PONE-D-20-26289

Magnitudes of post-abortion family planning utilization and associated factors among women who seek abortion service in Bahir Dar Town health facilities, Northwest Ethiopia, Facility-Based Cross-Sectional Study.

PLOS ONE

Dear Dr. Bekele,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Four experts in the field handled your manuscript. Although they found some interest in your study, several major comments arose during review. ALL of the reviewers' comments need to be addressed in your revised manuscript.

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We look forward to receiving your revised manuscript.

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Frank T. Spradley

Academic Editor

PLOS ONE

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Please ensure you have provided sufficient details to replicate the analyses such as:   

-    a description of any inclusion/exclusion criteria that were applied to participant recruitment,

-    a statement as to whether your sample can be considered representative of a larger population,

-    a description of how participants were recruited, and

-       descriptions of where participants were recruited and where the research took place.

3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses.

For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. 

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In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed).

If your study included minors, state whether you obtained consent from parents or guardians.

If the need for consent was waived by the ethics committee, please include this information'

5. Thank you for stating the following above the Acknowledgments Section of your manuscript:

'Funding

Bahir Dar University has funded this research'

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

a. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

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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

Reviewer #2: No

Reviewer #3: Partly

Reviewer #4: Partly

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

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

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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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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4. 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: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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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: Introduction

Para 2: “Globally an estimated 55.9 million abortions occur each year, from this 49.3 million occur in the developing”. This sentence is obscure, please make it clear.

Para 2: What the author meant by writing “long-term disability”?

Para 3: “Studies conducted in developing countries showed that the prevalence of post abortion family planning utilization was 73%, 73%, 81%, and 97.7% in Africa and Asia, Pakistan, India, and Brazil respectively” . Pakistan and India are Asian countries, why do you mention prevalence in Africa and Asia?

The last paragraph: Why do you conduct the same research in this area since there are studies concerning the utilization of family planning service in your country?

Method

The author should provide the data on the health institutions, such as the number of abortions and socioeconomic and obstetric profile of population studied.

I missed one paragraph describing inclusion and exclusion criteria.

It’s not clear the criteria for the inclusion of explanatory variables in the multivariate logistic regression. It should be explained.

Discussion

Again, why do you conduct the same research in this area since there are studies concerning the utilization of family planning service in your country? It is important to compare this result with findings from other studies from Ethiopia and eventually from abroad? The author stated” in the number of respondents who counseled about post abortion family planning” when explaining the difference, this is not convincing.

When the author explain: “The odds of post-abortion family planning use among women who received post-abortion family planning counseling were higher than the counterpart”, you should focus on the benefits which post-abortion family planning counseling might bring to abortion patients.

I missed one paragraph explaining: “sex preference of health care providers, and counseling about post-abortion family planning were predictors of post-abortion family planning method utilization”.

Conclusion

It should be shorter and concise. Recommendations should be more specific and target the risk factors in your research.

Reviewer #2: Understanding the utilization of postabortion family planning is a worthwhile undertaking and critical to reducing unintended pregnancies as well as maternal mortality in places like Ethiopia. Congratulations to the authors for conducting this research and putting together this draft for publication. Some specific feedback to strengthen the paper is listed here:

-Spend more time on the definitions and ensure the use of globally recognized definitions. It's unclear whether the authors are considering contraception after INDUCED abortions or also considering contraception after SPONTANEOUS abortions (miscarriages). Postabortion care generally refers to both and PAFP is important in both cases--and spontaneous abortions are much more common than induced (which means the globally cited numbers should be higher). It would be helpful to define PAC services broadly (treatment of complications, counseling, and provision of contraception) and emphasize that PAFP is an essential component of quality PAC services. Also consider using the global estimate for abortion from Guttmacher or another source.

-What's the population of Bahir Dar town? How many women of reproductive age? What's the contraceptive prevalence rate in the region/area? What's the total fertility rate? What other contextual information and population data can you provide to give a better picture of why understanding PAFP rates in Bahir town is important? What does studying this area contribute to broader learning about PAFP in Ethiopia / Horn of Africa / Globally?

-Why was Debre Markose town used as a proxy to calculate the sample size? What are the similarities? what are the differences? How was this considered?

-How many public and private health institutions provide abortion services in Bahir Dar town? What source of information was used to ensure ALL public and private institutions were included (assuming it's often difficult to enumerate all private providers)? Did all included institutions offer postabortion contraception in addition to abortion services? Did all institutions offer similar method options? Were there differences in PAFP acceptance rates for each facility? Was there any learning here? how did this factor into the statistical analysis?

-The methods section needs clarified. Were you collecting this information from patient register books (register extraction?)? Or were you contacting the women for a survey prospectively as they went in for their abortion? Were women approached in their homes? At the facilities? How was the data collected and protected? How many women were approached? How many women gave consent to participate? How many women refused? Would you expect any differences in those who consented and those who refused? The data quality control "pretest" does not make sense, what was done here?

-ETHICS: Was there any sort of ethical approvals for this study (I see in the declaration, but include in your methods section of the paper)? How did you ensure informed consent to approach these women and include their information? "Written verbal consent" does not make sense. How did you protect their information, given the sensitivity of the subject matter? A 100% response rate is quite impressive, but also raises questions about the consent process.

-In the discussion, PAC-FP research has been conducted in many places. Why choose to compare this data to Brazil? I'm sure there are many differing factors in addition to the marriage rate that should be considered.

-Is there any data on the quality of the PAC-FP counseling provided? The quality of the counseling matters for PAFP uptake.

-I would recommend to re-do the discussion and instead of comparing the results of this study to those conducted in other places far away, instead re-work to discuss what the implications of this data are. How can these findings be used programmatically to improve PAC and PAFP uptake in Bahir Dar? What should the MOH be doing? What should the private facilities be doing? What should change now that we have these data? What's next? So what?

Reviewer #3: The manuscript is riddled with a lot of typos and grammatical errors that could have been easily corrected. It is not clear what the sample size was and with such a large volume of clients sampled it would be important to add an exclusion criteria. The number of respondents is very high for the period of the study (one month). Had the study subjects come for treatment for abortion complications related to incomplete abortion or come for termination of pregnancy/safe abortionm is it legal in Ethiopia? at what stage post treatment were the interviews conducted?

Also, how were the data collectors assigned to the facilities for data collection? Finally would be good to revise the referencing - not clear what and where online the references were accessed or whether these were accessed as hard copies. Finally not clear what new learning the study is contributing and if it is specifc learning for the study area please add how the findinsg are expected to be applied. Globally there is not new evidence the study adds.

Reviewer #4: Thank you for inviting me to review this manuscript. It contributes to the science of postabortion care family planning globally and gives further data points on factors related to postabortion family planning. It is clear the authors and researchers worked diligently on this research.

1. Is the manuscript technically sound, and do the data support the conclusions? For the most part this manuscript is technically sound. The conclusions and discussion could be developed further. More specific recommendations are needed.

2. Has the statistical analysis been performed appropriately and rigorously? Yes, although an additional table with the bivariate analysis results would be useful as would the p values for the multivariate table. Also there is a need to clarify the title of Table 3

3. Have the authors made all data underlying the findings in their manuscript fully available? The information in the manuscript just states the data are available in an Excel form, but not exactly how to access them.

4. Is the manuscript presented in an intelligible fashion and written in standard English? There are a number of grammar, spelling, and proof reading issues in this manuscript that need to be addressed as well as inconsistencies in the use of acronyms.

Additional comments for the authors:

- Clarification of education levels – unclear to global audience what “Certificate and above” indicates for education - is also does not correspond to the levels in the analysis or discussion.

- Third paragraph percentage reports are confusing, recommend putting them in parenthesis next to the places

- Be more specific in aim of the study – include the region/area

- Define what you mean by post abortion family planning utilization

- Give what currency the monthly income is in

- Include information about legality of abortion/postabortion care in Ethiopia

- In the introduction and discussion, previous studies don’t specify exactly where they took place – for example in the first paragraph of the discussion is lists Addis Ababa and then Ethiopia – would be helpful to be more specific with the general Ethiopia information – list like with like places. This is the case also in the third paragraph of the discussion – I assume that Debre Markose and Gambella are in Ethiopia, but would be helpful to clarify this as the next one is about Kenya generally

- The last line of the conclusion does not really summarize the findings of the study or give specific recommendations – this is a broad recommendation that could be difficult to complete – it may be useful to specify more specific interventions – which could be related to education but also to the other variables.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: STEMBILE MUGORE

Reviewer #4: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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Attachments

Attachment

Submitted filename: renamed_669b2.docx

Attachment

Submitted filename: Reviwer Comments.docx

PONE-D-20-26289R1

Magnitudes of post-abortion family planning utilization and associated factors among women who seek abortion service in Bahir Dar Town health facilities, Northwest Ethiopia, Facility-Based Cross-Sectional Study.

PLOS ONE

Dear Dr. Bekele,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

There are still major concerns about your article. Notably, a professional copyeditor must be contacted to proof your manuscript for typographical errors and standard English. Please address ALL comments in your revised manuscript.

Please submit your revised manuscript by Jan 07 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

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

Reviewer #2: (No Response)

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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

Reviewer #2: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

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

Reviewer #2: No

**********

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: the language in submitted articles is clear, correct, and unambiguous. the statistical analysis has been performed appropriately and rigorously.

Reviewer #2: (No Response)

**********

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

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Magnitudes of post-abortion family planning utilization and associated factors among women who seek abortion service in Bahir Dar Town health facilities, Northwest Ethiopia, Facility-Based Cross-Sectional Study.

PONE-D-20-26289R2

Dear Dr. Bekele,

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