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: 2 Date: 05 Sep 2022
Reviewer's report:
While the authors edits have improved the paper, I still have some outstanding comments and
points of clarification detailed below. In addition, a number of my comments were answered by
the authors in their responses, but no text was edited in the manuscript. That means that there are
still some unclear or inconsistent places in the manuscript that would be confusing to a reader
or would benefit from additional citations.
Background:
-Lines 126-129:
Are first AND second trimester PAC services available from primary level facilities up to referral
hospitals? Please be specific.
The statement that second trimester PAC is only performed by sharp curettage is a little
confusing in the context of this study, which is about second trimester PAC management
with misoprostol, comparing doctors and midwives. Is second trimester PAC with misoprostol
by physicians not currently part of the Uganda clinical guidelines? If not, it might be worth
underscoring that somewhere in the Background, confirming that the literature shows that
second trimester PAC with misoprostol can be highly effective (even if that evidence is from
another country). Right now your only citation is about FIRST trimester medical PAC.
Here are some suggestions:
Mark AG, Edelman A, Borgatta L. Second-trimester postabortion care for ruptured membranes,
fetal demise, and incomplete abortion. Int J Gynaecol Obstet. 2015 May;129(2):98-103. doi:
10.1016/j.ijgo.2014.11.011.
Niinimäki M, Mentula M, Jahangiri R, Männistö J, Haverinen A, Heikinheimo O. Medical
treatment of second-trimester fetal miscarriage; A retrospective analysis. PLoS One. 2017 Jul
28;12(7):e0182198.
-Lines 88-89:
My previous comment requesting more detail on providing PAC services “equitably” is not fully
addressed by this edit. WHO is more likely to need PAC services, especially second trimester
PAC services? Is it young women, rural women, lower income women, women experiencing
GBV? Adding information here about ensuring women who might lack access to services at
hospitals have more access to care as a result of task-shifting would go a long way to clarifying
how this study could improve equitable access to services.
In addition, more detail is still needed about WHAT “lessons learnt from first trimester PAC
task sharing can be extrapolated to second trimester PAC as well.” What are the lessons? Add
2-3 here.
-Lines 114:
My previous comment is not addressed by replacing “methods” with “research paradigms”.
Please add 1-2 examples of what you see as benefits of integrating quantitative and qualitative
research that justifies using mixed methods.
Methods:
-Line 181:
I appreciate that the screening checklist and other patient selection detail are provided in the
protocol paper, but for the sake of clarity of this paper standing alone, I recommend adding
clarifying detail here, for example, “Using a predefined checklist developed by the research
team [citation],”.
-Lines 200-205:
I disagree that this section is clear and consistent with how acceptability and satisfaction are
described in the PAC literature. It is confusing to use the word “satisfactory” to describe
acceptability if satisfaction is truly a separate construct. There are other words that can be used
that are not the same as one of the constructs of the overall dependent variable.
-Lines 205-207:
The authors still did not provide any explanation or justification of why they also included a
visual analogue scale to measure satisfaction, in addition to their other measurements. While
the authors reported in their response that “This was explained to patients that zero meant “not
satisfied at all” and ten as maximally satisfied.”, this information was not added to the text.
Results:
-I disagree with the authors about the need to show the sociodemographic characteristics of the
full 1187 women who were randomized. Presumably, those results would be shown in the main
manuscript summarizing the primary objectives of this study (safety and effectiveness of second
tri medical PAC). It is inconsistent to show the sociodemographic characteristics of the total
sample when you are not assessing the main objective (acceptability) among that full sample.
-My comments about discussing the implications of the women not being blinded to who was
treating them possibly impacting the acceptability results has not been addressed anywhere in
the manuscript, including the Discussion or Limitations.
-The quote that the authors provided to demonstrate that providers are rude is vague and still
does not get that point across to the reader.
-It is still not clear from the Methods how participants were asked about side effects. Adding
that side effects was a yes/no variable does not make clear WHAT outcomes were considered
side effects by both participants and the researchers.
-While the authors mentioned that some women may be speaking to previous experiences when
discussing medical vs. surgical evacuation, that is not included in the text, which would help
add context to the results being presented.