Reviewer ’s report  
 
Title: Frequency, risk factors, and complications of induced abortion in ten districts of  
Mada gascar: results from a cross -sectional household survey.  
 
Version: 0 Date: 05 Dec 2019  
 
Reviewer: Mezgebu Yitayal  
 
Reviewer's report:  
 
Full Title: Frequency, risk factors, and complications of induced abortion in ten districts of  
Madagascar: a multistage, stratified cluster sampling survey  
 
Manuscript Number: BMWH -D-19-00453R1  
 
General Comments  
 
1. The tables shall be part of the manuscript rather than attaching as supplementary 
materials  
 
2. The title of tables should fulfill the standard, and indicate the place and time of the 
study.  
 
Abstract  
 
Methods  
 
3. Page 1, line 16 -17: What is multi -stage stratified cluster sampling survey? I am not sure 
there presence of this kind of sampling procedure.  
 
4. Page 2, line 22: ….. among sexually active women (aged 18 -49 at the interview). 
Women aged 18 and 19 years at the interview might not be the appropriate study participants if 
the age for sexually active women is considered 18 -19 years.  
Conclusion  
 
5. Incidence estimates from Madagascar are lower than those from other African settings, 
but similar when accounting for underreporting. I am not sure about the objective of this 
research. If the objective were to compare with the rates in African countries, it would be 
acceptable to conclude like this. However, the objective shall be to determine whether the 
abortion rate in Madagascar is high, medium or low based on the standards/recommendations set 
by the national or international authorities  
 
Background  
 
6. Page 4, line 2 -5: The proportion of unsafe abortions was highest in countries with 
highly restrictive abortion laws: 13% of all abortions in countries in which abortion was legal 
were unsafe, compared with 75% in countries where abortion was completely banned  or allowed 
only to save the woman's life or physical health. I am aware of the dilemmas regarding abortion 
laws. Laws regarding abortion are influenced many factors such as culture, religion, politics, etc. 
However, to present the argument like "The propo rtion of unsafe abortions was highest in 
countries with highly restrictive abortion laws" is not convincing since the authors used/cited 
only one reference/source. You could substantiate with more evidences.  
 
7. Page 5, line 12 -15: most of the studies the a uthors cited used the age category of 15 -49 
which is inconsistent with this study. How are you going to compare and contrast the findings of 
this study with previous studies in the presence of age classification differences?  
 
8. The background section lacks  theoretical and empirical evidence on the risk factors and 
complications regarding unsafe/ induced abortion. It would improve the quality of the 
manuscript if the authors try to include evidence on the risk factors and complications.  
 
9. I would have been better if the authors had stated some of the ethical dilemmas 
regarding abortion as this might be the one reason that could influence the outcome of abortion 
laws.  
 
Methods  
 
10. Page 5, line 19 -20: Women &lt;18 years were not included due to concerns about 
asking for consent from the parents…. What was the concern? Could not be possible to get 
consent from the parents and assent from women aged &gt;18 years?  
 
11. Page 5, line 20 -21: …. however, information was sought about all abortions occurring 
in the last 10 years, allowing us to capture information also about abortions. The concern is that 
you could not capture data from women aged 15 -18 years.  
 
12. Page 7, line 17 -18: …..target sample size was set to at least 17,100 censused 
individuals from the general po pulation (see Supplement for details). I could not understand why 
the authors did not use sample size calculation considering corresponding assumptions for 
sample size determination. Please indicate how you determined the sample size.  
 
13. In the method sec tion, the authors should describe how the variables were measured. 
For example, the authors should describe how the incidence rate of abortion was determined.  
 
14. Page 8, line 7 -8: Everything was done to ensure that the interview was conducted in the 
utmos t confidence. The phrase everything was done is very vague. It needs clarification what the 
authors did to ensure that the interview was conducted in the utmost confidence.  
Ethical Approval  
 
15. The authors need to provide details about ethical approval. Th ey should describe how 
consent was obtained from the study participants, and whether the consent was written or verbal. 
If verbal, why it was verbal?  
 
Results  
 
Frequency of Induced Abortions  
 
16. Page 9, line 16 -17: In total, 19,320 people were censused, of whom 4,096 were women 
aged 18 -49, 3,179 were 17 interviewed, and 2,955 women were retained in the analysis. Why did 
the authors interview 3,179 women rather than 4,096 women? Why did the authors use 2,955 
women rather than 3,179 women?  
 
17. The titles of ta ble 1, 2 and 3 should have the place and time of the study.  
Symptoms of induced abortions  
 
18. Page 12, line 14 -16: Increased risk of possible infection was significantly associated 
with increased month of pregnancy (p=0.02). It was not associated with abor tion method 
(misoprostol alone vs. other) or provider (qualified medical provider alone vs. other). I could not 
understand where this evidence came from. Before interpreting the findings, the authors are 
expected to indicate table of association.  
Care seeking for complications of abortion  
 
19. Page 13, line 3 -5: Women who sought  care for complication more often consulted 
private hospitals and clinics than public hospitals and health centers (p=0.02 by survey weighted 
paired t -test). The same commen t as comment number 17.  
 
20. Page 13, line 7 -9: Seeking treatment for abortion complications was significantly 
associated with increased month of pregnancy (p=0.01). It was not associated with abortion 
method (misoprostol alone vs. other) or provider (quali fied medical provider alone vs. other). 
The same comment as comment number 17.  
Factors associated with history of abortion  
 
21. Explanatory variables associated with the outcome/response variable should be 
interpreted indicating the values parameters such a s relative risk (RR) with 95% confidence 
interval.  
 
Discussion  
 
22. Page 14, line 21 -22: The lower value here could reflect either a true difference or be the 
result of differing methodology. If the authors report that the possible explanation is due to 
differing methodology, they are expected to describe the methodology used in other studies. 
Otherwise, it is simply personal speculation.  
 
23. I am not clear about the incidence rate of abortion in this study. The authors reported 
and discussed two figures i.e . 14/1000 and 28/1000. I recommend the authors to choose the most 
appropriate figure and compare and contrast with previous/existing evidence.  
 
24. The discussion lacks synthesis of evidences. or example, on page 16, line 4 -16, the 
authos used/cited only on e references.  
 
Conclusion  
 
25. I believe the conclusion should be based on the findings of the study, and no need to 
cite other evidence.  
 
26. Page 17, line 20 -21: The high use of invasive methods for clandestine abortions seen in 
this study is alarming and s hould also be considered in the country's future legislation. The 
recommendation should be based on the findings especially the variables associated with the 
outcome variable. It is not enough to say abortions should be considered in the country's future 
legislation. To recommend this, the authors need to capture information/data regarding abortion 
legislation, and should check it whether it was significantly associated with the outcome 
variable.  
 
Are the methods appropriate and well described?  
If not, please  specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
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 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.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscr ipt: 
 
Acceptable  
 
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, f ees, funding, or salary from an 
organisation that may  in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either n ow or in the future?  
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating t o the content of the manuscript?  
5. Do you have any other financial competing interests?  
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing int erests' 
below. If your reply is yes to any, please give details below.  
 
I declare tha t I have no competing interests.  
 
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