Reviewer's report
Title:How risky are second trimester clandestine abortions in Cameroon? A
retrospective descriptive study.
Version:2Date:3 June 2014
Reviewer: Silvina Ramos
Reviewer's report:
Major Compulsory Revisions
I find the topic addressed particularly relevant given the restrictive legal context
for abortion in Cameroon and the severe barriers to access even those abortions
permitted by law that has been documented so far.
In this context, the better understanding of causes and consequences of STA is
useful since literature shows that restrictive legal conditions as well as
institutional and cultural barriers affect the timely access to safe abortion as well
as the opportunities to get a safe abortion. The comparative analysis of women´s
profiles and abortion´s consequences among those who had a FTA or a STA
seems to be one of the analytical strategies to assess the topic. But much is
needed to say regarding the context so this kind of data can be appropriately
understand.
The central question of the study is not very clearly stated based on background
considerations and literature inputs on STA. As for the former, the article lacks
any reference to the two conditions under which abortion is not penalized in the
country: medical need and rape. Even though this is not the focus of the study, if
abortion consequences are measured, specific and accurate reference to the
legal context should be explicitly addressed.
The restrictive legal and cultural context is particularly negative for STA since
raped women are more prone to delaying seeking for an abortion given the
emotional distress they need to cope with. In these situations, on top of legal
clandestinity, women might face a family clandestinity which at the end affects
the abortion process and outcomes. As for the literature, even when STA is not
as safe as FTA, the most important difference is based on the technique used.
The study aims at "evaluating the outcome of STA and to compare it to that of
FTA". Given this objetive, a more comprehensive rationale and conceptual
framework may help to understand how the data sheds light on the phenomenon.
As for the methods used, it will be useful to know a little bit more about the
instrument used to gather the information, particularly the differences between
the contents of the pretested questionnaire and the fields normally included in
patients´files. It will also help to better understand the data gathering strategy
used if the particularities of the fieldwork done to collect the qualitative
information were reported and the rationale for having chosen the variables
assessed (e.g. maternal age, parity, method used, etc.) is explicitly addressed.
Given the scope of the study, data are sound. The results might be presented in
table format -both for quantitative and qualitative information- to be more concise.
Discussion section is well organized but it can be more powerful if more
interpretations for the results were provided. The descriptive nature of the study
might not refrain the authors from building hypothesis.Besides, this section lacks
considerations on the limitations for the analysis -and particularly for the
conclusions- derived from sample size, time sample, and selection of variables to
addressed.
For the purpose of the article, it will be useful to improve the assessment of the
conditions under which women get the STA (abortion practitioner and method
used are the only variables considered for this dimension of the problem) since
literature shows that they deeply affect the STA outcomes. The authors provide
some hypothesis for the figures presented. It will be a gain for the article if those
hypothesis are backed by what previous studies in the country or in similar
socio-cultural contexts show. Little is said about what is already known regarding
STA. For example, particularly relevant is the evidence about the high rate of
STA compared to other countries, or the fact that most of STA are perfomed by
nurses. These pieces of evidence should be discussed in more detailed.
Conclusions section does not provide specific considerations but a synthesis of
the results. A very specific policy recommendation is given but even this proposal
needs to be work it.
As a final remark, the focus of the article is very interesting and could contribute
to the debate regarding current conditions under which STA is performed in
restrictive legal contexts and particular socio-cultural contexts. The information
presented should be better contextualized, and the discussion and conclusions
sections should be expanded in order to make this article a soundable
contribution for the scientific debate on abortion.
Level of interest: An article of importance in its field
Quality of written English: Acceptable
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