Title: How, when and where? A systematic review on abortion decision making in legally
restricted settings in sub-Saharan Africa, Latin America, and the Caribbean
Version: 1 Date: 28 Sep 2021
Reviewer's report:
General comments
Whether and how decision-making trajectories impact access to abortion care is an important
line of research and this review of data on decision-making in legally restricted settings is an
important addition to the literature.  The methods and findings of this review are clear and well-
presented.  I have three overall comments which are also reflected in my detailed comments
below.  First, where possible it would also be useful to situate these findings more broadly
in a human rights frame—access to safe abortion care is important for health/to avoid unsafe
abortion and its sequelae, but also for people to be able to exercise their human rights and live
the lives they choose.  Second, my guess is much of the literature they authors draw on recruited
people who identified as women or did not specify/ask broader questions about gender identity.
It would be useful to state somewhere in the paper, even if a footnote, that the issue of abortion
decision-making applies to people who do not identify as women and to use gender-neutral
language where possible/appropriate.  Finally, the authors acknowledge a number of limitations
based on their search criteria, including geographical limitation and heterogeneity of abortion
restrictions in the settings covered.  A brief scan of the literature they included indicates that
the papers included cover a limited number of countries within SSA and LAC.  It would be
useful to address that/include some mention as well as discussion as the implications for the
findings, and what it might say in terms of recommendations for future research.  Thank you for
the opportunity to review this manuscript.
Specific comments
Background:  I appreciate the terrific summary of how increased information about and access
to medication abortion drugs can impact unsafe abortion, but would also love to see a human
rights frame included and suggest the authors highlight how much of the increase in attention
and access to medication abortion drugs has been led by feminist grassroots groups who see
their work as a fundamentally political act grounded in the human right of all people to build
their families and make decisions about their futures.
Methods:
Lines 129-132:  These repeat information presented above; could delete here or above.
Results:
Line 211:  Can you clarify what you mean by “positively” affected decision-making?  Do you
mean more likely to use a safer method?  Not experience delays?  Access a method?
Lines 372-374:  This is interesting and surprising—is there anything about the contexts of these
studies, the methods, or something else that might explain how cost was not a factor?
Discussion:
Lines 378-380:  It was clear in the methods that you were using the Coast framework to
understand the findings of the articles included in the review—but the language here also
suggests to me you were assessing the value/validity of the framework—i.e. if you found
something that didn’t fit that might indicate a need to revise/add to the framework.  Am I
understanding this correctly?  If yes, it might be useful to say that was explicitly a goal/part
of the work.
Lines 392-399:  This finding also indicates to me that data on preference for one method
over another (i.e. medication methods over surgical, for example) needs to take this into
account.  Many researchers have cited increased use of medication abortion drugs as indication
of preference, but because of other constraints it may not be a result of preference at all.  Does
that align with your findings and is it worth adding something to this effect to the discussion?
Line 414:  I think you mean “like” here not “likely”.
Lines 412-422:  This is also the case in legally permissive settings—i.e. that constraints are
compounded and lead to much lower access/fewer options for folkx with lower incomes/less
robust social capital/connections.  It might be worth adding that here.
Lines 444-447:  I wonder if this would be different in more recent literature/with recent
expansion of these approaches?  Or whether researchers were directly asking about these kind
of resources?
Lines 451-456:  Something in this first sentence seems confusing—impact of knowledge of
unsafe methods or frequency of use of unsafe methods?  And I worry that the final sentence
makes it sound like there are not some people who would just prefer a surgical method (i.e. not
related to safety or all safety considerations being equal).
Lines 465-467:  Do you feel this gap also exists in less restricted settings, i.e. do we need more
detailed research in all settings about these aspects of decision-making?
Lines 480-482:  Yes, important impacts on a person’s safety and physical wellbeing, but also
on people’s ability to exercise their human right to bodily autonomy, to build the families they
choose, and to determine their futures.
Conclusion:
(or perhaps Discussion?):  Do your findings also point to the potential value of research to
examine interventions that try and address some of the decision-making constraints you identify?
Could/should researchers looking at interventions to increase access to information or service
delivery options try and identify ways their interventions fit into decision-making trajectories?