this analysis make an important contribution to the literature looking at how
abortion services can be provided by a wide range of health care providers.  I provide detailed
comments below, and am grateful to have had the opportunity to review this manuscript.
Abstract
Conclusions lines 47-49:  I think these findings are relevant to not only places where physicians
are not available but potentially in a wide range of services where nurses are available to provide
misoprostol; there may also be circumstances where care by nurses would be preferred by people
seeking care.  Suggest revision/expanding this conclusion.
Suggest same change/expansion in lines 70-72 in the plain language summary.
Background
Line 78:  What does “all-inclusive” mean here?  Comprehensive?  All patients who need it?
Line 102-104:  I appreciate the authors’ point about mixed methods approaches not being the
norm in RCTs but they have become more common since the 2010 reference cited.  Perhaps
“not often” would be more appropriate than “rarely”?
Line 113:  Does the HIP guidance say especially where physicians are scarce?
Data Management and analysis
Line 246:  What does “to obtain a sense of whole” refer to?
Results
Line 293:  Should this read, “reported Islam as their religion”?
Are the clinical results of the RCT going to be published separately?  I kept wondering whether
the authors would mention those results and what they were.
Lines 321-330:  When you refer to HCPs here does that mean both physicians and midwives?
Lines 385 to 396:  Is this comparing across people who had misoprostol and didn’t need
a surgical intervention vs those who did need a surgical intervention, or were there some
participants comparing a current misoprostol treatment with previous surgical treatment?
Discussion
Line 435:  In the results this finding was described as more of the people who reported their
provider as pleasant and caring received care from physicians.  Is the data strong enough to
support the statement here?
Lines 454-455:  What does “outstanding phenomenon” mean here?  Something not reported in
other literature?
Lines 456-459:  I was not clear about these comments—I think this is the authors’ interpretation
of the data or did people in the study report appreciation of being treated as an emergency and
more confidence in public compared to private facilities?  I wonder if the data from this study
supports these statements?
Line 523:  I am not sure how you assessed comfort with the team or whether the info provided
was given freely?
Conclusions
Lines 539-541:  As above, I am not sure why this conclusion only applies to settings where
physicians are not available and would encourage the authors to think about other situations
where midwife-provided care could be preferable, and the value of expanding midwife-provided
second trimester PAC (and other services).  Other researchers have found that quality and
effectiveness of a range abortion care is equivalent across physicians and midwives, and this
acceptability data adds to that body of literature which can have an important influence on the
level of health care setting where care is provided and access in a wider range of health care
settings.