Title: Attitudes towards induced abortion among gynecologists in Kurdistan Region of Iraq
Version: 0 Date: 26 Jul 2023
Reviewer's report:
Dear Authors,
Thank you for submitting your manuscript titled "Attitudes towards Abortion among
Gynecologists in Kurdistan Region of Iraq" for our consideration. The study addresses an
important topic in reproductive healthcare, and we appreciate the effort you have put into
conducting this research.
1.[Abstract notes]
1. Specific Data: The abstract could benefit from including more specific data, such as the
response rates and the names of the specific cities in the Kurdistan region where the study was
conducted. These details would provide readers with a clearer understanding of the study's scope
and help contextualize the findings.
2. Inclusion of Key Findings: While the abstract mentions that "younger gynecologists tended
to have more liberal views on abortion," it could further elaborate on other key findings, such as
the overall negative attitude towards abortion among the majority of gynecologists in the region
and the varying attitudes towards abortion legalization.
3. Statistical Information: The abstract should include specific numerical data, such as
exact percentages or means, to represent the results accurately. Additionally, incorporating
information on statistical significance, such as confidence intervals or p-values, would
strengthen the interpretation of the findings.
4. Implications and Significance: The abstract briefly mentions the potential impact on women's
reproductive health but could expand on this aspect to highlight the implications of the study's
findings on access to safe abortion services and family planning options in the Kurdistan region.
5. Keywords: The abstract should include the relevant keywords related to reproductive health,
healthcare policies, and medical ethics, which would improve the discoverability of the study.
6. Sampling Method: The abstract and methods section lack information on how gynecologists
were selected for the study. It would be helpful to clarify the sampling method used and whether
the participants were randomly selected or if there was a risk of selection bias.
7. Participant Demographics: The study would benefit from including a detailed breakdown of
the demographic characteristics of the gynecologists surveyed, such as gender distribution, years
of experience, and specific cities of practice. Understanding the demographic makeup of the
sample would enhance the generalizability of the findings.
8. Limitations: The study should acknowledge its limitations, such as the possibility of response
bias, limited generalizability beyond the Kurdistan region, and potential confounding factors
that were not accounted for in the analysis.
9. Comparison with Other Regions: To contextualize the findings, the study could compare
the attitudes of gynecologists in Kurdistan with those in other regions, both within Iraq and
internationally, where abortion laws and cultural attitudes may differ.
10. Implications for Women's Health: The discussion section could delve deeper into the
potential implications of gynecologists' negative attitudes towards abortion on women's health
outcomes, especially regarding access to safe abortion services and family planning options.
11. Policy Recommendations: Based on the study's findings, the authors could consider
proposing policy recommendations to address the prevailing negative attitudes towards abortion
among gynecologists. This could involve targeted training programs or initiatives to promote
more patient-centered reproductive healthcare.
2.[Background notes]
1. Currentness of Sources: The background section relies on WHO data from 2008 and other
sources with no specified dates. To ensure the most up-to-date information, the authors should
consider referencing more recent publications or data sources, particularly for statistics related
to maternal mortality and contraceptive use in the region.
2. Clarification of Terminology: The term "induced abortion" is used throughout the background,
but it could benefit from a clear definition for readers who might be less familiar with the medical
terminology. Additionally, it might be helpful to differentiate between "safe" and "unsafe"
abortions early on, as these terms play a crucial role in the context of the study.
3. Information on Unmet Contraceptive Needs: The background mentions that one study found
an unmet contraceptive need of around 28% in the Kurdistan region, but further details about this
study (e.g., methodology, sample size, and publication reference) would enhance the credibility
of the information.
4. Estimation of Unsafe Abortions: While acknowledging the challenge in estimating the number
of unsafe abortions in the region due to the absence of an official database or published studies,
the authors could explore any existing data sources or relevant studies from neighboring regions
or countries that might shed light on the regional situation.
3.[Methods notes]
1. Sampling Rationale: While convenience sampling is a reasonable choice given the practical
constraints of accessing gynecologists, the authors could acknowledge this sampling method's
limitation in terms of potential selection bias. A discussion on how this sampling approach might
affect the generalizability of the findings could add clarity to the study's limitations.
2. Response Rate: The response rate of 53% is provided, which is valuable information.
However, it would be beneficial to elaborate on any potential reasons for non-response, as
understanding the characteristics of non-respondents can shed light on the potential impact on
the study's outcomes.
3. Digital Participation: Regarding the digital participation method, the study mentions that
150 online invitations were sent, but it does not specify how many gynecologists ultimately
participated digitally. Providing the actual number of respondents who participated online would
be useful for evaluating the proportion of digital participation.
4. Demographic Representation: While the demographic characteristics of the participants are
summarized, the authors could elaborate on the ethnic and religious diversity of the sample,
especially in the context of the Kurdistan region, where such factors might play a significant
role in shaping attitudes towards abortion.
5. Data Collection Method: The data collection method appears comprehensive, with the
questionnaire being self-administered and provided both in person and digitally. However, there
is a potential risk of response bias, particularly for sensitive topics like abortion. It would be
helpful if the authors discussed any measures taken to mitigate this bias and encouraged honest
responses.
6. Ethical Considerations: While the study mentions obtaining written or online consent from
participants, additional information on the ethical review and approval process from relevant
authorities or an institutional review board (IRB) would strengthen the ethical considerations
of the study.
7. Missing Data: The methods section does not address how missing data, if any, were handled
during the data analysis. It is important to clarify whether there were any missing data points,
and if so, how they were addressed to avoid any potential biases in the results.
8. Questionnaire Validation: The study mentions that the questionnaire used was validated, but
it does not provide information on the validation process itself. It would be beneficial to include
details on how the Taylor and Whitehead abortion attitude questionnaire was validated, which
will enhance the credibility of the instrument used.
9. Statistical Analysis: The statistical analysis methods used (Pearson chi-square and Fisher's
exact test) are appropriate for the study design and research questions. However, it would be
useful to mention any adjustments or corrections applied for multiple comparisons to avoid the
inflation of Type I error rates.
4[Results notes]
1. Sample Size Discrepancy: The number of participants in the study is mentioned as 171 in the
beginning, but later, in the "Legalization of abortion in Kurdistan region" subsection, the sample
size is referred to as 166. It is essential to clarify and reconcile this discrepancy to avoid any
confusion in the reader's understanding of the results.
2. Missing Data Handling: The results section does not mention any details about handling
missing data in the analysis. As this can potentially affect the validity and generalizability of the
findings, the authors should provide information on how missing data, if any, were dealt with
during the statistical analysis.
3. Gender Representation: The study mentions that only two out of 171 participants were male
gynecologists. This significant gender disparity in the sample might impact the representation
and generalizability of the study's findings, particularly considering that gender might influence
attitudes towards abortion. The authors could discuss this limitation and its potential implications
for the interpretation of the results.
4. Figure Labeling: Figure 1 is labeled as "Attitudes towards abortion among gynecologists,"
but it would be helpful to specify the number of gynecologists represented in the figure or the
percentage of respondents for each attitude category. Additionally, providing a clear explanation
of the Likert scale used in the questionnaire (e.g., 1 - strongly agree, 2 - agree, etc.) in the figure
caption would improve its interpretability.
5. Figure 2: The figure caption mentions "Encounters in daily work among gynecologists in
Kurdistan region of Iraq," but it does not provide the percentages or counts for each type of
complication. Including this information would enhance the visual representation of the data
and allow readers to understand the frequency of each encounterment.
6. Limitations of the Study: While the results are well-presented, there is a lack of discussion
on the limitations of the study. The authors should include a section in the discussion or results
section explicitly outlining the potential biases or constraints that may have affected the study's
outcomes, such as sampling bias, response bias, or the small number of male participants.
7. Statistical Significance: The results table (Table 2) presents statistical differences in attitudes
towards abortion based on demographic factors. However, the statistical significance level (p-
value) is missing. Providing p-values in the table or clarifying the statistical significance of the
observed differences in the text would strengthen the interpretation of the results.
8. Data on Encounters: While Figure 2 provides information on the types of complications
encountered by gynecologists, the results section does not elaborate on the implications of these
findings. It would be helpful to discuss the potential impact of encountering abortion-related
complications on gynecologists' attitudes and practices.
3. Incomplete Abortion Classification: The encounters in daily work section reports the most
common abortion complication seen among participants as "incomplete abortion" at 58%.
However, it would be helpful to clarify whether this refers to a complication of an unsafe abortion
or if it includes medically indicated or voluntary incomplete abortions (e.g., medication abortion)
performed in clinical settings.
4. Lack of Context for Encounterments: The "Encounterments in Daily Work" section provides
valuable information on the frequency and types of abortion complications encountered by
gynecologists. However, it would be beneficial to discuss the impact of these encounters
on gynecologists' attitudes towards abortion, as witnessing complications could potentially
influence their views on abortion legalization.
5. Data Analysis for Sociodemographic Factors: While Table 2 provides data on the attitudes
towards abortion legalization based on sociodemographic factors, there is no mention of any
multivariate analysis or control for potential confounding variables. The authors could consider
conducting a multivariate analysis to better understand the independent associations between
sociodemographic factors and attitudes towards abortion.
6. Addressing Potential Biases: The study uses convenience sampling, which may introduce
selection bias. The potential impact of this bias on the study's results should be acknowledged,
and any steps taken to mitigate its effects should be discussed.
7. Strengths and Limitations: The results section does not explicitly highlight the strengths and
limitations of the study. Incorporating a brief discussion of the study's strengths, such as the
validated questionnaire and inclusion of both public and private sector gynecologists, as well as
its limitations, would provide a balanced perspective to the readers.
5.[Statistical Analysis notes]
1. Descriptive Statistics: Descriptive statistics were used to summarize and present the
sociodemographic characteristics of the study population, including sex, age, marital status,
years of practice, ethnicity, religion, and religious belief. These descriptive statistics are
important for understanding the composition of the study sample.
2. Chi-Square Test: The Pearson chi-square test was used to compare categorical data related to
gynecologists' attitudes towards abortion and their sociodemographic characteristics. This test is
suitable for analyzing the association between two categorical variables and was used to assess
the relationship between attitudes towards abortion legalization and age groups, marital status,
and years of practice. The results of the chi-square test are presented in Table 2.
3. Fisher's Exact Test: Fisher's exact test was utilized when the sample size in one or more of the
compared groups was less than five. This test is an appropriate alternative to the chi-square test
for small sample sizes. The authors mentioned using Fisher's exact test, but the specific variables
and results that necessitated the use of this test were not explicitly stated in the results section.
4. Likert Scale Analysis: The attitudes of gynecologists towards abortion were assessed using
a 10-item questionnaire with a four-point Likert scale (strongly agree, agree, disagree, strongly
disagree). The responses were quantified and presented as percentages, allowing for a clear
understanding of the distribution of attitudes.
5. Interpretation of Statistical Significance: The authors appropriately used p-values to assess
statistical significance. They considered p-values less than 0.05 as statistically significant, which
is a common threshold in many research studies.
Highlighted points statistically:
1. Multiple Comparisons: Given that multiple comparisons were likely made across various
demographic factors, there is a potential for Type I error inflation. It would be beneficial if
the authors acknowledged this concern and discussed any adjustments, such as Bonferroni
correction, that were applied to address this issue.
2. Non-Response Bias: The study reported a response rate of 53%. While this is not uncommon
in survey research, the potential for non-response bias exists. It would be helpful if the authors
acknowledged this limitation and discussed possible implications for the study's results.
3. Missing Data Handling: The methods section does not mention how missing data, if any, were
addressed during the statistical analysis. It is crucial to clarify how missing data were handled
to ensure the validity of the results.
4. Multivariate Analysis: The study primarily focused on bivariate relationships between
attitudes towards abortion and demographic factors. Consideration of multivariate analysis, such
as logistic regression, could have allowed for controlling potential confounders and identifying
independent associations.
5. Limitations of Statistical Analysis: While the statistical tests used are appropriate for the
data and research questions, it is important to acknowledge that statistical significance does
not necessarily imply practical or clinical significance. The authors should discuss the practical
implications of their findings and avoid overgeneralizing based solely on statistical significance.
6.[Discussion notes]
1. Limited Generalizability: The discussion correctly points out the limitation of generalizability
due to the convenience sampling method used. However, it would be beneficial to further discuss
how the sample's characteristics might differ from the broader population of gynecologists in the
Kurdistan region. The authors could explore potential biases introduced by the sampling method
and discuss whether the findings are likely to be representative of the entire gynecological
community in the region.
2. Low Response Rate in Sulaymaniyah and Duhok: The discussion acknowledges the lower
response rate from Sulaymaniyah and Duhok and attributes it to not handing out questionnaires
face-to-face in those cities and generally lower research engagement in those areas. However, it
would be helpful to elaborate on the potential impact of this lower response rate on the study's
results and interpretations. Are there any demographic or sociocultural differences between
respondents from Erbil and those from Sulaymaniyah and Duhok that might affect the study's
outcomes?
3. Understanding of Terminology: The discussion acknowledges the potential for
misinterpretation of certain terms, such as "abortion" and "religious or secular beliefs." To
address this limitation, the authors propose including explanatory paragraphs in the consent form
and conducting interviews. While these suggestions are relevant, more in-depth discussion on
the specific challenges related to terminology in the context of Kurdistan's cultural and linguistic
diversity would be valuable.
4. Insights from Negative Attitudes: The discussion adequately highlights the conservative
attitudes towards abortion among gynecologists in the region. However, it would be beneficial to
delve deeper into the reasons for these negative attitudes, apart from religious beliefs. Are there
other cultural, societal, or legal factors that might contribute to these perspectives? Exploring
these aspects could provide a more comprehensive understanding of the underlying drivers of
gynecologists' attitudes towards abortion in Kurdistan.
5. Implications for Reproductive Health Policies: While the discussion identifies the potential
impact of negative attitudes towards abortion on the prevalence of unsafe abortions and maternal
health, it could further discuss the implications of these findings for reproductive health policies
in the Kurdistan region. How could policymakers and healthcare authorities address these
attitudes and promote safe and accessible abortion services without compromising cultural and
religious values?
6. Comparison with International Data: The discussion briefly mentions findings from other
countries, such as Guatemala, Egypt, and Mexico, to contextualize the results. However, more
in-depth comparisons and discussions of how these findings align or diverge with the Kurdistan
region's situation would enrich the analysis and broaden the study's perspective.
7. Interview-based Qualitative Data: While the discussion suggests conducting interviews to
better understand participants' attitudes towards abortion, it could provide more rationale for the
use of qualitative data in complementing the quantitative findings. How could qualitative data
offer additional insights that quantitative data alone might not capture? What specific research
questions could be addressed through interviews or focus groups with gynecologists in the
region?
8. Limited Qualitative Insights: The authors mention the necessity of conducting a qualitative
study to delve deeper into the attitudes of gynecologists towards abortion. While this is a valuable
suggestion, the discussion could benefit from elaborating on the specific aspects that a qualitative
study could explore. For example, qualitative interviews could help understand the underlying
reasons behind the contradictory attitudes towards abortion, the complexities of religious beliefs
and their impact on attitudes, and the experiences of gynecologists in providing post-abortion
care. Providing more concrete examples of potential research questions for a qualitative study
would strengthen this recommendation.
9. Addressing Potential Bias: In the methodological considerations, the authors acknowledge
potential limitations related to sampling and response rates. However, in the discussion, there
could be further discussion on how these limitations might impact the study's internal and
external validity. Specifically, the authors should discuss how the relatively low response rate
from Sulaymaniyah and Duhok might affect the generalizability of the findings to the entire
Kurdistan region.
10. Relating Findings to Healthcare Practice: The discussion could further explore the potential
implications of gynecologists' attitudes towards abortion on women's healthcare access and
outcomes. For instance, do conservative attitudes towards abortion impact the quality and
availability of family planning services in the region? Are there any barriers to accessing safe
abortion services that arise from gynecologists' attitudes? Discussing the potential consequences
of these attitudes on healthcare practice would provide a more comprehensive understanding of
the study's implications.
11. Regional and Cultural Context: While the study focuses on the Kurdistan region of Iraq, the
discussion could benefit from further contextualizing the findings within the broader cultural and
religious landscape of the region. Are there specific cultural norms or religious beliefs that may
influence attitudes towards abortion among gynecologists and the general public? Understanding
the unique cultural and social factors at play would add depth to the interpretation of the study's
results.
12. Future Research Recommendations: The authors mention the need for further research to
explore the complexities of gynecologists' attitudes towards abortion. While qualitative research
is suggested, the discussion could also propose other potential avenues for future research,
such as comparative studies across different regions in Iraq or investigations into the impact
of healthcare policies on abortion attitudes. Offering a broader range of research possibilities
would strengthen the recommendations for future studies.
7.[Conclusions notes]
1. Addressing Contradictions: The conclusion mentions that younger gynecologists had a more
liberal viewpoint on abortion, yet the overall attitude towards abortion among gynecologists in
the region is negative. The authors should address this apparent contradiction by providing a
possible explanation for why the overall attitude remains negative despite the more liberal views
of younger gynecologists. Is there resistance to change among older gynecologists, or are there
other factors influencing the predominant negative attitude?
2. Implications for Reproductive Healthcare: While the study rightly emphasizes the importance
of further investigation and raising awareness, the conclusions could further discuss the potential
implications of the negative attitudes towards abortion on women's reproductive healthcare
in the Kurdistan region. How might these attitudes impact women's access to safe and legal
abortion services, family planning, and overall reproductive health outcomes? Discussing the
potential consequences of these attitudes on healthcare practice and women's health is essential
for understanding the broader impact of the study's findings.
3. Policy Recommendations: While the conclusion discusses the importance of understanding
laws and policies in place, it does not explicitly provide specific policy recommendations
for addressing the issue of abortion in the Kurdistan region. Considering the sensitive
nature of this topic, offering well-considered policy recommendations would strengthen
the practical implications of the study. These recommendations could focus on improving
access to reproductive healthcare, addressing barriers to safe abortion services, and promoting
comprehensive reproductive health education.
4. Limitations and Future Research: The conclusions section could benefit from a concise
summary of the study's limitations, especially those that might impact the generalizability
and interpretation of the findings. Additionally, the authors should provide a more explicit
discussion of specific areas for future research based on the study's outcomes. For instance, what
further research is needed to explore the factors influencing attitudes towards abortion among
gynecologists and the general public in the region?
5. Cultural and Societal Context: While the conclusion emphasizes the importance of
understanding laws and policies, there could be further exploration of the cultural and societal
factors that shape attitudes towards abortion in the Kurdistan region. Considering the unique
cultural and religious landscape of the region, discussing how these factors influence the
perceptions of abortion would provide more context and depth to the conclusions.
8.[References notes]
1. Lack of In-text Citations: The review report for the sections (Introduction, Methods, Results,
and Discussion) did not include specific in-text citations to indicate which sources were
referenced for each statement. Providing in-text citations would help readers easily identify
the sources that support the study's findings and conclusions. It is essential to connect specific
statements in the text to the corresponding references to ensure accuracy and transparency in
citing the literature.
2. Dated References: Some of the references cited in the study are relatively old, dating back
to 2010 or earlier. While certain foundational sources may still be relevant, it is essential to
incorporate more recent literature to demonstrate up-to-date knowledge of the subject. Including
recent research articles and publications will strengthen the study's validity and relevance in the
current context.
3. Inclusion of News Reports: While news reports can provide useful contextual information,
it is generally preferred to rely on peer-reviewed academic sources for the main findings
and conclusions. News reports may lack the same level of rigor and scrutiny as scholarly
publications. Whenever possible, the study should prioritize academic research articles and
official reports over news sources to maintain the scientific integrity of the work.
4. Review Article Citation: Reference [2] appears to be a review article that likely provides
an overview of the topic rather than primary data. It would be beneficial to complement such
review articles with original research studies to strengthen the evidence base and ensure that the
conclusions are well-supported by empirical data.
5. Complete Formatting of Citations: In some references, certain details like page numbers or
issue numbers are missing. Ensuring that all references are complete and accurately formatted
according to the chosen citation style (e.g., APA, MLA, etc.) is crucial for maintaining scholarly
rigor and consistency.