Title: Partner involvement in abortion trajectories and subsequent abortion safety in Nigeria
and Côte d’Ivoire
Version: 1 Date: 01 Feb 2022
Reviewer's report:
This paper examines the cross-sectional relationship between partner involvement in abortion
decision and method selection, and use of a “most unsafe” abortion method/source among about
1,500 women in Nigeria and Cote d’Ivoire who have ever had an abortion in the PMA sample
(2018-2020).
The paper contributes to the literature, demonstrating an association between partner
involvement and safer abortion and suggesting that educating men about safe abortion methods
and sources in restrictive settings might help to reduce abortion-related morbidity and mortality.
Data on people seeking abortion in such settings and outside of legal facilities are very
challenging to collect; harnessing the representative PMA sample and infrastructure to examine
abortion experiences is thus a strength of the paper. The paper is well-written; statistical analyses
used are appropriate; and conclusions drawn largely based in findings presented. Another
strength is the coding of abortion safety, which accounts for the possibility of relatively safe
abortion outside the legal context (e.g., mifepristone/misoprostol medication abortion); I also
appreciate the terminology used to elicit abortion history (lines 194-197).
My largest concern is unmeasured confounding. I suspect that unmeasured factors (stigma of
abortion generally or under certain circumstances, gender disempowerment, differing fertility
intentions, context of the unwanted pregnancy, low education and mobility) are strongly related
to women not divulging the pregnancy to the partner / not obtaining his help in finding a method,
and to constrained access to safe care. To the extent there is such confounding, the conclusion
of educating men about safe abortion options might not have the intended effect of changing
abortion safety.
There are also important limitations to the sample, including that it excludes women who
died from an abortion; those who were unable to access abortion (including due to partners);
those whose abortions were ineffective (took non-abortive pills). Many of these limitations are
common to abortion data, and the authors thoroughly acknowledge them in the Discussion.
Suggestions to strengthen the paper in a revision:
*Overall the paper would benefit from substantial streamlining of the text.
Throughout the paper (including the title and abstract), the investigators use the term abortion
“trajectory.” This term seems inaccurate. The word “trajectory” implies following a person over
time, and this analysis doesn’t really look at trajectories. See also my comment below about the
portrayal of an abortion trajectory as linear.
Given the cross-sectional nature of the data and the inability to determine causality, I suggest
avoiding the word “affect” in the title (perhaps use “associated”).
Introduction:
Framing of partner disclosure seems to assume “involvement” is voluntary, i.e. that women
choose whether or not to disclose to the partner. I think it is important to note that partner
disclosure about a pregnancy can also be involuntary – male partners find out or women are
unable to hide a pregnancy. This is mentioned in the Discussion but might be made clearer
upfront.
Lines 100-130: Describes abortion decision-making and care-seeking as a linear process. Just
noting that, at least in settings outside of Africa, not such a linear progression. For instance
a person can decide they want an abortion, seek one, not find one, and then determine they
need to involve a partner in order to circumvent obstacles encountered. Suggest revising and
acknowledging the nonlinear nature of the abortion experience for many.
Line 119: Reference needs a year.
Methods:
How long ago were the abortions that respondents reported? I am wondering about confounding
by time: that abortions further in the past were both more unsafe (lack of mife/miso availability)
and also were less likely to involve a partner. The investigators might consider repeating analyses
removing abortions sought prior to the last decade (or controlling for time since abortion).
How did respondents know which pills they had obtained? Did interviewers show samples of
different types of pills? This seems important for the coding of the outcome.
Line 175: “these most unsafe abortions” – which? Implies that an abortion to save a woman’s
life or resulting from rape is “most unsafe.”
Line 187: Clarify “November-February 2018.” Should this be “November 2018-February
2019?”
Line 210: Clarify here that “first” refers to the first method tried in a single abortion experience,
not the first of multiple abortions sought.
Lines 228-236: Clarify that mife/miso from a non-clinical source was considered safe. (I had to
look at Table 4 to understand this.)
Lines 274-276: Clarify “including an interaction term for the two types of partner involvement.”
I think this means that the investigators hypothesize that the partner’s being involved in both the
decision AND the method selection would have a multiplicatively greater effect on safety than
the independent effect of each individually?
Results:
Tables 3 and 4: The investigators might consider presenting column percentages instead of row
percentages. It was difficult (for me) to assess differences in the current presentation.
Table 3: Error with “parity” p-value?
Table 6: Please clarify the independent variable here. It looks like the model had both partner
involvement in decision and, separately, selection. But those would be two separate models – so
it is unclear from which model the covariable effect estimates come. (Text lines 367-368 note
that this is not an interaction model, so both exposures shouldn’t be in one model.)
Discussion:
Could the authors comment (here or elsewhere) on the lifetime abortion prevalence in these data
and the degree of underreporting they suspect based on other estimates? Is 20% or so about what
would be expected?
Line 384: Again, per comment above, would not assume partner involvement in decision was
at “the beginning of their abortion trajectory.”
Lines 402-403: The finding that men were more often involved in the decision than the method
selection could also be because men lack information about abortion sources. This seems an
important point to support the conclusions drawn.
Lines 512-519: Text belongs in Results