Reviewer ’s report  
 
Title: Reducing underreporting of stigmatized pregnancy outcomes: results from a mixed -
methods study of self -managed abortion in Texas using the list -experiment method  
 
Version: 0 Date: 27 Mar 2019  
Reviewer: Lisa Martin  
Reviewer's report:  
I thank the authors and journal for the opportunity to review this manuscript. I find it very well -
written, easy to understand and significantly contributes to the field. The authors are taking on an 
important research question - how accurate are our current estimates of self -managed abortion 
experiences - and can we improve our instruments to obtain better estimates?  This issue is 
timely because as medication abortion becomes more accessible and acceptable and restrictions 
at the state -level in the US continue to erode abortion access, assessin g self -managed abortion 
practices in the US will only become more important.  I also appreciated the author's use of a 
novel approach - the list experiment method to try and address self -report biases of a stigmatized 
health practice. While the authors are  quite clear about the limitations of the results of this 
current survey, given the findings from the cognitive interviews, nevertheless the study makes a 
worthwhile contribution to the literature.  I believe that with minor revision this manuscript 
could be suitable for publication.  I have summarized suggested revisions and questions below, 
by section of the manuscript. Please note, I have referred to pages based on the pdf file - not the 
pages listed on the original document.  
 
BACKGROUND:  
Pg 4, line 5, C ould you please change "Nationally" to reference these were searches conducted in 
the US - this is an international journal, so nationally doesn't hold a specific context.  
Pg 4, line 24, could the authors please expand a little on the "best friend" metho d for those 
readers unfamiliar with the technique?  
Pg 5, line 35 can you expand the description of what "careful design and analysis" means? For 
example, can only 1 item vary on the lists subjects are given to do these estimates?  
 
  
METHODS:  
General questi on - could you provide an explanation or rationale for why you conducted 
cognitive interviews with women living OUTSIDE and inside Texas, instead of just Texas 
residents?  
 
RESULTS:  
Pg 12, line 196, could you rephrase the sentence regarding the self -inducti on status of one 
cognitive interview participant - currently reads "one was not known at the time of recruitment" - 
which could be read as not being known to the participant, but I believe the authors mean her 
history was not known to the researchers.  
Pg13, lines 211 -12, Can the authors please report the percentage of participants who interpreted 
the item wording as it was intended in the list experiment, rather than just reporting "the most 
common interpretation".  Getting this meaning is really at the he art of why you're doing the 
cognitive interviews - because you want to have some confidence in how respondents in the list 
experiment interpreted the item.  Without that percentage it's difficult to know whether you are 
(or should) be fairly confident.  
Pg 17, lines 321 -323, Did the authors use the opportunity to test out any other phrases to refer to 
ectopic/tubal pregnancy or pap smear, as participants reported not knowing what those terms 
meant?  
 
DISCUSSION  
Pg 17, line 325, The authors traced the history  of the list -experiment to the 1980's and stated its 
intent was to be used for reporting stigmatized experiences at that time - so I would caution how 
much they term it a "novel" approach - unless being specific to measuring self -managed abortion 
experienc es.  
Pg 21, line 403, The authors claim that the diversity  of geographic regions that are sampled in 
the cognitive interviews are a strength, but as mentioned earlier - that rationale was never 
provided and is not expanded on here. If the authors truly s ee this as a strength of the study it 
would be helpful if they could elaborate on that point.  
General question: Recently abortion doulas have become more common in the United States and 
anecdotally this reviewer knows that abortion doulas have been consulted for assistance with 
self-managed abortion.  How would the authors characterize an abortion doula - would you put 
them in the category of medical professional, lay health worker, or something else? How else 
might that complicate the way your questions are worded?  Did any of the participants in the 
cognitive interviews mention doulas?  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
 
 
Are the conclusions drawn  adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
 
 
Are you able to assess any statistics in the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is r ecommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
 
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
 
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financia lly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold o r are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do yo u have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the  above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests . 
 
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