Title: Recent trend and correlates of induced abortion in China: Evidence from the 2017 China
Fertility Survey
Version: 2 Date: 20 Apr 2022
Reviewer:  Monica Malta
Reviewer's report:
According to the authors, ‘induced abortion’ is a key public health problem that needs to be
addressed, and this point of view perpasses all this manuscript.
I would like to respectfully disagree with the premisses that seem to be at the core of this
manuscript and, perhaps, of the study itself.
Comprehensive abortion care is included in the list of essential health care services published by
WHO in 2020. Abortion is a simple health care intervention that can be effectively managed by
a wide range of health workers using medication or a surgical procedure. In the first 12 weeks of
pregnancy, a medical abortion can also be safely self-managed by the pregnant person outside
of a health care facility (e.g., at home), in whole or in part. This requires that the woman has
access to accurate information, quality medicines and support from a trained health worker (if
she needs or wants it during the process).
The history of population planning in China, with one, two and most recently three-child policy
has been incredibly abusive and coercive. I would urge the authors to be imparcial while
presenting and discussing their study findings.
BMC Women's Health focus on the physical, mental, and emotional health of women - and
access to safe abortion is a basic healthcare need for millions of women, girls and others who
can become pregnant.
Having said that, I will highlight key sections that need to be reworked.
Introduction
Introduction, 1st paragraph: “Induced abortion is a worldwide concern”
Please review this statement. Access to safe, legal induced abortion, and quality humane post-
abortion care is a core public health strategy, based in women’s rights principles. What is of
great concern is unsafe abortion, mostly conducted where abortion is illegal. Unsafe abortion is
a leading – but preventable – cause of maternal deaths and morbidities. It can lead to physical
and mental health complications and social and financial burdens for women, communities and
health systems.
Introduction, 2nd paragraph: Please include one or two sentences here to explain what
percentage of Han Chinese there are nowadays in China. Is there any key characteristics that
differentiate this group from other ethnic minorities?
Introduction, 2nd paragraph: “Due to the unbalanced development between urban and rural
areas, induced abortion among women of childbearing age in urban areas is higher than that
in rural areas” I would like to question this assumption. Isn’t it the lack of access to safe/legal
abortion in rural communities a key problem, instead of a ‘development imbalance’ between
rural/urban communities? Barriers to access safe abortion in rural communities often force
women to travel outside their communities, while a percent risk to undergo unsafe procedures.
That’s a core problem to reach reproductive justice…
Introduction, 2nd paragraph: “Some other studies believe that women with high education are
more likely to choose short-term contraceptive methods to postpone marriage and childbearing,
resulting in a higher risk of induced abortion after contraceptive failure”
I would like, once again, to request the authors to maintain an impartial and scientifically
adequate tone… Postponement of parenthood and fertility outcomes among highly educated
women have been studied over and over again, but it’s highly important to note that parenthood
is not at all related with marriage, those are two completely constructs and decisions.
Introduction, 3rd paragraph: “With the opening of ideas, marriage is no longer the only outlet
for sex. The increasing of people's acceptance of premarital cohabitation and premarital sex, as
well as the advance of sexual maturity and the delay of the age of first marriage, increase the
risk of premarital pregnancy of young women, induced abortion is becoming more and more
common in unmarried women.”
Those are really outdated ideas. Worldwide, the vast majority of adolescents have their first
intercourse before turning 18yr. Sex before marriage is not increasing slowly, it is the norm
worldwide - and many people will never get married. The percentage of women choosing to be
single and childless is higher than ever, while on the other hand one e in eight women aged 18-60
are unmarried and have children in their household worldwide. Please refer to world statistics
to discuss your study question, those statements are completely outdated for a manuscript being
published in mid 2022. If China has a completely different scenario, at least compare what is
happening in China with the rest of the world….
Introduction, 4th paragraph: Please expand here the underlying reasons for sex-selective
abortion in China. This is highly important and should be thoroughly explained for readers, as
it might be a key reason for higher abortion rates.
Introduction, 4th paragraph: Consider explaining a little bit more how the changing policies
about number of children in China might be another key reason for those high rates of abortion.
Cite the year of each law (one, two, three-child policies)
Introduction, 5th paragraph: Most of this paragraph belongs to the methods section, include here
just one/two sentences briefly presenting what you did to answer the problem described before
on the introduction.
METHODS
Data, 1st paragraph: Describe the China Health Statistical Yearbook and the China Statistical
Yearbook - characteristics, variables, frequency of study etc.
Please include a more sophisticated method, at least a logistic regression needs to be conducted
with this huge sample of 249,946 participants…. Only descriptive results of proportions/
cumulative proportions and cumulative numbers is just too basic and unacceptable here.
RESULTS
I was impressed to see only descriptive figures as the study results… The authors utilized a
survey with roughly 250K participants, at least two tables should be included: a basic SES table
with social-economic characteristics of study participants and a regression analysis.
What are the predictors of induced abortion among this population? With just those figures, it
is hard to tell for sure… The authors could estimate generalized linear multivariable regression
models to assess whether known or potential risk factors are independently associated with
experiencing induced abortion after controlling for other predictors. Additional models could
be estimated, controlling for calendar year (including known key demographic factors such as
age, marital status, number of children…), then a second model could be estimated including
both demographic and social variables (e.g. education, social class, income…)… If the authors
have access to health-related data, another model could be fitted including healthcare use and
other clinical variables available.
Figures: Is it possible to highlight (e.g. include a line) when the one, two and three-child policies
were introduced?
CONCLUSION
The conclusion/discussion section is weak, mostly because the methods and results are basic
and descriptive. The research question is highly important, and should be thoroughly evaluated
with robust methods such as regression models. I trust the authors are capable of conducting
this additional analysis to present a more reliable and comprehensive results section, and
consequently a better discussion.
In this section, it will be interesting to compare the regression findings with similar studies
conducted in other countries - what is unique in China? How the results compare to studies
conducted in the US, UK and other countries? The predictors of induced abortion are different?
What is the influence of China’s legislation (one, two, three-child)? Is there any cultural/
behavioral characteristic that might influence abortion in China in a different way than it has
been reported in other countries?
The notion that ‘premarital pregnancy’ influences high rates of abortion in China seems
somehow confusing and outdated. If being a single parent is really that burden in China, a better
description of this unique reality should be included on your introduction. All over the world
single parenting is a highly common reality, as is sexual intercourse among unmarried couples -
if in China the reality os completely different, again, a better explanation of this unique cultural
reality should be included.
Sexual orientation and gender identity doesn’t seem to be included on the survey, but I was
wondering if those variables are available at all. Some studies have identified that lesbian and
bissexual women are often at higher risk of sexual assault, and might be more willing to have an
abortion. If data about LGBTQ+ persons is not available, the survey included questions about
sexual assault? Survivors might be more prone to opt for an abortion as well…
It is also important to include the study limitations here.
Thanks for the opportunity to review your work. I look forward to see a revised version of this
important study.