Induced abortion in Africa: A systematic review and meta-analysis

Teklehaimanot Gereziher Haile; Teklehaymanot Huluf Abraha; Gebreamlak Gebremedhn Gebremeskel; Kidane Zereabruk; Tesfay Hailu Welu; Teklit Grum; Negasi Asres

doi:10.1371/journal.pone.0302824

Peer Review History

Original SubmissionJuly 12, 2023
26 Jan 2024 Decision Letter - Johanna Pruller, Editor PONE-D-23-21853 Induced Abortion in Africa: A Systematic Review and Meta-analysis PLOS ONE Dear Dr. Haile, 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. ============================== The manuscript has been evaluated by two reviewers, and their comments are available below. The reviewers have raised a number of minor concerns, specifically they feel that including more details in the methodology section would strengthen this manuscript. Could you please carefully revise the manuscript to address all comments raised? ============================== Please submit your revised manuscript by Mar 04 2024 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'. 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If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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. [Note: HTML markup is below. Please do not edit.] 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: Yes Reviewer #2: Yes ****** 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: 1. Is the manuscript technically sound, and do the data support the conclusions? Yes, the manuscript is technically sound, as it follows a systematic review and meta-analysis method to estimate the pooled prevalence of induced abortion and its associated factors in Africa. The data support the conclusions, as they show that the prevalence of induced abortion is high and varies by country and year of study. 2. Has the statistical analysis been performed appropriately and rigorously? Yes The statistical analysis has been performed appropriately and rigorously, as the authors use a systematic review and meta-analysis method to combine the results of different studies on the prevalence of induced abortion and its associated factors in Africa. The authors use software called STATA 14, which is a widely used and reliable tool for statistical analysis. They also use funnel plot and Egger regression test to assess the potential publication bias, which is the tendency of published studies to report more favorable or significant results than the true effect. They perform sub-group analysis by country and year of study to explore the sources of heterogeneity and to compare the results across different settings and time periods. The authors follow the standard and rigorous procedures for conducting a meta-analysis and reporting their findings. 3. Have the authors made all data underlying the findings in their manuscript fully available? Yes 4. Is the manuscript presented in an intelligible fashion and written in Standard English? Yes, The manuscript is presented in an intelligible fashion and written in Standard English, as it follows a clear and logical structure of background, methods, results, and conclusion. Reviewer #2: 01) The manuscript titled "Induced Abortion in Africa: A Systematic Review and Meta-analysis" provides a comprehensive investigation into the prevalence of induced abortion in Africa and associated factors. The manuscript is well-structured, offering a clear understanding of the research scope, methods, results, and implications. Also, the topic of induced abortion in Africa holds immense importance in the realms of public health, reproductive rights, and policy development. Here are some specific points for consideration and potential improvements: 02) In reference to line 86, the inclusion of unpublished articles is highlighted by the authors. It is crucial that the authors offer a clear explanation regarding the decision to incorporate unpublished articles in the review. Additionally, readers would benefit from a detailed description of the methodologies employed to assure the quality and reliability of information derived from these unpublished sources." 03) In reference to line 90, where the authors indicate that 'All articles published up to May 1, 2023, were included in this study,' it would enhance clarity for readers if the date range, specifying both the starting and ending dates, is explicitly mentioned. 04) From line 120 to 131, the inclusion and exclusion criteria are provided as a list. It is suggested to consider presenting these criteria in a tabular format to enhance readability and the overall structure of the manuscript. 05) In line 130, the authors mention the exclusion of manuscripts with methodological problems. It is important for the authors to provide details on the nature of these methodological problems, how they were identified, and who made the decisions regarding exclusions. This information is crucial for maintaining objectivity and transparency in the review process. 06) In line 165, the authors state that 'At first, 976 studies were found through a thorough search of electronic databases.' It would be beneficial for readers to know how many articles were found from each database. Consider presenting these details in the PRISMA flow chart (figure 01) for improved clarity. 07) In reference to line 177, where the authors note the inclusion of studies with small sample sizes, as low as 64, alongside the exclusion of studies with methodological problems, there arises a concern about the consideration of sampling and sample size in the analysis of the papers' methodological comprehensiveness. It would be helpful for the authors to provide clarification on how the adequacy of sample size was assessed and whether it was a factor in evaluating the overall methodological quality of the included studies. 08) The manuscript indicates that the final sample comprises 46 studies, yet in line 189, the authors highlight the inclusion of only 42 studies in the meta-analysis. To enhance transparency and clarity regarding the study selection process, it is imperative for the authors to provide detailed explanations on why the remaining four studies were excluded from the meta-analysis 09) "In lines 279 to 281, the paper asserts that 'Our study found a strong association between unintended pregnancy and induced abortion, with women who had unintended pregnancies being nearly ten times more likely to undergo induced abortion compared to those with intended pregnancies.' It is suggested to rephrase this statement as 'unintended at the time of pregnancy / conception' to enhance clarity." ****** 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: Yes: Getnet Melaku Reviewer #2: Yes: M. Suchira Suranga ******** [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: Reviewer Comments for authors.docx https://doi.org/10.1371/journal.pone.0302824.r001
Revision 1
12 Feb 2024 Author Response Date: February 08, 2024 Subject: Response to editors, and reviewers for the revised manuscript submission. Title: Induced abortion in Africa: a systematic review and meta-analysis; [PONE-D-23-21853] Dear Editor and Reviewers, We are grateful for your careful reading of our work and your insightful comments. We truly value the time and energy you invested in offering thoughtful feedback and recommendations. Every one of your comments has been thoroughly reviewed, and the appropriate changes have been implemented in response. The individual reviewer comments have been addressed by explaining the adjustments made and offering a thorough response to each comment. We have also considered the journal requirements and ensured that our paper conforms to all relevant guidelines and formatting requirements. We believe that these changes have greatly improved our study's quality, precision, and clarity. We are certain that the revised manuscript now successfully addresses the issues brought up throughout the review process and complies with the journal's requirements. We would want to thank you again for all of your helpful advice and suggestions during this process. We welcome any further comments or advice you may have. Thank you for your time and consideration. Sincerely, The authors Reviewer #1: 1. Is the manuscript technically sound, and do the data support the conclusions? Yes, the manuscript is technically sound, as it follows a systematic review and meta-analysis method to estimate the pooled prevalence of induced abortion and its associated factors in Africa. The data support the conclusions, as they show that the prevalence of induced abortion is high and varies by country and year of study. Response: We appreciate your compliments on our manuscript. We appreciate you acknowledging the thorough systematic review and meta-analysis we carried out to estimate the prevalence of induced abortion in Africa and take into consideration differences by country and study year. Your evaluation of our methodology and the evidence supported by the data is quite positive. Once again, thank you so much for your valuable feedback. 2. Has the statistical analysis been performed appropriately and rigorously? Yes The statistical analysis has been performed appropriately and rigorously, as the authors use a systematic review and meta-analysis method to combine the results of different studies on the prevalence of induced abortion and its associated factors in Africa. The authors use software called STATA 14, which is a widely used and reliable tool for statistical analysis. They also use funnel plot and Egger regression test to assess the potential publication bias, which is the tendency of published studies to report more favorable or significant results than the true effect. They perform sub-group analysis by country and year of study to explore the sources of heterogeneity and to compare the results across different settings and time periods. The authors follow the standard and rigorous procedures for conducting a meta-analysis and reporting their findings. Response: Thank you for taking the time to review and positive feedback. Your positive feedback on the rigor of our statistical procedures is greatly appreciated. 3. Have the authors made all data underlying the findings in their manuscript fully available? Yes Response: Thank you for your review and for recognizing that we have made all the data underlying the findings in our manuscript fully available. Once again, we appreciate your acknowledgement of our efforts in this regard. 4. Is the manuscript presented in an intelligible fashion and written in Standard English? Yes, the manuscript is presented in an intelligible fashion and written in Standard English, as it follows a clear and logical structure of background, methods, results, and conclusion. Response: Thank you for your review and positive feedback. Your recognition of our efforts in presenting the study clearly and using appropriate language is encouraging. Once again, thank you so much for your valuable assessment. Reviewer #2: 1) The manuscript titled "Induced Abortion in Africa: A Systematic Review and Meta-analysis" provides a comprehensive investigation into the prevalence of induced abortion in Africa and associated factors. The manuscript is well-structured, offering a clear understanding of the research scope, methods, results, and implications. Also, the topic of induced abortion in Africa holds immense importance in the realms of public health, reproductive rights, and policy development. Here are some specific points for consideration and potential improvements: Response: We appreciate your compliments on our manuscript. Thank you for acknowledging the thoroughness of our research on the prevalence of induced abortion in Africa and associated factors. We are pleased to hear that the manuscript's structure effectively conveys the research scope, methods, results, and implications. Once again, we are very grateful for your review. 2) In reference to line 86, the inclusion of unpublished articles is highlighted by the authors. It is crucial that the authors offer a clear explanation regarding the decision to incorporate unpublished articles in the review. Additionally, readers would benefit from a detailed description of the methodologies employed to assure the quality and reliability of information derived from these unpublished sources." Response: Thank you for taking the time to review and insightful comments regarding the unpublished papers we included in our manuscript. We recognize that unpublished research plays a significant role in offering insightful information and increasing the sample size and number of studies included in the analysis, which can improve the statistical power and precision of the findings. We provide a thorough explanation of the procedures followed to evaluate the accuracy and consistency of data obtained from unpublished sources, including the application of the Newcastle-Ottawa Quality Assessment Scale. We appreciate you bringing these crucial points to our attention once more. We value your feedback, and we hope that this will provide a clear explanation and a detailed description regarding the inclusion of unpublished articles. 3) In reference to line 90, where the authors indicate that 'All articles published up to May 1, 2023, were included in this study,' it would enhance clarity for readers if the date range, specifying both the starting and ending dates, is explicitly mentioned. Response: We appreciate your review and insightful suggestion. We believe that providing readers with precise information about the starting and ending dates will enhance clarity. Therefore, based on your suggestion, we have added a clear and explicit date range in our amended manuscript (lines 89-90), specifying both the starting and ending dates. We are grateful for bringing this to our attention and for your suggestions on improving the clarity of our study. 4) From line 120 to 131, the inclusion and exclusion criteria are provided as a list. It is suggested to consider presenting these criteria in a tabular format to enhance readability and the overall structure of the manuscript. Response: We appreciate your evaluation and insightful recommendation. We agree that organizing these requirements in tabular format can make our study easier to read and better organized overall. In our revised version (line number 119), we have included a table to enhance the understanding of the inclusion and exclusion criteria. Once again, we appreciate you bringing this to our notice and helping to improve the clarity and presentation of our study. 5) In line 130, the authors mention the exclusion of manuscripts with methodological problems. It is important for the authors to provide details on the nature of these methodological problems, how they were identified, and who made the decisions regarding exclusions. This information is crucial for maintaining objectivity and transparency in the review process. Response: We appreciate your review and valuable feedback regarding the need for additional information on the nature of methodological problems, how they are identified, and the decision-making process regarding exclusions. In our amended manuscript (Table 1, line 120), we have included more precise information on the nature of methodological problems encountered in the studies. We also identified these methodological problems through a careful review of the studies to ensure accuracy and consistency in the evaluation process. We appreciate your feedback, and we will ensure that the revised manuscript provides greater clarity on the nature of methodological problems, their identification, and the decision-making process for exclusions. Thank you for bringing these important aspects to our attention. 6) In line 165, the authors state that 'At first, 976 studies were found through a thorough search of electronic databases.' It would be beneficial for readers to know how many articles were found from each database. Consider presenting these details in the PRISMA flow chart (figure 01) for improved clarity. Response: Thank you so much for your review and insightful feedback. We have updated the PRISMA flow chart (Fig 1) in our revised manuscript to reflect the number of articles that were found in each database. We have taken note of your advice and made the appropriate changes to our manuscript. We appreciate you pointing this out to us and helping to make our manuscript better. 7) In reference to line 177, where the authors note the inclusion of studies with small sample sizes, as low as 64, alongside the exclusion of studies with methodological problems, there arises a concern about the consideration of sampling and sample size in the analysis of the papers' methodological comprehensiveness. It would be helpful for the authors to provide clarification on how the adequacy of sample size was assessed and whether it was a factor in evaluating the overall methodological quality of the included studies. Response: Thank you very much for your review and valuable feedback. In our manuscript (lines 175-178), we have provided an explanation of how we assessed the studies included in our analysis. While inadequate sample size is considered an indication of a methodological problem for inclusion in the analysis, the studies included in our study met the criteria of the Newcastle-Ottawa Quality Assessment Scale, which evaluates the quality and accuracy of the study. Furthermore, it is crucial to remember that study quality and eligibility for inclusion in a systematic review and meta-analysis are not solely determined by sample size. In addition, other elements including study design, methodology, and bias risk should be considered. We appreciate your feedback on the importance of sample size and its role in evaluating the overall quality of our study. Once again, we sincerely appreciate your contribution in bringing these concerns to our attention, and we value your efforts to improve the quality of our study. 8) The manuscript indicates that the final sample comprises 46 studies, yet in line 189, the authors highlight the inclusion of only 42 studies in the meta-analysis. To enhance transparency and clarity regarding the study selection process, it is imperative for the authors to provide detailed explanations on why the remaining four studies were excluded from the meta-analysis Response: We appreciate you bringing up the discrepancy between the final 46 studies and the inclusion of just 42 studies in the meta-analysis in the manuscript. We apologize for any confusion caused by this inconsistency and appreciate the opportunity to provide clarification. In our revised manuscript (lines 163-168), we have provided a more explicit explanation to clarify this distinction and ensure transparency regarding the inclusion and exclusion of studies in the meta-analysis and associated factors analysis. We appreciate you bringing this to our notice and helping to make our study more transparent and clearer. 9) "In lines 279 to 281, the paper asserts that 'Our study found a strong association between unintended pregnancy and induced abortion, with women who had unintended pregnancies being nearly ten times more likely to undergo induced abortion compared to those with intended pregnancies.' It is suggested to rephrase this statement as 'unintended at the time of pregnancy / conception' to enhance clarity." Response: We appreciate your evaluation and thoughtful advice regarding the phrasing of the statement about the association between unintended pregnancy and induced abortion. In line with your suggestion, we have rephrased the statement in the amended manuscript (lines 272-278) to clarify that the pregnancies were unintended at the time of pregnancy, in accordance with your advice. This modification will enhance the clarity of the statement and provide a more accurate representation of our findings. Thank you for bringing this to our attention, and we value your contribution to improving the clarity of our study. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0302824.r002
27 Mar 2024 Decision Letter - Renato Teixeira Souza, Editor PONE-D-23-21853R1Induced abortion in Africa: a systematic review and meta-analysisPLOS ONE Dear Dr. Haile, 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 May 11 2024 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: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Renato Teixeira Souza Academic Editor PLOS ONE Journal Requirements: 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. Additional Editor Comments: Thank you for the opportunity to manage the submission of this current manuscript. I had the opportunity to review the current and latest versions and the comments from the reviewers. The manuscript is improved and it is very well-written. In order to improve clarity and reproducibility, I suggest making the data extraction process and objectives related to the subgroup analyses done in the meta-analysis clear: unintended pregnancy, unmarried women, educational status, and substance abuse. It was not clear enough whether such analysis was planned before conducting the systematic review or whether it was conducted after retrieving papers and looking at the available data. Data-driven analysis can introduce many biases. Make it clear whether the study protocol has been previously registered or published. [Note: HTML markup is below. Please do not edit.] 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: (No Response) Reviewer #2: All comments have been addressed ******** 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: Yes ****** 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: 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) Reviewer #2: The author's revised version exhibits significant improvements in various aspects. With minor editorial and language corrections, the manuscript is poised for acceptance and publication. We extend our best wishes for your future research endeavors and studies. ****** 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: Yes: Getnet Melaku Reviewer #2: Yes: M. Suchira Suranga ******** [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. https://doi.org/10.1371/journal.pone.0302824.r003
Revision 2
6 Apr 2024 Author Response Dear Editor and Reviewers, We would like to thank the editor and reviewers for their time and expertise in reviewing our manuscript. your valuable input has undoubtedly contributed to the enhancement of our manuscript. We appreciate your time and effort in reviewing the previous version and considering our responses to your comments. We are glad that the revisions we made in response to your previous comments have addressed your concerns and met your expectations. We have carefully considered and incorporated your suggestions into the manuscript to improve its quality, clarity, and scientific rigor. Once again, we sincerely appreciate your positive response and we are grateful for your thorough evaluation of our manuscript. Additional Editor Comments: Thank you for the opportunity to manage the submission of this current manuscript. I had the opportunity to review the current and latest versions and the comments from the reviewers. The manuscript is improved and it is very well-written. In order to improve clarity and reproducibility, I suggest making the data extraction process and objectives related to the subgroup analyses done in the meta-analysis clear: unintended pregnancy, unmarried women, educational status, and substance abuse. It was not clear enough whether such analysis was planned before conducting the systematic review or whether it was conducted after retrieving papers and looking at the available data. Data-driven analysis can introduce many biases. Make it clear whether the study protocol has been previously registered or published. Response: We appreciate your careful reading of our manuscript and your insightful comments. We acknowledge the concerns expressed about the data extraction process and objectives related to the subgroup analyses, publication biases, and study protocol, as well as your recommendations for enhancing clarity and reproducibility. Regarding the data extraction process, it is stated explicitly on pages 5-6 (lines 106–112) that "The data were separately extracted by three authors using a structured method of data collection." the objective of subgroup analyses is to compare these overall estimates across groups and determine whether the considered grouping helps us explain some of the observed between-study heterogeneity, and the studies were grouped based on the study area and study year, and an overall effect size was computed for each group, This is covered in detail on page number 12 (lines 204–215). "Unintended pregnancy, unmarried women, educational status, and substance abuse" are not subgroup analyses; rather, they are characteristics that significantly predict the likelihood of an induced abortion. Regarding publication bias, we have reported the results of the funnel plot, Egger's test, and trim and fill test, all of which showed no significant publication bias; this suggests that the results of our meta-analysis are not unduly influenced by the selective publication of studies based on their outcomes. Page number 11-12 (lines 189-202). We regret to notify you, nonetheless, that a study protocol was not registered or published for this research. We recognize that in order to improve transparency and reduce biases, pre-registration or publication of the study protocol is crucial. We have taken many precautions to reduce potential biases by adhering to established guidelines for systematic reviews and meta-analyses, following a rigorous methodology, and providing a detailed description of our methodology and analysis approach, even though the lack of a registered or published protocol is a limitation. Finally, the lack of a registered or published protocol is mentioned as a limitation for this study, on page 16 (lines 298–303) of our work. We hope to keep things transparent and let readers know about this restriction by doing this. Once again, we appreciate your thorough review and constructive feedback. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0302824.r004
15 Apr 2024 Decision Letter - Renato Teixeira Souza, Editor Induced abortion in Africa: a systematic review and meta-analysis PONE-D-23-21853R2 Dear Dr. Haile, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Renato Teixeira Souza Academic Editor PLOS ONE Additional Editor Comments (optional): 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 #2: All comments have been addressed ******** 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? 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 #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 #2: 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 #2: The authors have addressed all the recommendations of the editor. I have no further suggestions from my side. ****** 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 #2: Yes: M Suchira S Suranga ******** https://doi.org/10.1371/journal.pone.0302824.r005
Formally Accepted
26 Apr 2024 Acceptance Letter - Renato Teixeira Souza, Editor PONE-D-23-21853R2 PLOS ONE Dear Dr. Haile, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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. Renato Teixeira Souza Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0302824.r006

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