Title: Community-based intervention improves abortion knowledge and reduces abortion
stigma among women in Oromia, Ethiopia: a quasi-experimental mixed methods evaluation
Version: 1 Date: 15 Jul 2022
Reviewer's report:
Thank you for the opportunity to review this manuscript detailing research evaluating the impact
of an intervention on community-level abortion stigma in Ethiopia. The approach taken is
appropriate for the research aims; it is both scientifically sound and empowers the community.
The manuscript presents the research project clearly and outlines important takeaways, impacts,
and directions for future research. Below are questions and suggestions for the authors to
consider when revising their article. I hope this feedback helps progress this article. I look
forward to seeing more from this body of work.
MAJOR ISSUES
To ensure this article reflects abortion as a healthcare procedure sought by and benefiting a
variety of people and the community (i.e., the article does not contribute to abortion stigma), I
suggest rephrasing language to be gender inclusive or neutral. Not only is gender-neutral and
inclusive language accurate and inclusive, it can help destigmatise abortion by framing abortion
as healthcare rather than a gendered issue. An example of gender-neutral language by the authors
is on line 171 (“those accessing abortion services”). Suggestions for change include “women’s
right to abortion” # “right to abortion access” (line 164), “women who have had an abortion” #
“people who have had an abortion/s” (line 166), ”all women who” # ”all people who” (line 169),
“women and men” # “community members” or “people” (line 184)., “women seeking abortion”
# “people seeking abortion” (line 395).
Introduction: A concise overview with a clear explanation of conceptual background. The
coherency and study rationale could be improved by addressing the below point.
• Paragraph 4 of introduction (lines 89-97): It is unclear why, and confusing that, the authors are
presenting research on “women’s experiences with abortion stigma” (individual level stigma)
rather than continuing with the research explaining stigmatisation from/among ‘community
members’. The information presented in paragraph 4 doesn’t fit with the paper’s narrative and
aim of focusing on community rather than individual levels. Suggestion: Present the information
in paragraph 5 after lines 87-89 (i.e., insert after second sentence) to form a paragraph about
evidence of community-level stigma in Ethiopia. The individual-level/women’s experiences
of stigma information (lines 89-97) could form its own paragraph demonstrating the potential
impact of community-level stigma on people who access, or may access, abortion.
• Line 89 (page 5): Unclear if by “women’s experiences with abortion stigma” refers to anyone
who has had an abortion/s or women in the community with and without abortion history who
perceive abortion stigma.
• Line 523-525 (conclusion): This is a novel component of this study. I suggest making this clear
in the study rationale.
• Make clear mixed methods, community participatory research – important strengths of this
research to highlight early on.
Methods: An appropriate approach has been taken and is clearly presented. Please see questions
and suggestions below about missing information that will clarify the strengths of this study’s
methodological rationale.
• Would the authors please include an explanation as to why the intervention is on women’s
abortion knowledge, attitudes, beliefs, and actions, rather than all community members. Is it
expected women hold the most community-level stigma in the intervention woreda? Because
women are expected to benefit the most from de-stigmatising abortion in Oromia? Were women
an accessible sample for the intervention and research?
• Lines 193-194 (page 9), 243-247 (page 11), or 263-266 (page 12): Would the authors please
include information on why the SABAS was chosen to measure abortion stigma. What are the
psychometric properties of the SABAS? Has the SABAS been used in community-level abortion
stigma research in Ethiopia before? Including this information will help readers be informed
on the validity and reliability of the instrument and the suitability of its use in this study. If
word count restricts the inclusion of this information, I suggest including this information as a
footnote or supplementary text.
• Was the study conducted in English? If not, has the included survey content been validated
for the project’s language?  How has an accurate translation of the findings into English been
ensured? If word limit prevents the inclusion of this information intext, I suggest it be included
in supplement text.
Discussion and conclusion: A well-written overview of how results compare with published
work, acknowledgment of limitations, and recommendations for future work. The conclusion
would benefit from the consolidation of information. See suggestions below.
• I suggest reducing the conclusion to be the key takeaway points presented in one paragraph.
This could be done by moving the second conclusion paragraph outlining suggestions for future
work to the discussion. If the word count is a concern, lines 489-499 and 530-543 could be
integrated.
• The final conclusion paragraph should be revised to ensure it reports on takeaways from this
study’s results. Suggest blending lines 544 to 546 with the first discussion paragraph and lines
548 to 552 included in the introduction as a rationale for addressing abortion stigma.
• Line 543: Suggest future community-delivered abortion stigma interventions adding support
for community educators who are potentially stigmatised for communicating abortion access
information with the community.
MINOR ISSUES
Line 94 (page 5): “exposure” # “disclosure”?
Line 127 (page 6): “…were intended ensure..” # “…were intended to ensure…”?
Line 155-156 (page7-8): Where can the baseline survey and qualitative results be found?
Line 159 (page 8): Who are community educators?
Line 208 (page 10): Would you please include a rationale for set power, stigma reduction points,
and non-response rate.
Line 385-286 (page 20): Is “some felt that the community educators were not all considered
knowledgeable professionals on the topics covered” meant to read “some felt that not all
community educators were knowledgeable professionals on the topics covered”? Please clarify
this sentence.
Line 417 (page 23): missing opening quotation marks.
Discussion paragraph 3 (line 457): Did the studies these results are compared to also use the
SABAS?
Table 3: Is table 3 to be included in-text or as supplementary text? It is currently located after
references.