Reviewer's report
Title:Assessment of the magnitude and determinants of abortion among Wolaita
Sodo female university students, Wolaita zone,Ethiopia.
Version: 2Date:9 July 2013
Reviewer: Holger Unger
Reviewer's report:
The authors present the results of a descriptive cross-sectional study assessing
the magnitude and determinants of abortion among female university students in
the Wolaita zone, Ethiopia. Given the high number of maternal deaths in Ethiopia
overall, and in view of unsafe abortions contributing 32% to maternal deaths in
the country, such research is clearly of importance.
The authors collected a large amount of data yielding potentially important
information that may contribute towards shaping national and international policy
and strategy addressing the high burden of maternal morbidity and mortality in
low-income countries.
In order to prepare for publication the paper requires significant editing,
restructuring and re-review. Nevertheless, I believe this research is very
worthwhile to be published in BMC Womens’ Health once changes have been
made.
Minor essential revisions
1. The paper is too long: introduction, results and discussion chapters need to be
written more succinctly. The introduction contains a lot of interesting background
data but this could be summarised further, both in the ‘burden’ and ‘determinants’
sections (Personally, I would not use sub-headings in the introduction, just
separate content by paragraphs). The results section could be trimmed down –
there is a lot of data here but not all of it may be needed to get your message
across. The discussion chapter sometimes repeats data already presented in the
results section – this needs to be avoided.
2. The flow and presentation of results in the paper does not reflect the title (first
magnitude/burden, then determinants). Personally, I would start the results
section with presenting the abortion rates you observed, and characteristics of
these abortions, and then explore risk factors, knowledge of legal situation, and
wider context (sexual debut, condom use etc). Think about the structure a) How
many?, b) Who?, c) Why? Etc.
3. It is really important to state the number of women who experienced abortion
in your cohort (n=32/493) early on in the paper (first thing in your results section).
When assessing for potential risk factors in a case-control fashion, the small
sample size may introduce bias and increase statistical error (needs to be
discussed as a limitation).
4. Introduction: The first sentence needs to be referenced. The use of ‘on the
other hand’ in the third sentence is not appropriate – I suggest deleting it.
Consider restructuring the first paragraph – a) situation worldwide, b) situation in
sub-Saharan Africa overall, then situation in Ethiopia. The same applies when
reviewing abortion/burden thereof. This section needs to be summarised
significantly – select the most important figures and present them, and ‘just’
reference the rest - those interested can read up the primary reference(s).
Include a couple of sentences that briefly and succinctly summarise the legal
situation regarding abortion in Ethiopia so that the ‘scene is set’ for the reader
right from the start. Make it very clear why this study was needed, given there are
already quite a few, and university students may not necessarily be at highest
risk, compared to other groups of women in the country (rural, illiterate etc).
5. Methods: I am not entirely sure excluding all those participants who did not
provide complete answers (n=21) is the correct thing to do, unless they contained
no data at all – you may introduce some bias here (those who are not completing
all questions may do so for a reason and may indeed by ‘high-risk’). It might be
better dealing with missing data afterwards. The rate of abortion used in your
sample size calculation (20%) is significantly higher than the one you found in
your cohort (6.5%) and the one you cited in the abstract (2.3%). How does this
affect your analysis? There are too many sub-headings in the Methods section.
Variables used in your analyses could be summarised and included in the data
analysis section – how did you chose the variables you looked at univariately,
and how did you decide which ones to include in the multivariate mode (e.g.
stepwise regression analysis etc)? You are stating that you were using two
research methodologies – qualitative (by questionnaire) and quantitative (by FGD
and key informant interviews). It is unclear which of results originate from
quantitatively or qualitatively collected data. In fact, it seems that the majority of
data presented came from the questionnaires. If you are using data from your
qualitative part of the study you need to describe qualitative research
methodology in more detail (was this data analysed by content analysis,
grounded theory, how were participants - e.g. key informants – recruited, etc etc),
and highlight it in the results section (e.g. by using quotes). This is really
important.
Your initial study design is cross-sectional and explorative, but you are then
doing post-hoc case-control work to determine risk factors for getting an abortion
(and for intercourse and contraceptive use). This might be worth mentioning in
your methods section.
6. Results. As mentioned earlier, you may wish to consider restructuring this:
How many had abortions (name rate here, not only in abstract), what type etc,
then look at risk factors for abortions (basically table 3 – I am surprised you did
not include religious affiliation in this analysis – it may be important), then explore
other things such as knowledge of legal situation in Ethiopia in the whole cohort
(interesting!), attitudes towards pregnancy and abortion, methods of prevention
etc. Once you presented this data it might then be worth discussing the fact that
when looking at your cohort not many women actually had their sexual debut yet
and if they did 1/3 or so ended up having an abortion – that is shocking and
needs urgent intervention.
Table 1 – I do not understand why you have n=897 for pocket money. Also, it
seems you were missing data for some variables e.g. age etc. – I suggest you
create a separated identifier for ‘missing data’ for each variable and present
percentages for the total sample set (n=493).
Figure 2 – n=11. Is this correct? It seems that total number is 26. What is
‘Embway’?
Table 3 – there is a typo there, I think it is meant to say abortion yes/no, not ‘ever
had sex’ which is what you looked at in table 2. Table 3 does not seem to be
referenced in the main text.
Table 4 – remove the duplicate ‘in case of rape’
For your main outcome measure (abortion versus no abortion) consider stating
results of your univariate analysis (significant ones) and subsequently state
which ones remained significantly associated with the outcome in your
multivariate logistic regression analysis.
7. Discussion.
Try and summarise this a little more, and structure it according to the results.
Avoid repeating results already presented in the paper. Include areas of future
research (e.g. what do young men at university know about contraception etc.)
8. Recommendation: (include this at the end of your discussion). Awareness
work seems very important too (condom use, other methods of family planning,
etc). How many women in your cohort would actually have fulfilled the criteria for
a legal abortion by Ethiopian legal standards – perhaps not so many, in which
case strengthening access to, and supply of, places that provide safe termination
of pregnancy is important, but prevention of unwanted pregnancy, and lobbying
the government to amend legislation may be equally important. Given the
relatively high use of hormonal emergency contraception it seems that there
hormonal EC AND abortion may be perceived as ‘acceptable’ means of family
planning – this needs addressed. Alcohol use has been found a potential risk
factor for abortion/unwanted pregnancy in the first place. In addition to reducing
alcohol intake etc it might be worth targeting stores/bars as a main point for
condom distribution, health awareness, etc. We may not be able to stop young
people to drink, and engage in sexual activity early, but we may be able to
convince them to take control by using condoms or hormonal contraception.
What role have Ethiopian men have to play? How much control do Ethiopian
women truly have over their reproductive lives? It is really important that men are
included in the fight to reduce unwanted pregnancy, unsafe abortion and
maternal mortality (future research).
Other comments:
Use one tense through (e.g. past tense)
Grammar problems - language editing required
Editing work (e.g page 6 first sentence – ‘lack of interest interested’) etc.
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, but I do not feel adequately qualified to assess the
statistics.
Declaration of competing interests:
I declare that I have no competing interests