Title: How, when and where? A systematic review on abortion decision making in legally
restricted settings in sub-Saharan Africa, Latin America, and the Caribbean
Version: 1 Date: 08 Sep 2021
Reviewer:  Antonella F Lavelanet
Reviewer's report:
Background:
General comment - It is hard to know if you are setting the reader up for a review that will focus
on decision-making broadly or if you really seek to address self-management. One such review
that may be relevant here and does not seem to captured by this review is “Why do they take the
risk? A systematic review of the qualitative literature on informal sector abortions in settings
where abortion is legal.” Chemlal and Russo, 2019 (BMC Women’s Health)
Lines 58-62 - This seems to be mixing two different points. The first is that misoprostol is more
available, but there are still questions of quality that need to be addressed. The second is about
self management generally, which also can be done safely with access to information and care
if desired. Additionally, while I appreciate that availability of misoprostol is an important point,
this seems to deviate from the objective of the paper. Would stay focused on larger issues around
decision-making, otherwise you need to more clearly link the background to contextual issues
around self management (ie privacy, security, autonomy etc) and then to misoprostol use.
Line 65 "safer termination options" - Misoprostol is safer than unsafe methods, but you have
not presented any references that speak to the safety profile on its own compared to for example
mife/miso. Thus, would caution how such sentences are written.
Line 83 "Guttmacher-developed categorization" - Reference needed if no explanation provided
Methods:
General comment - This review is meant to focus on the time after which the individual has
decided to proceed with an abortion. It seems to me that it may be difficult to truly keep the
analysis limited to this, as many of the factors identified in this framework will likely impact
the decision to have an abortion (include knowledge about the actual process/procedure and
consequences; individual, partner or community context; self-efficacy, agency, autonomy and
power).
Line 107 - noting the limitation of no French, but please note that this is quite a large limitation as
you are specifically looking at countries where French (and also Portuguese) are the predominant
languages
Lines 113-115 - women and girls? Just noting also there is growing literature on trans
populations, so should note the intentional limitation here
Line 116 - Would consider describing what you included first for flow. Also it seems you
included both quantitative and qualitative so you may want to explicitly say so.
Line 128 - "geographic considerations (such as proximity to women’s homes) and the provider
type " - provider or facility?
Line 132-133 - Would be good to expand here as you make the above point that the African and
Latin American region are similar in terms of restrictions.
Results:
General comment - It is a bit odd to quote the author’s view from an included study. The purpose
of the SR should be to conduct the analysis of included studies, as you have done, and quote
text that supports your thematic analysis. You will of course include the findings as it informs
the thematic analysis but to quote the author’s position is odd for a systematic review. Perhaps
this just needs to be rephrased to make it clear you are reporting on the study findings, not the
author’s opinions about those findings. Use of the word “note” for example and the quote seems
to be their summary of their findings. This is done in several places (lines 204, 221, 240, 253
are only a few examples). Lines 304-312 on the other hand are a nice summary of the studies'
findings for the SR.
Discussion:
General comment - There are  several places where the statement that these issues are known
to exist elsewhere comes up. However, just saying that it exists elsewhere doesn’t really add to
discussion. Would be good to draw parallels and differences to your review and what has been
stated elsewhere. Much of what is here thus far is a recap of results. It would be good to elaborate
on what is known and how this study contributes to that evidence base – either by expanding on
existing knowledge, showcasing particular nuances etc.
Line 382-383 - "While providers and researchers may refer mainly to one frame type of abortion
safety—specifically based on a medical perspective " - Unclear what this clause means and in
particular the use of frame type.
Lines 417-422 - These 3 sentences essentially say the same thing repeatedly. Women have fewer
options.  What else can his review contribute to the field?
Line 433 - "something that scholars and practitioners are already doing " -What is the something
here? And why is understanding the decision-making process important? What are the larger
implications of that knowledge? Meeting the needs of underserved? Changing the way in which
information is delivered? (h paper starts out by mentioning harm reduction but it has yet to come
up here). Besides programmatic interventions, are there policy interventions?
Line 436 - "counseling" - Counseling? Information? Both?
Line 446 - "women mentioned or relied on" - This is an interesting statement. The fact that they
didn’t know about them doesn’t mean they need them. If they are managing their abortions just
fine, then why? It is only where there are harms to be reduced that these are needed. Additionally,
it may not be surprising that they didn’t know about them as even with fear of law they pursued
this option right? So salience is a factor.
Line 456 - "preferable" - It is important to recognize that women present to facilities for all sorts
of reasons, including confirmation of success.
Line 476 - Ref needed as there are several databases that exist which provide data on legal
context globally. CRR and WHO (Global Abortion Policies Database) to name 2.
Line 478 - "this is the first review" - Would refrain from such statements. Not needed and
furthermore the temporal relationship (ie decision-making after the decision to terminate has
been taken) is not clear from this review.