Title: Post-abortion needs-based education via the WeChat platform to lessen fear and
encourage effective contraception: A Post-abortion Care Service intervention-controlled trial
Version: 3 Date: 01 Dec 2023
Reviewer's report:
Recommend rejection.
This article has numerous problems that do not make it suitable for publication including: lack
of citations and inaccurate statements not based in current scientific literature, and unclear
methodology and outcome measures make it impossible to evaluate the merits of this article.  I
think the use of WeChat for education is the most interesting part of this article, and encourage
the authors to do more extensive reading of current literature on abortion, contraception and
unintended pregnancy, and substantially revise their methodology to make their research aims
and process clearer. I would encourage them to remove anxiety as a measure unless they can
more clearly demonstrate its relevance to their evaluation of the different educational methods.
Introduction: The entire beginning of the introduction needs more citations supporting the claims
of the authors. Also, some of the statements are too vague and need specificity to understand
what the authors are referring to. For example, what “drug provision” are authors referring to
on line 96? Contraception? Additionally some of the statements are incorrect.
Line 113: I’m not sure if this is a language issue, but I don’t understand what is meant by “abort
artificially or medically" as this is not in line with international understandings of abortion.
Line 118: Not sure what types of contraception authors are referring to as "highly effective" -
assume LARC but this is not clear.
Line 120-128: These statements are not based on current science on abortion and rather
repeat debunked science on abortion care. The authors did not include any citations to
support their claims on the psychological and physical harms of repeated abortion,  as
this is not supported with current science, which finds that abortion is extremely safe and
safer than pregnancy continuation (https://www.acog.org/advocacy/abortion-is-essential/come-
prepared/abortion-access-fact-sheet; https://www.who.int/health-topics/abortion#tab=tab_1),
and is not linked to adverse psychological impacts (https://www.apa.org/
monitor/2022/09/news-facts-abortion-mental-health; https://www.ansirh.org/sites/default/files/
publications/files/mental_health_issue_brief_7-24-2018.pdf). I advise the authors to do
additional research into global literature on abortion and repeated abortion care, which finds
that primary issues with repeated abortions are the intersectional inequalities experienced by
people who are experiencing lower levels of reproductive autonomy due to financial insecurity,
intimate partner violence or reproductive coercion, adverse effects of contraception,  and
other disparities in access to reproductive healthcare options  (Weitz T, Kimport K. A need
to expand our thinking about “repeat” abortions. Contraception 2012;85:408–412; Jones R,
Jerman J, Ingerick M. Which Abortion Patients Have Had a Prior Abortion? Findings from
the 2014 U.S. Abortion Patient Survey. J Womens Health (Larchmt). 2018 Jan;27(1):58-63.
doi: 10.1089/jwh.2017.6410. Epub 2017 Aug 23. PMID: 28832238; PMCID: PMC5771530.).
After doing some additional reading in this area, I advise the authors to refocus their premise
on the issue of reproductive autonomy, and the ability to effectively use contraception to
prevent unintended pregnancy, which I believe is more in line with the methods and goals of
their study (Potter JE, Stevenson AJ, Coleman-Minahan K, Hopkins K, White K, Baum SE,
Grossman D. Challenging unintended pregnancy as an indicator of reproductive autonomy.
Contraception. 2019 Jul;100(1):1-4. doi: 10.1016/j.contraception.2019.02.005. Epub 2019 Mar
7. PMID: 30851238; PMCID: PMC6919552.).
Methods:
Line 155: I am again not sure if this is a language question - but I would consider the statement
that the hospital provided care to higher socioeconomic status individuals to be a limitation of
this study. The lack of diversity in patients' economic status might be a large factor in their ability
to access contraceptive care, as is shown in other studies (Metcalfe A, Talavlikar R, du Prey B,
Tough SC. Exploring the relationship between socioeconomic factors, method of contraception
and unintended pregnancy. Reprod Health. 2016 Mar 22;13:28. doi: 10.1186/s12978-016-0151-
y. PMID: 27000406; PMCID: PMC4802908.).
The methods need a figure to explain who is in which part of the study, because as it is written
it is very confusing in how the groups were divided. What are the "private interviews"?  And
how do the private interviews connect to the different education groups?  (line 160)
I am not at all sure what the anxiety is measuring based on reading the methods. Anxiety
about the choice of contraception? Anxiety about getting pregnant again? Anxiety about  the
abortion and post-abortion care?  It does not make sense as a measure and seems like it would
make more sense to do a longitudinal measure of if patients became pregnant again, desire to
avoid pregnancy scale, their use of preferred contraceptive option, and their understanding or
satisfaction with the educational materials.
Table 1 is formatted in such a way that I cannot read it in the downloaded word document. Also,
are these the message being presented to patients? It's interesting that contraception doesn't start
until two weeks after the abortion, and I don't understand why that would be the case, is it not
standard of practice to prescribe or make appointments for contraception at the time of abortion?
Figure 1 is not really readable in its current presentation and a more effective way of presenting
this data should be considered.
Line 169: what is meant by the criteria "no contraceptive requirement in the last year?"
I'm also very confused about the creation of the WeChat educational materials. Is part of this a
pilot study to determine what educational materials people were most interested in, and then that
information was pushed out during the actual WeChat education? Were these things happening
simultaneously?  Also, the time scales for the control and the WeChat groups don't appear to
be the same, in terms of frequency of interventions and also (maybe, very unclear?) length of
intervention. This seems to be a very clear discrepancy that would shape effectiveness, if one
group is hearing the same messages more frequently than the other, and that is not discussed
in the limitations.
(paragraph 246) I have no understanding of how the types of methods are categorized by
effectiveness after reading this paragraph. This needs serious revision.
Results: There are almost no results presented in text and the explanation of them in inadequate.
The anxiety results are especially confusing based on the results given, as it seems to be
measuring the distress of unintended pregnancy. Is the second measurement supposed to be of
the lack of unintended pregnancy? Knowing about contraception? The relief at having had an
abortion? I have no way to judge the significance of these results because this is just a generalized
anxiety scale and may or may not have any relevance to the questions around pregnancy.
Discussion:
Lines 316-320: This sentence is very confusing and requires additional explanations, as it seems
from the methods section like the WeChat group had many more frequent interventions and
educational categories than the control group, and this sentence appears to be arguing the
opposite of your results.
Line 333: what is meant by "luck based precaution?"
Line 337-341: It is very unclear from this sentence what differences you are describing between
the two education methods. What do you mean by "graphic enough"?
I think the opportunity to address the many different questions that people have post-abortion in
the WeChat group is a very interesting approach and has a lot of potential benefits for providing
people with high-quality education and care, I encourage the authors to reevaluate their methods
and framing in future work on this topic. I also encourage the authors to utilize more editing
services, as there are broad issues with clarity in this article which impact understanding of the
methods.