Reviewer ’s report  
 
Title: Risk Factors of Induced Abortion among Preparatory School Female Students, Guraghe 
Zone, Southern Region, Ethiopia: Cross -Sectional Study  
 
Version: 2 Date: 30 Aug 2018  
 
Reviewer: Heidi Jones  
 
Reviewer's report:  
 
The authors implemented a population -representative cross -sectional study of adolescen t girls 
attending preparatory schools in the Gurage Zone of Ethiopia to assess the prevalence of induced 
abortions and their complications, as well as predictors of abortion to enable targeting of 
interventions.  The authors have collected valuable data th at will be a nice addition to the 
literature.  However, the paper needs editing for grammar and word usage; I recommend 
finding/hiring an English language editor to help with the text. Additionally, I have a few 
substantive comments to strengthen the paper : 
 
1. In the Background section, I am not clear what the authors are trying to say in the first 
paragraph where they say that half of all maternal deaths are due to unsafe abortion (this 
part is clear), but the second half of the sentence and how it relate s to the first half (14% 
in sub -Saharan Africa) is not clear.  
 
 
2. In lines 12 -18, please make it clear that you are talking about complications under unsafe 
conditions.  Induced abortions under safe conditions have an extremely low rate of 
complications (f ar lower than complications from pregnancy/childbirth). See for example 
paper by Ushma Upadhyay et al in Obstetrics & Gynecology, "Incidence of Emergency 
Department Visits and Complications after Abortion".  This paper found major 
complication rate to be 0 .23 cases per 100 women (0.23%) in other words one quarter of 
one percent - extraordinarily low, as these can be extremely safe procedures.   
 
 
3. It is also unclear if you are suggesting that getting an abortion causes adolescents to 
suffer from emotional problems - is there evidence to suggest that when they get 
abortions in a safe and supportive environment they have emotional problems? If so, 
please include the references for data that support this.  
 
 
4. In the second paragraph, is there evidence that abo rtion rates are higher in rural areas in 
Ethiopia?  If so, please add a reference to the first sentence.  Also, the information on 
legal status of abortion belongs in this paragraph, with additional information about the 
number of abortions that are legal versus illegal and whether abortions that are occurring 
are likely to be occurring in a clinic with qualified health care providers or whether these 
are being done outside of the clinic setting.  The high rates of complications suggest that 
they are not be ing done by clinicians with appropriate training.  Again, in settings in 
which it is legal and trained providers do abortions, complication rates are extremely low.  
 
 
5. In general, the background section does not tell a cohesive story.  It would benefit fro m 
editing so that it is clear how the paragraphs fit together as the background rationale for 
the current study.  
 
 
6. On page 7 line 13 - I am very confused what the authors mean by being 'aware about 
when life begins'.  This is a religious/philosophical deb ate that does not have a known 
correct/wrong answer.  Please clarify what you mean.  You need to rephrase these 
findigns as when respondents 'believe' life begins not when they 'know' life begins.  
 
 
7. On page 7 line 31, there is no such thing as 'confoundi ng factors' when you are running 
predictive statistical model (confounding is only relevant when you are trying to identify 
causes based on causal hypotheses - see Schooling & Jones, "Clarifying questions about 
"risk factors": predictors versus explanation " In Emerging Themes in Epidemiology 
2018:15:10 for more information about this).  Please rephrase to say, "In fully adjusted 
logistic regression models, living relationship... were excluded."  
 
 
8. Table 1 should include row percentages - not total percentag es.  So for example, for <17 
28/(28+167) =28/195= 14.4% have had an induced abortion / 167/195 = 85.6% have not.  
These are the percentages to include next to the counts.  For >=18  27/(27+182)= 27/209 
= 12.9% have had an induced abortion / 182/209=87.1% h ave not.  You could then run a 
chi-squared statistic to see whether 14.4% is statistically significantly different from 
12.9% - that is whether age is associated with having an induced abortion and include it 
in the table.  All of the percentages should be  calculated in this manner.  The N for yes / 
no for abortion should be at the top of the table in the header rather than included as the 
last two rows of the table.  
 
 
9. Table 2 should be reformatted in the same fashion as suggested for Table 1.  Also some 
of the categories here need to be clarified.  For example, I do not understand what 
"Enforcing to abortion" means.  I find it very interesting that 32 of the girls who had an 
abortion said that they never agree with having an abortion.  This shows the exte nt of 
stigma around abortion; it is this stigma which could lead to emotional harm, from my 
perspective.  It might be useful to discuss this finding a little.  
 
 
10. Table 3 - for this table I would present column percentages - as you have done for some 
of the variables such as abortion frequency - only I would present column percentages for 
all of the variables. (That is the percentages should sum to 100% within e ach column for 
a given variable) - you should include chi -squared statistics comparing the distribution 
among girls who had an abortion vs. those who did not in this Table as well.  
 
 
11. The number of girls who reported rape as a reason for pregnancy is qui te high - 18% of 
those who had an abortion.  This is something it may be worthwhile to include in the 
discussion.  Should interventions target ensuring girls' safety?  
 
 
12. In table 3, abortion complications yes/no should be in the same column under induced  
abortion.  It would be interesting for the authors to include the complications by 
safe/unsafe, as it seems as though girls with 'safe' abortions also had complications 
(which should not be the case), unless these girls are reporting pain.  
 
 
13. The discuss ion should talk a bit more about the implications of the findings from this 
study.  How can these findings be used to target interventions?  
 
 
 
Here are some specific suggestions for grammar and word usage:  
 
Page 2, Line 3 it should read 'spontaneously or i ntentionally induced' - not 'suddenly'.  The 
official term for miscarriage is spontaneous abortion.  
 
The first sentence should read, "Abortion is defined … weight; spontaneously or intentionally 
induced in either safe or unsafe conditions."  
 
Page 2, Lin e 7 - should be 'practice' not 'practices'  
 
Page 2, Line 10 - 'may lead to' not 'leads'  
 
Page 3, Line 60 - should read 'Centers for Disease Control and Prevention'  
 
I hope these comments are helpful.  
 
 
 
 
 
 
 
 
 
 
 
Are the met hods 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.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or sa lary from an 
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3. Do you hold or are you currently applying for any patents  relating to the content of the 
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