Delays in obtaining hospital care and abortion-related complications within a context of illegality

Romina M. Hamui; Estela M. L. Aquino; Greice M. S. Menezes; Thália Velho Barreto de Araújo; Maria Teresa Seabra Soares de Britto e Alves; Sandra Valongueiro Alves; Maria da Conceição C. Almeida

doi:10.1371/journal.pone.0286982

Peer Review History

Original SubmissionAugust 20, 2022
3 Mar 2023 Decision Letter - Surangi Jayakody, Editor PONE-D-22-23361Delays in obtaining hospital care and abortion-related complications within a context of illegalityPLOS ONE Dear Dr. Romina, 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. Please submit your revised manuscript by 24/03/2023. 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. 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The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf. 2. Thank you for stating in your Funding Statement: “EMLA This study received financial support from the Brazilian Ministry of Health (DECIT) and the Ministry of Science and Technology - National Council for Scientific and Technological Development (CNPq), grants MCT/CNPq/MS-SCTIE-DECIT/CT - Health 22/2007 (#551249/2007-2) and MCT/CNPq/MS/ SCTIEDECIT 54/2008 (#402680/2008-1). Additionally, a CNPq research productivity grant (306295/2017-2) was provided. https://www.gov.br/saude/pt-br https://www.gov.br/mcti/pt-br https://www.gov.br/cnpq/pt-br The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” Please provide an amended statement that declares all the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement. Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf. 3. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. 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: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 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: No Reviewer #2: No ****** 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: Yes Reviewer #2: Yes ****** 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 is a further analysis of a study conducted in 2010, it contributes to the understanding of the delay in performing uterine evacuation and occurrence of abortion-related complications. The author has provided reasonable explanation regarding the restrictions in availability of data in the manuscript (review question (3)). Comments: 1. Page 5 - Introduction I suggest including information regarding the legal status of abortion in the areas where the study was conducted as it is not clear. There is a statement on regions with restrictive legislation in line 74, however, it is not clear whether this include the regions of study. The meaning of restrictive legislation for abortion needs to be explained. 2. Page 9, line 178: The statement ‘to calculate the number of losses’ is not clear; does ‘number of losses’ means ‘missing data’? This need clarification. 3. Tables 1 and 3: To state the exact number of indigenous women and those of Asian descent which were excluded. Reviewer #2: The authors of this manuscript have described " Delays in obtaining hospital care and abortion-related complications within a context of illegality" technically sound manner. However, the original study was conducted in 2010 which is more than 12 years back. Publishing an article and applicability of the recommendations based on a study which was conducted more than 12 years back is arguable. Table 2 is on time interval between admission and uterine evacuation according to the occurrence of complications. If the data are being skewed, better explain with median and IQR rather than explaining all mean, SD and median. Also author can mention the number of cases outside from this table. Table 3 - If Asian and Indigenous women were excluded, under ethnicity author can mention the number as n = ....... The authors have included the recommendations also under conclusion. Better if the limitations have been mentioned. ****** 6. 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. Attachments Attachment Submitted filename: Comments.docx https://doi.org/10.1371/journal.pone.0286982.r001
Revision 1
30 Apr 2023 Author Response In response to the academic editor’s suggestions: 1. Please ensure that your manuscript meets PLOS ONE style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_b ody.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_aut hors_affiliations.pdf. The text has been reviewed once again to ensure that we meet with your requirements and to the best of our knowledge we believe that we have complied with the PlosOne guidelines 2. Thank you for stating in your Funding Statement: Please provide an amended statement that declares all the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement. Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf. An amended statement has now been included in the cover letter, as requested: Funding statement: This study received financial support from the Brazilian Ministry of Health (DECIT) and the Ministry of Science and Technology - National Council for Scientific and Technological Development (CNPq), grants MCT/CNPq/MS-SCTIE-DECIT/CT - Health 22/2007 (#551249/2007-2) and MCT/CNPq/MS/ SCTIEDECIT 54/2008 (#402680/2008-1). In addition, EMLA received a CNPq research productivity grant (306295/2017-2). There was no additional external funding received for this study. URLs to sponsors’ websites: https://www.gov.br/saude/pt-br https://www.gov.br/mcti/pt-br https://www.gov.br/cnpq/pt-br The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. 3. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. The reference list has been checked as requested. Two of the references have been updated: 6 - Shah I, Ahman E. Unsafe abortion in 2008: global and regional levels and trends. Reprod Health Matters. 2010;18:90-101. https://doi.org/10.1016/S0968-8080(10)36537-2. 27 - Goes EF, Menezes GMS, Almeida MC, Araújo TVB, Alves SV, Alves MTSSBE, et al. Racial vulnerability and individual barriers for Brazilian women seeking first care following abortion. Cad Saude Publica. 2020;36(Suppl 1):e00189618. https://doi.org/10.1590/0102-311X00189618. In response to Reviewer 1: 1. Page 5 - Introduction I suggest including information regarding the legal status of abortion in the areas where the study was conducted as it is not clear. There is a statement on regions with restrictive legislation in line 74, however, it is not clear whether this includes the regions of study. The meaning of restrictive legislation for abortion needs to be explained. We are grateful to the reviewer for this suggestion. Text has now been added to the Introduction, as follows (Page 5, lines 72-74): Abortion is illegal in Brazil except when performed to save the woman's life or in cases of rape. In 2012, the Brazilian Supreme Court authorized abortion in cases of fetuses with anencephaly. 2. Page 9, line 178: The statement ‘to calculate the number of losses’ is not clear; does ‘number of losses’ means ‘missing data’? This need clarification. We are particularly grateful for this comment as it gave us the opportunity to correct and provide a clearer explanation regarding these losses. To identify those eligible for the survey, the women admitted daily to each of the hospitals involved in the study were checked and a list of those to be interviewed by the investigators was prepared. A total of 2,848 interviews were carried out, with 5.8% of losses and 2.7% of refusals. This information has now been added to the text. (Page 9, lines 184-185) 3. Tables 1 and 3: To state the exact number of indigenous women and those of Asian descent, which were excluded. Thank you for this suggestion. The information requested has now been added to page 12, lines 243-245 and as a footnote to both tables, as follows: Seventy-six indigenous women (2.8%) and 69 women of Asian descent (2.5%) were excluded due to their small numbers and due to the presence of differences that would make it difficult for them to be included in any other group. In response to Reviewer Nº2: 1) The authors of this manuscript have described " Delays in obtaining hospital care and abortion-related complications within a context of illegality" technically sound manner. However, the original study was conducted in 2010 which is more than 12 years back. Publishing an article and applicability of the recommendations based on a study which was conducted more than 12 years back is arguable. Thank you for this comment. The following text has now been added to the Conclusion: Abortion continues to be illegal in the country, with the only change being the incorporation by the Supreme Court in 2012 of a third legal exception to the law – in cases of anencephaly. Therefore, no change has occurred in unsafe abortion care within the public health network. 2) Table 2 is on time interval between admission and uterine evacuation according to the occurrence of complications. If the data are being skewed, better explain with median and IQR rather than explaining all mean, SD and median. Also author can mention the number of cases outside from this table Thank you for pointing this out. The Shapiro-Wilk test was performed and the distribution of the data is indeed not normal. Therefore, results have now been reported as medians. Means and SD have been removed from the table, as suggested. (Page 16). 3) Table 3 - If Asian and Indigenous women were excluded, under ethnicity author can mention the number as n = ....... Thank you for this suggestion. This information has now been added to the Results section (page 12, lines 243-245) and as a footnote to Tables 1 and 3, as follows: Seventy-six indigenous women (2.8%) and 69 women of Asian descent (2.5%) were excluded due to their small numbers and due to the presence of differences that would make it difficult for them to be included in any other group. 4) The authors have included the recommendations also under conclusion. Better if the limitations have been mentioned. We chose to present the limitations and strengths of the study in the Discussion (lines 479-498), reserving the summary of the main findings and their implications for future research and the reorganization of abortion care for the Conclusions. We would prefer to retain the manuscript in this format; however, should the editor deem it necessary, we are willing to make the changes suggested by the Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0286982.r002
30 May 2023 Decision Letter - Surangi Jayakody, Editor Delays in obtaining hospital care and abortion-related complications within a context of illegality PONE-D-22-23361R1 Dear Dr. Hamui, 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. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Surangi Jayakody, MBBS, MSc, MD Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0286982.r003
Formally Accepted
7 Jun 2023 Acceptance Letter - Surangi Jayakody, Editor PONE-D-22-23361R1 Delays in obtaining hospital care and abortion-related complications within a context of illegality Dear Dr. Hamui: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr Surangi Jayakody Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0286982.r004

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