Title: Partner involvement in abortion trajectories and subsequent abortion safety in Nigeria
and Côte d’Ivoire
Version: 1 Date: 21 Feb 2022
Reviewer's report:
Thank you for the opportunity to review this paper. I found it to be a rigorously designed and
executed analysis. The paper is well written and was very interesting to read, and explores an
area where research is limited, and I believe will be of interest to this journal’s readership and
the field. I have a few suggestions of places where the authors could strengthen their paper and
findings:
Background
Line 98 – totally a personal preference, so feel free to take or leave it, but juncture 3) could be
rewritten as “deciding what abortion method to use” or something (to preserve symmetry of all
three junctures being “decisions.”
Line 128 – Line 130 – findings from Freeman et al seem to correspond with juncture 1)
(disclosure of pregnancy) versus the third juncture – probably should be moved to an earlier
paragraph
Methods
Analytic Sample – Can the authors provide details about the total number of respondents in the
female survey (to get a sense of how many of the N reported they had an abortion?). I know it’s
in the Figure, but maybe just a sentence of what % reported an abortion (to get a sense of under-
reporting / potential selection bias at this stage)
Line 216 – unclear if 79.6% is among the total 1790 respondents or among the consented
respondents
Outcome – I imagine the authors are using the WHO classifications of most unsafe, less safe, and
safe (and my assumption is that MA self-use / self-managed medication abortion is categorized
as “less safe”, or dichotomously as not most unsafe, but it is a bit unclear to me whether this
assumption is correct based on the description in the methods. I would suggest including the
coding schema in supplementary materials, or perhaps a box / text box of the most common
abortion methods described by participants and how they were categorized?
Covariates – How did the authors choose this set of covariates (DAG, other conceptual model,
prior literature, etc).
Statistical analysis – Can the authors include the interaction analysis and the model with
gestational age as supplementary material? I know that they state there were no qualitative
differences, but given the novel nature of this analysis / research question, I think it would
be beneficial for future researchers studying this topic area to see this data / findings. I agree
that inclusion of gestational age is tricky, since it might be on the casual pathway between
partner involvement and abortion method (vis a vis partner involvement causing a delay or
influencing the timing around when someone attempts to have an abortion), OR could be a
confounder / covariate (where gestational age determines whether or not someone decides to
involve their partner). I would recommend highlighting this as a limitation in the discussion,
because gestational age does seem like an important variable to consider especially around
method, but given the structure of the data it is impossible / difficult to assess its impact /
relationship.
Results / Tables
Table 1 & Table 3 – would be nice to see gestational age as a covariate in these tables to
understand the distribution of that variable
Table 2 – Can you include method success in this table too? And for abortion was most unsafe
– it would be nice to have a couple examples of some of the most common method combos
reported and how they were classified, just to give the readers some tangible examples (either
in a footnote, box, or supplementary material if no room in the text).
Table 3 – I think you have a typo with the p value for parity at abortion (it’s probably not exactly
0, no?)
Table 6 – I recommend strongly against presenting the coefficients / ORs for the other covariates
in the model, especially as the authors conceived of this analysis with a clear exposure and not a
set of predictors, and recommend just presenting the main effects. See Table 2 fallacy for more
thorough examination of this (https://academic.oup.com/aje/article/177/4/292/147738)
How do you conceptualize involvement from multiple sources – is this controlled for in the
analysis in some way? Might be more of an interaction to explore – whether people who report
involvement from other people in addition to their partners are more / less likely to have a safe
abortion. Could add to Table 1 / Table 3 whether any involvement from non-partners to see if
there are differences there – I’m struck with not knowing whether it’s the partner, specifically,
who has a role in abortion safety, versus involvement from others (if it’s true that those who
involve their partners are also more likely to involve others).
Discussion
Overall, I think the discussion could be condensed – there is a lot of rehashing /duplication of
the findings in the results. I recommend streamlining the discussion to focus on how some of the
key findings are situated in the literature and WHY the authors think some of these relationships
exist, rather than just restating some the findings from the results. (particularly the paragraphs
on lines 410 – 450).
Line 410 – 423 – Given the data presented, I would assume that the primary reason for
differences in involvement between the two countries are the differences in marital / relationship
status – I’d recommend potentially moving this up to earlier in the paragraph.
Line 439 – I think a citation is missing (re: “documented disparities in abortion access.”)
Line 443 – 446 – I would caution against comparing the relative “strength” of this association
between the two countries, since you didn’t formally test the differences in this MoA – they
are both highly significant and protective / in the same direction, so I think you can simply say
“any partner involvement was significantly associated with lower odds of an unsafe abortion
in both countries.”
Overall – I think the regression findings are the most important and more time / space in the
discussion should be focused on WHY the authors think partner involvement is related to safety,
what else could be going on, etc.
Line 454 – 460 – I think the authors could cut this section altogether or reduce to one sentence–
it’s a rehash of the results, which is not needed (could just say that respondents consulted other
people, which is aligned with the literature).
I would add to the limitations the reliance on how involvement is conceptualized / the crudeness
of the  measure/conceptualization of partner “involvement” – ie, you have measured whether the
partner was notified about the pregnancy, but unclear about decision making involvement. To
me – it’s almost that you have measured whether disclosure to one’s partner is linked with safety
Line 512 – 519 – I appreciate the discussion/ exploration of differences in between analytic
sample and eligible sample. These differences are somewhat concerning to me, since many of
these factors are related to the outcome so potentially could have a strong bias on the outcome.
Would love to see a couple lines on how these selection factors may have influenced/biases
the results that we see. Even if full sensitivity analyses is outside the scope of the paper, some
discussion of how this could have influenced the results is warranted – as well as justification
for not employing methods like censoring / loss to follow-up weights to try and account for
these sources of bias.
In the main survey – did you collect data on abortion method? (or was this just in the follow-up
survey) – it would be important to see whether abortion safety was different between those in
the main survey and those in this analysis (if possible / that data exists).