Reviewer’s report
Title: Why do they take the risk? A systematic review of the qualitative literature on informal sector  
abortions in settings where abortion is legal
Version: 0 Date: 24 Oct 2018
Reviewer: Tamara Fetters
Reviewer's report:
Dear Authors,
I found this manuscript very interesting and very helpful.  Even though the number of articles was  
small, it is an important question to review. I have very minimal comments and suggestions.   I look  
forward to seeing it in print.  
I believe that the current proportion of maternal deaths due to unsafe abortion is 8% (Sedgh G et al.,  
Abortion  incidence  between  1990  and  2014:  global,  regional,  and  subregional  levels  and  trends,  
Lancet, 2016, 388(10041):258-267).
I think that somewhere in this discussion you should mention that there are not just two outcomes for  
an abortion, but that morbidity can be lengthy and can lead to delays which increases risks if a lay or  
formal woman or a provider needs to complete that abortion.  Also, taking ineffective medication or  
even effective medication that is in the wrong dosage, may not cause morbidity but can be ineffective  
and lead to further delays and expense.  
I think that this is an important article to reference in your discussion: 1.Developing a forward-looking  
agenda  and  methodologies  for  research  of  self-use  of  medical  abortion;  Kapp,  Nathalie  et  al.;  
Contraception , Volume 97 , Issue 2 , 184 – 188.
On page 3, in the section on The Adopted Methodology, I think it would be good to mention here that  
even self-induction and unsafe abortions outside of facilities can have legal consequences for women  
and providers. Also, in this section, it would be good to be clearer that these two options presented as  
"two trajectories" are often intrinsically intertwined.  Many, if not most, women trying to have an  
induced abortion outside of a health facility end up trying multiple times to have a complete abortion.  
Can you mention why you did not include Spanish in the paper?  I wonder if you may have found  
significantly more articles?  
In Table 2, I would love to see you add a column for the size of these samples in the included studies. 
I think that there may be articles on unsafe/clandestine abortion from Cambodia which would meet  
your criteria.  Can you check that one more time?  
On page 9, in the section on lack of knowledge, please consider that a lack of knowledge might be  
different from an inability or confusion about how to navigate the health system.  Did any of the  
articles discuss this?  It seems an important distinction. 
Women's social networks.  I know that at least one of these studies refers to knowing a health worker as  
a determinant for accessing a safe abortion.  This might be useful to mention, especially if there are  
others, or even if not.  This does imply that SES might be a factor as these networks are more common  
among families of professionals. 
I think that you might like to reference this article in your discussion: Trajectories of women's abortion-
related care: A conceptual framework. Coast E, et al. Social science & medicine (2018), ISSN: 1873-
5347, V ol: 200, Page: 199-210 
On page 11, you mention, "ISA is seen as the normal trajectory".  Is there another descriptor perhaps?  
Most common? one of the challenges of a review like this is capturing articles with odd names, did you  
consider this article as possibly meeting your inclusion criteria?  Meselu Taye Kebede, Per Kristian  
Hilden & Anne-Lise Middelthon (2012) The tale of the hearts: deciding on abortion in Ethiopia,  
Culture, Health & Sexuality, 14:4, 393-405, DOI: 10.1080/13691058.2011.649495 
Just a couple of comments in the Discussion section.  Did any of these articles mention that women  
thought unsafe abortion was dangerous?  Did they think all abortion was dangerous?  Were they  
fearful?  
Are there programmatic implications for your findings and for abortion services, in general?  Could  
you give this a little more thought?
You present findings on cost of services as a deterrent but in fact some of these articles found that ISA  
cost more than in-facility abortions.  It would be good to present these as perceived costs and also  
mention this finding.  
I am not sure that a first mention of misoprostol for harm reduction on page 13 is appropriate.  If it was  
a finding, it should be in the Results, if not, this should be removed. 
In terms of your reference [41] there are actually many many organizations, networks and digital  
sources for this now.  It would be good to round that out.  Perhaps the Kapp article will help?  
In the last paragraph before the conclusion, you comment on regulations.  These regulations should in  
fact not be burdensome impediments, the role of these policies should be to facilitate safe abortion care,  
no?  I don't think it is only about anonymity.  Also, regulations are to be written by ministries and  
medical professionals and not lawyers, they might work better!  
I have one of the articles you are looking for by Rosemary Likwa from Zambia.  I have attached it as a  
reviewer attachment.    
I think your conceptual framework is maybe too simple.  Please review the ones in the Coast studies.  I  
think that an outcome can also be short and long-term morbidity or death.  I think that these trajectories  
often cross.  In our research a significant proportion of women who sought legal services had already  
tried trajectory 1 and there is a premise that many of the women in trajectory 1 are really just trying to  
get to PAC services (I am not sure I believe that but it should be mentioned).  I am not sure how to  
show this visually but this feels too black and white.  
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Yes
Are you able to assess any statistics in the manuscript or would you recommend an additional  
statistical review?
If  an  additional  statistical  review  is  recommended,  please  specify  what  aspects  require  further  
assessment in your comments to the editors.
Not relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
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