Title: Perspectives on self-managed abortion among providers in hospitals along the Texas-
Mexico border
Version: 1 Date: 04 Jan 2021
Reviewer's report:
The study topic is important in order to inform future research directions especially considering
that SMA may increase if U.S. legislation becomes more prohibitive. The authors have addressed
reviewer feedback from the first reviews, however, there remain important gaps in the paper that
will need to be addressed to better understand and contextualize the study findings and inform
next steps for research. For example, in the introduction, the authors state that “it is important to
understand the capacity and needs of ED providers regarding abortion and postabortion care”,
however, the introduction does not provide data or information on research gaps in abortion
and postabortion care that would help strengthen the importance of the study. Mention of WHO
guidelines and where the gaps are in care in the introduction would help to address this. Detailed
comments follow.
Introduction.
(line 54) It is unclear whether the % of abortion patients is referring to US or Texas (2%), please
provide both national and Texas %s to avoid confusion.
Technical: There is information repeated in lines 46 and 50 when SMA methods are reported
(Texas). Line 50 seems to have all the information in addition to impact of COVID.
The current legal context of abortion in Texas should be presented in the introduction.
Data is not presented for the reader to understand whether in fact SMA is higher in the Texas-
Mexico border region. A more robust introduction of abortion data in the border region overall
would be helpful, including gaps in research.
That medications in Mexico are less expensive and less regulated than in the U.S. is not has
meaningful unless we can understand (even if an estimate) of how frequently purchase of
misoprostol is happening by persons who cross from the U.S. to Mexico.
The following statement should be supported with a reference “the large population of
immigrants from Latin America, who are familiar with SMA in the context of restrictive abortion
laws” as a reason for SMA being more common in Texas.
More detail is needed on change in abortion behavior, health consequences from unsafe abortion
and current abortion service access in Texas (SMA or otherwise) along with this statement (line
64) “limited availability of facility-based care due to the closure of abortion clinics after House
Bill 2, a restrictive Texas law targeting abortion, that went into effect in 2013 (10, 2)”
(65) Abortion stigma should be more clearly defined (is it stigma felt by the individual?, stigma
that some providers may have towards individuals who have undergone abortion?). The reason
this is important is that there are different types of stigma and how these types may affect care
and patient health.
(71) unclear what is meant by the safety profile statement “Because of the procedure’s safety
profile, few abortion patients seek care for complications in an emergency department (ED).)
What leads to poor health outcomes among women with SMA? This aspect of the introduction
is important to frame the study.
(89) the following is important “it is important to understand the capacity and needs of ED
providers regarding abortion and postabortion care” and the introduction could give the reader
more information on gaps in abortion and postabortion care that would help strengthen the study,
specifically, What specific type of care that is different from non-SMA care be needed? This
needs to be well established for us to appreciate the importance of the study. (mentioning the
WHO recommendations in the introduction would be helpful.
Methodology
Since the study focus is on SMA, it would be helpful to provide a rationale why were providers
not screened specifically for experience with SMA or suspected SMA? (eligibility criteria)
what was the rationale for including “experience with patients presenting with early pregnancy
complications in the ED or L&D” more broadly?
(21) “We stopped recruitment for the full study when no new themes or findings were noted (i.e.
thematic saturation)” Additional information on how thematic saturation was monitored and the
target sample size would be helpful.
(38) “The interviewers reviewed the professionally transcribed interviews to ensure consistency
with the recalled encounter and to redact any identifying information” Transcription consistency
with the interview could be verified by the audio recording
(46) the following sentence is unclear, what is meant by collaboratively identified? “The coders
collaboratively identified new themes as they emerged in the data, using inductive and deductive
coding”
Technical: The 2nd & 34d sentences (Line 11) do not correspond with initial recruitment efforts
and revised recruitment strategy,
Results
(159) snowball recruitment methodology is mentioned in results but not clearly articulated in
the methods section.
That 30% (16/54) of providers interviewed did not mention experience with an SMA and only
27 (50%) had only 1 SMA case discussed is important to address in the discussion. That means
that only 11 of 54 providers had at least 2 cases or more to discuss. It is not clear how this data
from Table 1 corresponds to “Providers’ anecdotal estimates of the frequency of seeing patients
suspected of SMA in the hospital setting ranged from one case per month to 10 cases in 20 years”
210 this statement seems contradictory: “Though most providers said that they had not witnessed
any complications related to SMA, there were several cases mentioned where patients required
additional treatment, such as dilation and curettage for retained placenta or a blood transfusion,
or monitoring of their continuing pregnancy after attempting SMA”
(239) Reflections on reporting SMA cases (suspected SMA cases?)
Technical: adding the sex of respondent after quotes may be useful for further understanding
of findings.
Discussion
More discussion about abortion stigma is warranted given that some providers revealed
stigmatizing attitudes (either their own or of others) towards persons with suspected SMA.
Provider-level stigma can make the patient feel worse and lead to diminished care quality.  (384)
“including being aware and sensitive to abortion stigma and potential legal risks to the patient
of reporting SMA”
Richness of having conducted the study in a border region could be further expanded in the
discussion. What do we need to know to better support border dwelling women who use SMA?
What information relevant to the border and Latina immigrants is missing from the research?
That some patients may be undocumented poses additional risk for her health and wellbeing if
police are called; this merits consideration.
Recommend adding to the limitations that provider discussion of SMA were largely based on
cases they suspected an SMA had occurred, with a few exceptions is appears that providers
may have not known for certain that an SMA had occurred. Some perspectives may have been
provided on women with mis-identified SMA.
Quantitative data is needed to understand actual trends in SMA, the frequency of complications
from SMA and the frequency with which hospitals are treating patients with these complications.