PONE-D-19-30083

Women’s reproductive health decision-making capacity and pregnancy termination in sub-Saharan Africa: a multi-country analysis of 27 cross-sectional surveys

PLOS ONE

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2. Thank you for including your ethics statement:

"The DHS obtain ethical clearance from the Ethics Committee of ORC Macro Inc. as

well as Ethics Boards of partner organizations of the various countries such as the

Ministries of Health. During each of the surveys, either written or verbal consent was

provided by the women. Since the data was not collected by the authors of this

manuscript, we sought permission from the website of MEASURE DHS and access to

the data was provided after our intent for the request was assessed and approved on

27th January, 2019. Permission to use the data set was sought from MEASURE DHS."

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This paper examines reproductive health decision making capacity and pregnancy termination in 27 sub-Saharan countries. The study was an informative descriptive study of the relationship between a number of factors and PT, with reproductive health decision making key among them.

Title: maybe add “and other factors related to…”. This is because the discussion is equally about RH and all other sociodemographic factors. So the paper is not solely about theory in RHDM but a more comprehensive perspective.

Abstract.

Say something about how RDM capacity is measured within the abstract.

Give an indication of which one was the dependent variable in the Binary Logistic Regression Analysis

Consistently use the term “prevalence of’ instead of prevalence then proportion in the methods vs Results

Its 27 countries in the analysis, the comparison or focus on three Gabon, Congo and Angola does not seem informative. Maybe add the associated sociodemographic factors as they were also assessed.

Conclusion: it is not clear from your results what the policy attention should be. And your study did not explore safety issues at least not mentioned in the results. Maybe your conclusions should be related more to reproductive health decision making capacity and the policy recommendation in that regard.

Background

Line 70-71: Please give a little more context. 830 women from where?

Line 73: all global UNSAFE terminations not 97% of all terminations

Line 73-76: Please provide a source.

What is the context for an unsafe PT? Is it one undertaken outside of hospital for instance? This will be important to define especially as the numbers are so high.

Line 99: Seidu et al

Line 99-106 ; Maybe link these also to then the safe PT issue. Does lack of RDM capacity also have a bearing on how safe/unsafe the abortion procured is? And also to link in objects out of the women’s control such as health facilities with no abortion services.

Line 107-109: These need to be elaborated a little more so that the reader can get a true sense of where the gap in the literature is. See also my comment above of what still needs to be discussed. If concerned about brevity, maybe cut out some of the definitions that may not be necessary to include in the beginning of the background.

Materials and Methods

127-143: I feel this can be made briefer with references to outside sources to get more detailed information on DHS sampling and data collection procedure. This is for the sake of brevity and not to lose focus on the actual materials and methods for the current study.

144-145: Is it all the women in the sample or just a sub-set of them?

170: Does capable mean two “yes” answers for each variable?

Table 1: is pregnancy terminated column a percentage?

209-210: refer to Table 2 here, so that the reader can refer to it early not at end of paragraph.

230: isn’t that 1.48, please double check.

230-232: is this difference in countries tied to the RDM capacity of women in those countries?

I wonder if an analysis of the relationship between the RDM and other socio-demographics could also be informative

Discussion

302; kindly just fix the grammar – maybe skip “our findings support the findings of’ and just put the citations at the end of the first sentence if they apply there.

Maybe list as a limitation that the relationship between RHDM and PT is generalized for the SSA region, not the individual countries.

Conclusion

349-350: Maybe clarify – PT and RHDM were linked when analyzed across countries. PT was high in Congo and Gabon yes, and in the discussion you provide a reason why. By referring to other literature. So I don’t believe this conclusion in this particular sentence is merited by your own findings. The RHDM dynamics in these individual countries or even the outcomes were not discussed specifically so I believe this conclusion is a leap. The dynamics in these countries had to do with pregnancy prevalence and lack of access to contraceptives.

The issue of safety, “medically sanctioned” and the like should be explored more in the background.

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Reviewer #1: No

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What has women’s reproductive health decision-making capacity and other factors got to do with pregnancy termination in sub-Saharan Africa? Evidence from 27 cross-sectional surveys

PONE-D-19-30083R1

Dear Dr. Sambah,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No