Title: Extra-legal abortion and post-abortion care knowledge, attitudes, and practices among
obstetrician-gynecologist clinicians and medical residents in San José, Costa Rica: A qualitative
study
Version: 1 Date: 06 Jul 2023
Reviewer:  Deborah L. Billings
Reviewer's report:
Thank you for conducting this research, especially given the paucity of publications regarding
the situation of abortion and abortion access in Costa Rica. The following comments and
suggestions aim to strengthen this important work.
ABSTRACT: RESULTS
Lines 16-18: there's reference made to awareness of unsafe abortion, but then followed by
reference to medication abortion and dosing for induction.  The implication is that medication
abortion is unsafe, when it generally is not.  See https://www.thelancet.com/journals/lancet/
article/PIIS0140-6736(17)31794-4/fulltext
"WHO defines unsafe abortion as a procedure for termination of a pregnancy done by an
individual who does not have the necessary training or in an environment not conforming to
minimal medical standards. However, abortions done in accordance with these standards are
considered safe and the risk of severe complications or death is minimal." (citation provided in
the text is: Ganatra B Tunçalp Ö Johnston HB Johnson BR Gülmezoglu A Temmerman M From
concept to measurement: operationalizing WHO's definition of unsafe abortion. Bull World
Health Organ. 2014; 92: 155)
INTRODUCTION
It would be good to clarify that spontaneous abortion = miscarriage. Not every reader will know
this.
PAC- and its three components- should be defined at the outset of the paper. This is not a term
that is known widely to a general readership. See https://www.postabortioncare.org/
Corbett, M. R.; Turner, K. L. (2003). "Essential elements of postabortion care: Origins, evolution
and future directions". International Family Planning Perspectives. 29 (3): 106–11. doi:10.1363/
ifpp.29.106.03. PMID 14519586.
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.postabortioncare.org/
sites/pac/files/USAID_Model.pdf
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://pdf.usaid.gov/pdf_docs/
PA00MJTW.pdf
p4-5: possible additional resources for articles focusing on provider-barriers (and addressing
barriers) to comprehensive abortion care
Silva, Martha, Deborah L Billings, Sandra G. Garcia, Diana Lara. 2009. Physicians’ agreement
with and willingness to provide abortion services in the case of pregnancy from rape in Mexico.
Contraception. (79) 2: 56-64.
Billings DL, Moreno C, González de León D, Ramos C, Ramírez R, Villaseñor L, Rivera
Diaz M. Constructing Access to Legal Abortion Services in Mexico City. Reproductive Health
Matters, 10(19):86- 94, 2002.
METHODS
How were emails and whatsapp numbers (phone numbers) obtained to recruit participants?
What originally was the sample size goal? Or was a data saturation approach used to define
when to stop recruitment?
How many private and how many public facilities were included in recruitment efforts?
Were all facilities in San Jose, exclusively, or was recruitment done elsewhere?
Line 20: "After an initial round of interviews..." please state how many were conducted in this
initial round- with OB/GYBNs and with Medical residents.
Please describe who conducted the interviews. Were all interviews conducted in Spanish?
What measures were taken to ensure confidentiality when using the online calendar tool?
RESULTS
When participants referred to "medicine", were they ONLY referring to misoprostol or were
other "medications" also named?
p9, lines 18-19 "...unless speaking out of fear for their health." Please say more about this
statement. Even if women were fearful, why would they state that they had induced the abortion
rather than say they were experiencing a miscarriage? Did participants have insights into this?
Did participants use the term "feto" (fetus) or is the use of the term "fetus" a translation issue? If
feto was not used, it will be important to use the literal translation of terms used by participants.
p12, line 19-20, reference is made to "unsafely induced abortion"- it's more accurate to say,
illegally induced. One does not know the source of the misoprostol and if someone who is trained
in its use is providing it.
Is misoprostol not used for treatment of incomplete miscarriage? If it is, is it only administered
in the hospital or can people also use it at home? I ask because if the latter, women could come
to the hospital with traces of miso in the vagina but when completing a miscarriage.
Page 13, line 5. Change the word "marriage" to "miscarriage".
DISCUSSION
The issue of conducting interviews on zoom and how that may have affected what participants
shared with the interviewer (someone they did not know) needs to be addressed and discussed
as a study limitation.  For example, page 13, line 19:
Participants may actually be very aware of how methods are used but reluctant to state this in
a zoom call to someone they don't know.
Note that PAC was developed as an intervention to address unsafe induced complications.
p14, lines 11-12. Please check the Nigeria and Uganda studies-- my reading is not that they
objected to providing PAC (life saving care) but to inducing abortion.
It is not clear from the Results why there may be opportunities to employ the harm reduction
model- there is no indication in the data presented that OBGYNs and residents would be open
to providing information that would result in safe (but illegal) induced abortion.
CONCLUSIONS
The authors need to be very humble with their conclusions in terms of generalizing to OB-GYN
clinicians and residents throughout Costa Rica. This study is qualitative and so provides deeper
understanding of the phenomenon among a small sample of providers working in the capital
city. This context needs to be clear when presenting conclusions from the study.
Overall, participants in the study expressed empathy and the need to not judge. Please describe
how this finding is (might be) related to the specific sample of clinicians who participated-- (see
p5, lines 18-19 "our interest in recruiting the individuals most likely to perform abortions").