Title: ‘It’s a secret in my life’: Frontstage and backstage experiences of women undergoing
induced abortions in a rural community of Pakistan
Version: 2 Date: 03 Jun 2024
Reviewer's report:
Manuscript BMC Women’s Health 2024 06 03
‘It’s a secret of my life’: Frontstage and backstage experiences of women undergoing induced
abortions in Pakistan
In this grounded theory (GT) study, women with experiences of induced abortions are sharing
their views and experiences via individual interviews and focus group discussions (FGDs).
Even if abortion is legally sanctioned in Pakistan (before 16 gestational weeks, and specific
reasons?), there are sociocultural and religious barriers and patriarchal norms that affect and
disrupt the choices women can take when they become pregnant unintentionally. The authors
elicit that people in Pakistan regard reproduction and motherhood as central.  Erwing Goffman’s
dramaturgical theory of frontstage and backstage seems innovative to apply in the manuscript,
especially in the Result section.  Abortion is a very important topic and has its place in BMC
Women’s Health, and the manuscript is very interesting. There are several issues that needs to be
clarified and further elaborated in the manuscript before it can be published. A language check
seems also relevant.
Below, I provide comments to each part of the manuscript.
Title
The title is creative. A minor comment. The sample consists of women who are living in a rural
area of the country, and this could be mirrored in the title.
Introduction
We need to know more about what types of abortions that are performed, i.e. provide statistics on
surgical and medical abortions in Pakistan. Which methods are most common. A guess would be
that surgical abortion with sharp curette is still common (Abortion in Pakistan (guttmacher.org)).
How much does an abortion cost for the patient? Is it possible to carry out safe abortions in
Pakistan- especially in the rural areas. What is the fertility level in the country? How many
miscarriages each year?
Background
Here you may want to evolve the situation for women in Pakistan, and especially in the rural
areas when it comes to abortions. Has the abortion law changed over time? Living conditions,
social norms, patriarchy etc. Therefore, the theory may be better placed in the method section
and can be condensed. Be clear with how the theory was used. Did the theory come up after the
preliminary analysis was performed or was the theory guiding the interview guide?
Aim
In both the Introduction and Background sections, several aims are presented. A suggestion is
to formulate an overall aim, and to exclude the research questions on page 6. These questions
could be merged with the overall aim. Make sure that the aim is in line with the GT approach.
Theoretical framework
Very creative and a good choice to use Goffman’s dramaturgical theory. Please, see the
above comments concerning where to present the theory. The theory seems proper to move
to the Method section, but of course it depends on the type of design (inductive, abductive
or deductive). GT is very often an inductive method, and inductive analysis is the principal
technique used in the grounded theory method. “Inductive analysis means that the patterns,
themes, and categories of analysis come from the data; they emerge out of the data rather than
being imposed on them prior to data collection and analysis” (Patton, 1980, p. 306).
Explain the concept decorum.
Method
The context description is informative. The text in the footnote can be part of the text in the
context. Year for the ethical approval is missing. Please, provide info.
In the interview guide, the themes and questions that were discussed should be visible.
Data collection needs polish and clarifications.  At page 12, line 278, The number of participants
in this manuscript? It is 38 semi structured interviews, 9 with health care providers, 5 older
women, and 6 FGDs with 12 partners, 4 healers and 16 older women in the whole project? How
many women were interviewed in this part of the project and how long was the interviews? How
many women were taking part in FGDs, how long were the FGDs?
Check Table 1 carefully, which says a total of 24 women. Exclude age group 15-20 as no one
was placed in that group and here it seems as 26 women took part? Marital duration, 1-5 years,
6-10 years, 11-15, and 16 or more, Education, two women are missing. Moreover, Women’s
occupation lacks two women. This table is very messy.
Abortion is a sensitive topic so why did the interviews take place in the interviewees home?
How did that affect their sense of talking freely?  This could be discussed in ethichs.
Data analysis- Bowen is briefly mentioned in one line, and then Charmaz is referred to, but I
would not claim that Charmaz uses a classical GT methodology.  Please, be more specific about
the analysis, how the analysis was performed and which GT method that was used. Surprisingly,
there is no core concept/category emerging from the data analysis? Why not? The impression is
that the method is not fully described and developed.
Results
Very good with quotes that show the interaction between the group members in FGDs.  The
results need a second round of interpretation on a higher level of abstraction. A recommendation
is to provide a table or a figure that visualise the categories or themes and then analytically
describe the result. I think that the inclusion of a core concept/category would be helpful in
addressing the interviewed women’s situations.
Discussion
This part must be reworked. Unfortunately, most of the text is solely a repetition of the Results.
Goffman’s theory is rather invisible.
Conclusion
Can be reworked when the Results and Discussion sections are evolved.
References
Please check the references. Sometimes capital letters are missing in journal title. Update WHO
s ref on abortions from 1970.
Thank you for reading this interesting manuscript.