Reviewer's report
Title:How risky are second trimester clandestine abortions in Cameroon? A
retrospective descriptive study.
Version:4Date:18 July 2014
Reviewer: Ilana G Dzuba
Reviewer's report:
It is clear that the authors have put in much work to address the reviewers'
comments. I strongly believe that this is a better manuscript as a result. I do still
have reservations about the comparison between FTA and STA. I discuss this in
more detail below.
Majpr Compulsory Revisions
1. I appreciate the authors' inclusion of sample size information. If they are using
as a primary outcome description of complications due to clandestine abortion,
this method of calculation is fine. But based on their stated aim to compare first
and second trimester complications, this would be an incorrect method of
calculating sample size for a 2-arm comparative study. The authors should
clearly state their primary outcome in the section on sample size calculation and
ensure they are using the correct method to estimate the corresponding sample
size.
2. Since the study is likely not sufficiently powered to compare first and second
trimester complications, they need to make that very clear in their methods and
then in the discussion. One way to overcome this problem is to avoid comparing
FTA and STA at all, and rather just describe them without calculating ORs. I think
the most interesting aspects of this paper are unrelated to this comparison
anyway.
3. "Also, there is a small sample size especially with respect to the STA." In my
opinion, this is only a limitation with regards to comparing outcomes to FTA.
Otherwise, I think the authors are able to observe some interesting things within
the STA group. Of course, we wish there were no women in the study, which
would indicate that abortion-related complications in Cameroon were very rare.
4. I thank the authors for describing better the explanations for why nurses
provided the most abortions in the study. I think it would be more clear to the
international audience if the authors briefly commented on whether or not nurses
are trained in abortion. They do refer to "nurses" and to "untrained providers" but
I believe it would be helpful to link the two. I understand the authors point that
women more commonly go to untrained providers, which is unsafe and why
complication rates can be high, but I still feel that they are remiss in
acknowledging that nurses will likely continue to provide clandestine abortion for
all those reasons they state and that an important consideration is how to ensure
that those nurses are adequately prepared to provide safer services. I realize that
is a strong political statement, but it would be no stronger than saying that
women should go to trained ob/gyns for clandestine abortions, as the authors do.
5. "Given the high rate of complications associated with STA, women should be
advised not to terminate pregnancy anymore when there is quickening." I
understand what the authors are trying to say here, but looking at their sample,
many women had complications with first trimester abortion as well. As stated
above, I don't believe that the data from this study enables the authors to make
recommendations based on gestational age or trimester. Based on these data, it
can be concluded that serious complications can occur and clandestine providers
lack the necessary training to be able to provide safe services.
Discretionary Revisions
1. FTA is defined in this manuscript as less than 14 weeks. In the literature and in
clinical practice, first trimester is most commonly 12 weeks and under. This is
worth pointing out in the discussion and when comparing to other studies.
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests