Title: Pathways to medical abortion self-use (MASU): Results from a cross-sectional survey of
women's experiences in Kenya and Uganda
Version: 1 Date: 08 Dec 2022
Reviewer:  Sarah Raifman
Reviewer's report:
Dear authors,
This is an important topic and a very underrepresented population, so your research is valuable.
However, I recommend re-working the manuscript so that it is more appropriate for a peer-
reviewed journal (as opposed to a report). I have included some specific comments by section
below, but in general I recommend including more detail  and more explicit and rigorous
reasoning behind each of your study design questions. I also think you need to go deeper
in your analysis of the qualitative data and consider whether you have any analytic aims
for the quantitative data (beyond description). I believe that mixed methods studies are more
complicated than presenting descriptive statistics with quotations, but I am not an expert in this
area.
Abstract:
Can you add more details to the methods section of the abstract regarding main outcomes, models
used, and whether or not you compared experiences by country for example? From the other
results listed in the abstract, it seems like the this is mostly a descriptive study that did not
include multivariable analyses and did not make formal comparisons between experiences in
Kenya and Uganda.
It would be helpful to add the proportion of the sample that was in Kenya compared to Uganda.
From this sentence, I’m confused about how 79% and 21% average out to 73.6%... I am assuming
that the sample comprised of many more women from Kenya?  “Of 2,366 women, 73.6%
accessed MA in both Kenya (79%) and Uganda (21%).”
This sentence is missing the proportion in Uganda: “Significantly more women were referred
for MA in Kenya (49.9%) than in Uganda (p<0.05).”
The conclusion of the abstract mentions “contraceptive use after MA” but it is not clear until
this point that contraceptive use is part of the focus of this study.
Main Manuscript:
Background:
Referring to the first sentence of the manuscript, I am confused as to what self-use of MA has to
do with the WHO’s policy guidelines on safe abortion up to 9 weeks. Does the WHO’s policy
include self-use explicitly?
“Though the World Health Organization (WHO) developed policy guidelines on safe abortions
for pregnancies up to 9 weeks gestation (63 days)[1], medical abortion (MA) self-use is yet to
be fully operationalized in developing countries.”
The following sentence mentions that MA is available on prescription in pharmacies in Kenya,
but what about Uganda?
“While women in Kenya can procure MA drugs with prescriptions through pharmacies; there is
no documentation in Kenya and Uganda on women’s experiences with MA self-use thus making
it difficult to plan care and interventions for women and girls who need these MA services.”
In the next paragraph, there is reference to “with the need for a clinical visit being a key
impediment”. Does this mean that clinic visits are required for MA even in Kenya where MA
drugs are available on prescription in pharmacies? It would help to clarify the legal access to
MA in each country. This is essential background information for defining what self-managed
abortion care is in these contexts. Is sourcing the medications from the pharmacist considered
self-management? If yes, then does self-management include taking medications outside of the
clinic? It would help to define terms. This study specifically focuses on pharmacies, but seems
to include many more sources of MA meds as “self-management”, so it would help to include
some justification for why the study focusing on pharmacies in particular.
Define SRHR the first time you use it in the background section.
The background should be organized with more detailed background information for each of the
points made in the following sentence: “Given the high proportion of unsafe abortions in Kenya
and Uganda, the restrictive abortion laws, self-care becoming a mainstream approach to health
care, and the cultural practice of seeking healthcare services from medicine sellers, it is critical
to understand women’s experiences with medical abortion use in Kenya and Uganda.”
Please include references for Ipas’s Big Ideas project, in particular the findings from this project.
Why is Ipas’s Nimechanuka website described in the background? Is it a data source for the
study? If so, perhaps these details would fit better in the methods section.
Methods:
There should be more information about why the particular sites were selected and what other
sites are not included in the study so we have some sense of the extent to which these findings
represent the broader context in Kenya and Uganda.
Why were focus groups only in Kenya?
When was the study conducted?
Can you provide more information about the structured tool used to extract data from pharmacy
records? What items did it include? How was it designed and tested?
How were the 40 MA users identified for focus groups? More detail is needed.
You refer to dependent and independent variables but it is not clear what the independent
variables are (and are all “outcome measures” dependent?).
For mixed methods studies, there should be clear aims with regard to the quantitative and
qualitative components of the study.
Results:
There should be much more context provided for the quotations in the results. The authors mostly
list quotations by category or theme but do not provide much analysis of the qualitative data.
I am not an expert in mixed methods, but I believe there is more to it than simply providing
summary statistics and quotations by theme.