Title: Evaluating women’s acceptability of treatment of incomplete second trimester abortion
using misoprostol provided by midwives compared with physicians: a mixed methods study
Version: 1 Date: 13 Aug 2022
Reviewer's report:
This paper describes the results of a mixed methods study investigating patient acceptability
of second trimester post-abortion care (PAC) services in Uganda, comparing acceptability of
care provided by physicians compared to midwives. This is an important topic for investigation
particularly in the context of task-shifting/sharing, where people might be seeking PAC in more
rural areas where physicians are not available to provide care. The authors find similar levels
of acceptability between second trimester PAC care provided by the two different types of
providers. The qualitative results are not as clear as presented, and would benefit from additional
thought from the authors about whether the results presented are in line with the stated objectives
of the study. In addition, many of the points emphasized in the Discussion do not seem to follow
from the Results presented. I have provided considerable feedback on how I think this paper
can be strengthened.
Major comments:
Background
-Up front, I think the Background would benefit from a clearer description of the prevalence of
postabortion care offered annually in Uganda to give some scope of the health burden, as well
as what methods of post-abortion care are available in the first and second trimesters (e.g. MVA
or misoprostol – this is currently not mentioned until Line 110) and offered by what cadres of
providers and at what levels of facilities. This would help ensure all readers are clear on the
Ugandan context before discussing task-shifting/sharing of PAC and “medical PAC” later in
the Background.
-Another general comment about the Background is that the authors refer to “acceptable” PAC
services throughout, but it is unclear if they are referring to services that are acceptable to
women/patients themselves, providers, or both. For example, in Line 82 it is not clear who the
PAC services are acceptable to from the review, in Line 85 there is a reference to provider
preferences, and then in Lines 88-89 it seems to be client acceptability.
-There are a number of places in the Background where the authors could be more explicit about
what they are referring to, and perhaps reconsider their language to avoid blaming individuals,
rather than inequitable systems, for health outcomes. Some examples:
-Line 76: The authors state that deaths from unsafe abortion are preventable if “unintended
pregnancies are avoided”. I would encourage the authors to think critically about why people
might experience unintended pregnancy. Are contraceptive services widely available? What if
people become pregnant as a result of rape?
-Line 77: what is meant by providing PAC services “equitably”? State clearly the inequities in
who is currently more at risk of dying or suffering morbidity as a result of unsafe abortion so
that solutions can be more targeted to at-risk populations.
-Line 80: Be clearer about what is meant by “accessible”. Do the authors mean geographically
accessible? Or services that are free/low-cost and free of stigma?
-Line 81: include among which cadres of providers the task-sharing for first trimester medical
PAC was shown to be safe, effective and accessible.
-Line 83: Provide some more explicit details about what the “lessons learnt” might be. Are they
related to medications, timing, etc? Also please provide some additional context or citations on
why higher complication rates might be expected in second trimester PAC.
-Line 89: Recommend adding detail about how long after the intervention that the follow-up
visits were conducted in previous studies, as it might help the authors support the argument in
lines 90-91.
-Line 104: Provide more details about what the authors see as the “benefits of both methods”.
-Recommend that the authors make clear, either at the end of the Background or beginning of
the Methods, whether the analysis described in this paper is of a secondary objective of the main
study, as it seems that assessing safety and effectiveness of the task-shifting/sharing was the
primary objective (Lines 122-123), but those results are not presented in this paper.
Methods
-One main comment regarding the Methods section is that it is a little unclear exactly at what
time points patients were asked quantitatively about acceptability. From Line 166, it looks like
they were asked about acceptability at the follow-up visit only. If that is correct, I was surprised
since the authors discussed at length in the Background that limitations of previous studies were
that patients were only asked about acceptability at follow-up visits, and it’s not clear that the
methodology as described in this paper is any different from that of previous studies in terms
of timing.
-Line 152: It is not clear what the authors are referring to when mentioning “saturation” here.
Saturation of themes? Or something else?
-Additional details about the randomization and data collection process could be clarified:
-Line 157: Where did the predefined checklist come from? Is it a standard checklist used in
Uganda? Was it developed or adapted from international standards? If so, perhaps provide the
appropriate citation or additional details. Also, how was it determined that people were seeking
PAC in the second, rather than the first trimester? It may help to specify how the timing of
gestational age was determined for eligibility for enrollment in the main study.
-Line 159: were research assistants and/or women blinded to treatment assignment?
-Line 163: The authors state that “the research assistants used pretested interviewer administered
questionnaires”. It’s not clear if the research assistants are the same as the interviewers.
-Was transport reimbursement provided as an incentive to complete both surveys or just the
follow-up visit?
-It was a little hard to follow the description in Lines 174-179 of how someone was determined
to find the care acceptable or not, I think because the word “satisfactory” is used to describe
acceptability when the authors are measuring satisfaction as a separate construct. I recommend
clarifying the categorizations for acceptability. For example, in Lines 177-178 the authors could
revise to: “Patients were recorded as receiving acceptable PAC if the treatment experience
was as expected/easier than expected and the patient was satisfied. The PAC was considered
unacceptable if the patient reported the treatment experience was worse than expected or the
patient was not satisfied.”
-To confirm: If what I have suggested above is correct, than a patient who said the treatment was
worse than they expected, but they were also satisfied would be classified as “unacceptable”,
correct?
-Similarly, I would recommend that the authors go through the Methods again and ensure that
they are correctly distinguishing between when they are measuring acceptability as a multi-part
construct vs. satisfaction. For example, in Lines 223-224, the authors state “as the difference in
proportion of participants in each group that found the treatment satisfactory”. If what you are
actually measuring is acceptability, being consistent with word choice would reduce confusion.
This happens again in the Results in Line 346 and Lines 377-382.
-Lines 179-181: It’s a little unclear why the authors also chose to measure satisfaction with a
visual analogue scale, and what that adds to the study, especially since the authors have argued
that satisfaction may only be one facet of acceptability of treatment. If the authors want to include
results for this score as well, it may help to provide the exact wording used on the scale (for
example, was it explained to patients that zero means “not satisfied at all”?)
Results
-Since acceptability results were only collected among those who returned for a follow-up visit,
I would strongly encourage the authors to consider only presenting descriptive statistics for that
specific analysis sample. If there is only follow-up data for 1140 women, it would be clearer if
Table 1 was limited to that sample. This would also require revision of Lines 137-138 where the
authors state that 1187 women were randomized, received treatment and returned for 2 weeks
follow-up visit, which implies that 1187 returned for a follow-up visit.
-Overall, most of the qualitative results seem very general and do not provide a lot of specific
details about the treatment experience, or many distinctions between what was experienced
between respondents treated by physicians compared to midwives and how that might have
impacted their acceptability. In addition, is it clear that respondents knew whether their provider
was a physician or a midwife? It is common across country settings for people to assume that
all providers they come into contact with are physicians, for example.
-Lines 322-323: again, in order to better interpret some of the qualitative results distinguishing
different perspectives on midwives and physicians from respondents, it would help to clarify in
the Methods if women were blinded to the type of provider that was treating them.
-Line 329: While the second quote here mentions a doctor who was tired, there is not any quote
in which a respondent describes a provider as rude. A demonstrative quote here might provide
support to that statement.
-Line 364: it would help with interpretation for readers if the authors explained or contextualized
in their results text what the respondents meant when they say “washed” in the stomach in the
quote presented.
-It’s not completely clear what Lines 369-374 add to a discussion of acceptability of treatment,
so it would be useful to make that linkage. Also, to what extent would as respondent even have
control over a “choice” of subsequent treatment?
-Line 377: It would help in the interpretation of the results here if the authors provided some
additional detail in the Methods on how timing of bleeding was measured (and technically post-
treatment bleeding after PAC might not be considered “menstrual bleeding”). Did the questions
about bleeding ask about the bleeding immediately after treatment? And/or in the two weeks
between treatment and the follow-up visit?
-Line 385: is experiencing side effects coded as a binary variable? (e.g. any experience of pain,
prolonged bleeding, prolonged duration in hospital, etc?) If so, the authors should make it clear
in the Methods to help with interpretation in the Results.
-Lines 388-391: is this section of the Results describing quantitative or qualitative results? It’s a
little confusing because the focus is on preference between misoprostol and surgical evacuation,
but my current reading of this study is that people were all provided medical PAC management
and only some would have needed additional surgical completion. Therefore it seems misleading
to make statements like “the majority of the respondents preferred misoprostol” or “most women
were afraid of surgical evacuation”, since not all participants would have had experience with
both. Are the authors referring to people’s preferences BEFORE they agreed to participate in
the study and get medical PAC treatment? That’s what Line 397-400 seem to imply.
-Lines 404-408: it’s not clear that these Results add much to the overall understanding of
acceptability of second trimester medical PAC in this population, especially considering that the
actual number of SDA/ Born again respondents is quite small.
Discussion
-Lines 414-415: the summary here is a little inconsistent with the Results presented above,
as there was no significant relationship identified between experience of side effects and
acceptability in the quantitative analysis.
-Lines 427-430: Rephrase sentence to improve interpretability. In addition, since the finding of
94% acceptability is in the range of previous first trimester PAC estimates, it’s not clear that
this explanation is needed.
-Lines 431-433: Would caution the authors about overstating what different aspects of
acceptability can truly be captured with only 3 questions, especially about values, perceptions,
and the health delivery system.
-The Discussion of perceptions of caring, kindness, and rudeness of the providers should be
reviewed in line with the Results presented, and the authors could consider emphasizing the
finding that actually few differences in perceptions between physicians and midwives were
identified. For example, it is not clear from the Results presented that physicians were perceived
as more pleasant or caring than midwives.
-Line 437: does this reference refer to more rudeness in overall health care from nurse-midwives?
Or in PAC care specifically? The latter may be more relevant if there is information in the
previous literature on the differences.
-Lines 441-450: Overall, would caution the authors about making too many broad conclusions
on the topic of cost when it appears to have been mentioned in only a few IDIs in the Results
(and does Line 447 present new results?). In addition, cost overall or acceptability of cost does
not appear to be a main objective of this study.
-Also if the authors retain the text, mentions of “our” health system in Lines 443 and 449 should
probably be edited to the “Ugandan” health system for clarity.
-Statements about meagre salaries and poor supervision likely warrant citations from previous
literature on this topic.
-Lines 452-453: clarify if the previous studies mentioned here are specific to PAC (which would
provide more support for the statement as it relates to this research).
-Lines 454-459: the mention of the treatment as “life-saving” is presented here for the first time;
should be mentioned in the Results. Similarly it’s unclear how the interpretation that the health
care system treated these cases as emergencies follows from the Results that are presented. In
addition, drawing conclusions about private health facilities seems unclear here, since they were
not mentioned in the Background or Results up until this point.
-Lines 460-466: This information about Ministry of Health policy for PAC treatment should
be presented in the Background section to orient readers to the context in which the study is
being conducted. Additionally, most of the content of this paragraph reads as new results that,
if important, should have been mentioned in the Results section. For example, this is the first
mention that “most” women approaching the facilities anticipated surgical evacuation or people
who had previous experiences with misoprostol for PAC were more likely to choose medical
PAC management in the future. If the authors want to discuss implications of these results in
the Discussion, they should be more clearly presented in the Results section.
-Paragraph that starts on Line 470: This paragraph does not follow closely with the main
objective of the study or the Results presented, which is necessary if the authors want to
incorporate points about decision making, choice, or autonomy into the Discussion. Also, since
the sample of women who participated in this study had already agreed to participate in a
study in which they knew that they were going to get medical PAC management, it is unclear
what relevance a discussion about decision making regarding treatment options adds to the
understanding of the findings of this study, which is about acceptability with the treatment that
was received.
-Paragraph that starts on Line 477: In line with some similar comments in the Results section,
it would be helpful to better explain for what length of time bleeding post PAC treatment was
measured (e.g. was it “during” treatment as stated here? Immediately after treatment? In the
weeks between treatment and the follow-up visit?)
-In addition, I would encourage the authors to consider moderating their conclusions regarding
women feeling calm and safe after treatment as a result of the “good counseling they had
received”, unless that link is clearly articulated, perhaps in a quote from one of the IDIs. It is
also possible that people were feeling calm and safe because they had reduced pain, had been
treated appropriately, etc.
-Is the comment related to undesired effects of misoprostol in Line 488 in reference to results
from this study? Or the study cited? Or both?
-As noted in the comments on the Results section, it does not seem that differences in
acceptability by religion were the main or strongest conclusion of this study.
-Line 510: Can the authors explain further why they think that randomizing women to care with
health care providers who worked in close proximity would negate differences in the outcome?
-Line 512: Methodological considerations: much of this section could be either integrated into
the Strengths and Limitations section or the Methods section above. Some statements such as
“Respondents were comfortable with the research team and freely shared information.” in Line
523 appear to be a matter of the researchers’/authors’ perception and should be stated as such.
-Overall the Discussion section would benefit from an additional paragraph describing what
the implication of this study’s results would be for Ugandan MOH policy regarding second
trimester medical PAC services. For example, will these results provide evidence for revision
of policies and practices in the country regarding the types of providers who are able to provide
these services? If so, how could it be anticipated to improve service delivery for patients?
Conclusions
-Again, overall would caution the authors from drawing significant conclusions from minimal
qualitative data. For example, patient perceptions of counseling is not measured in the
quantitative results and only barely touched on in the qualitative results. In addition, shortage of
supplies appeared to be mentioned by one person based on the qualitative results presented and
while payment is mentioned in the qualitative results, it’s not clear if that is common practice for
many health services, rather than “extortion”. Finally, please make the conclusions specific to
the Uganda context specifically, in addition to other “settings that lack adequate staffing levels
of physicians.”
Minor comments:
Background
-Line 86 – Do the authors mean that acceptability was studied as a sub-objective of larger studies,
rather than a sub-study?
Methods
-Recommend stating clearly in the first sentence of the Methods that the study took place in
health facilities in Uganda to help orient the section.
-Line 121: Make clear who the subset of women who participated in the IDIs were. The authors
detail this further below, but would add here that they were women who also participated in
the RCT.
-Line 123: Clearer to say midwives “compared to doctors”?
-Lines 127-128: Perhaps add the acronym (COREQ) here in case readers are more familiar with
it.
-Line 146 – what is meant by “negative cases”?
-Line 156: “Over 183 trained health care providers” implies that there were more than 183. Can
the authors just provide the exact number?
-Line 246: I think a few words might be missing from this sentence.
Results
-Line 278: the authors provide the mean gestational age in the text, but Table 1 lists the median,
so it’s not clear if one or the other is incorrectly stated.
-Line 293: change to “practiced Islam” or “Muslim”, rather than just “Islam”.
-Additional File 1: the authors might consider presenting the characteristics of the IDI
participants in proportions and mean/median values to make it more directly comparable to
Table 1.
-Table 2: the authors might consider formatting the order of the rows in the table slightly
differently to make clear that the Overall Acceptability score is made up of responses from
Treatment experience and Overall Satisfaction (and Overall Satisfaction is made up of responses
from two separate questions, as described in the Methods). It would help with the logical flow
of the Results in the Table.
-In addition, it’s not totally clear what providing the Median satisfaction score in this table adds,
as from my reading the Methods section, that score is not a part of how the Overall Acceptability
is determined.
-Line 336: If the authors are trying to emphasize that these experiences were felt among people
no matter which cadre of provider treated them, it might be clearer just to say something like:
“In a few instances, women parted with money to pay a HCP or buy some supplies like gloves
that were lacking in the health facilities, and this was mentioned by women treated by physicians
and midwives alike.”
-For all of the participants who are quoted, the authors may consider adding some minimal
characteristics of the patient to the text so that a reader does not have to go to the Additional
File1  to know who each participant is. Perhaps add age, gestation at treatment, and type of
provider who treated them could be included with each participant’s quote (e.g. participant 20,
XX years, XX weeks pregnant, treated by physician)
-Include Ns for analysis sample, perhaps in titles, for Tables 3 and 4.
Discussion
-Line 480: it may be worth clearly stating the proportion who experienced side effects in the
Results section and referring to Table 4, as it reads a bit like new results are being presented here.
-Line 504: “proportion of satisfactory overall acceptability” is unclear.