Prevalence of pregnancy termination and associated factors among married women in Papua New Guinea: A nationally representative cross-sectional survey

McKenzie Maviso; Paula Zebedee Aines; Gracelyn Potjepat; Nancy Geregl; Glen Mola; John W. Bolnga

doi:10.1371/journal.pone.0309913

Peer Review History

Original SubmissionAugust 13, 2023
12 Mar 2024 Decision Letter - Blessing Akombi-Inyang, Editor PONE-D-23-24906Prevalence of pregnancy termination and associated factors among married women in Papua New Guinea: a nationally representative cross-sectional surveyPLOS ONE Dear Dr. Maviso, 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 Apr 26 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. 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You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. We will update your Data Availability statement on your behalf to reflect the information you provide. [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: No Reviewer #2: Yes ****** 3. 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Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: No Reviewer #2: No ****** 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: The study discusses the prevalence and associated factors of pregnancy termination among married women aged 15–49 in Papua New Guinea (PNG), where abortion is not decriminalized and access to safe abortion services is scarce. The study concludes that pregnancy termination rates remain high in PNG, highlighting the urgent need for health interventions and support services to prevent unwanted pregnancies and unsafe abortion practices. Emphasizing the necessity of expanding access to safe abortion services and integrating them into existing sexual and reproductive healthcare is crucial for addressing this issue comprehensively. Although it is a very relevant and important report for the current issue surrounding unsafe abortion in PNG, there are some points that should be addressed before further evaluation for publication, here are some comments to improve the manuscript: 1- Line 41: Please add «married» women as the sample is restricted to those populations if it is the total number of women who participated in this survey, then you should mention it and also include the age group. 2- Line 147-149: you have mentioned that women who were married or in a formal union and responded to whether they had ever terminated a pregnancy with complete information on all factors of interest were eligible to participate. Since you have used secondary data and not conducted the survey, it is better to revise the sentence and write you have only included the married or in formal union women who had ever terminated a pregnancy with complete information on all factors of interest. 3- you have only included the married or in formal union women, I believe if traditionally and culturally, marriage is the only accepted practice to get pregnant in PNG then the risk of illegal abortion and complications would be higher than those who are in formal relation such as girl friend and boy friend or cohabiting partners that have not married. My recommendation would be to separate them and do a separate analysis for these two groups and see if there is a difference unless you have a reasonable explanation for why you have included both. 4- I strongly believe that you should exclude those who are less than 18 years old as they are considered children by definition and illegal abortion, risk factors, and complications are often more prevalent among them especially if they are exposed to violence and discrimination in informal relationships. 5- line 165: education and literacy are different concepts, therefore I advise including literacy. It has been shown that women with literacy even with no formal education have a better pregnancy outcome. Some of those with no education still have literacy of reading and writing 5- another important variable could be the husband or partner's age, education, and employment. I suggest to include it 6- how the missing data were handled? 7- the analysis strategy for multivariate analysis including the choice of the independent variables that included in the models and the technique that has been used to do so as well as the strategy to construct the final optimal model should be explained 8- Reviewer #2: Thank you dear editor for inviting me to review this manuscript which provides interesting findings for policy makers in the respective country. I have provided the following comments for the author. 1.Prevalence of pregnancy termination and associated factors among married women in Papua New Guinea- the tittle is informative and clearly understandable however the focus of your study is on induced abortion particularly unsafe abortion so why did you used the general term ‘’pregnancy termination’’? 2. What do you think about the non-response rate which is very high in this study so how did you manage it? 3. On the conclusion part you said the prevalence of pregnancy termination among married women remains high in PNG. What was your reference to say it is high? 4. On the data source line number 149 you said that the extracted data on these women included information on their socio-demographic characteristics and the history of termination of pregnancy within the three years preceding the survey. You did not exclude those mothers without the history of pregnancy within the three years. I raised this issue because it has no importance of including them in this study since they were not pregnant within the three years. 5. The line umber 159 ….Women were asked whether they had ever terminated a pregnancy. The response was coded as “0” for “No” and “1” for “Yes” for pregnancy termination. For this study, the terms pregnancy termination and induced abortion are used interchangeably. This part should be written in the operational definition. ****** 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: Omid Dadras Reviewer #2: Yes: Yosef Haile Gebremariam ******** [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 for author.docx https://doi.org/10.1371/journal.pone.0309913.r001
Revision 1
2 Jun 2024 Author Response Reviewer #1: The study discusses the prevalence and associated factors of pregnancy termination among married women aged 15–49 in Papua New Guinea (PNG), where abortion is not decriminalized and access to safe abortion services is scarce. The study concludes that pregnancy termination rates remain high in PNG, highlighting the urgent need for health interventions and support services to prevent unwanted pregnancies and unsafe abortion practices. Emphasizing the necessity of expanding access to safe abortion services and integrating them into existing sexual and reproductive healthcare is crucial for addressing this issue comprehensively. Although it is a very relevant and important report for the current issue surrounding unsafe abortion in PNG, there are some points that should be addressed before further evaluation for publication, here are some comments to improve the manuscript: Response: Thank you for your time in reviewing our manuscript. Your comments and suggestions are very important and have been taken into consideration to improve the paper. We have looked through the areas and sections highlighted and made the necessary changes and corrections which are now reflected in the manuscript. 1- Line 41: Please add «married» women as the sample is restricted to those populations if it is the total number of women who participated in this survey, then you should mention it and also include the age group. Response: Thank you for highlighting this oversight. We have now included “married” and is reflected in the text. 2- Line 147-149: you have mentioned that women who were married or in a formal union and responded to whether they had ever terminated a pregnancy with complete information on all factors of interest were eligible to participate. Since you have used secondary data and not conducted the survey, it is better to revise the sentence and write you have only included the married or in formal union women who had ever terminated a pregnancy with complete information on all factors of interest. Response: Thank you for highlighting this to improve the clarity of the sentence. The sentence has been revised. It is corrected and is reflected in the text. 3- you have only included the married or in formal union women, I believe if traditionally and culturally, marriage is the only accepted practice to get pregnant in PNG then the risk of illegal abortion and complications would be higher than those who are in formal relation such as girlfriend and boyfriend or cohabiting partners that have not married. My recommendation would be to separate them and do a separate analysis for these two groups and see if there is a difference unless you have a reasonable explanation for why you have included both. Response: Thank you for the recommendation. Our analysis focused mainly on those women who reported that they were married and not in any boy-girl relationships or as cohabiting partners. Also, the demographic and health survey (DHS) data did not specifically ask about the type of relationships the women were in, during the time of the survey. The survey questions only asked whether they were married or not. Some women who were married and were divorced, separated, or widowed were recorded. Only those women who reported being married were included in this study. We, therefore could explore the determinants of pregnancy termination among women in informal (unmarried) relationships in future analyses, as presumptively, these group could yield higher results of pregnancy termination. 4- I strongly believe that you should exclude those who are less than 18 years old as they are considered children by definition and illegal abortion, risk factors, and complications are often more prevalent among them especially if they are exposed to violence and discrimination in informal relationships. Response: Thank you for highlighting this for further explanation. It is established that marriage in most societies in PNG is closely linked to socio-cultural influences. In most instances, women often marry at an early age (>18 years). It is possible that women were unsure of their date of birth and indicated the wrong age during the survey, especially young married women from rural areas. The survey data lacked a specific age of marriage, and we are unsure whether women were married too early (<18 years); therefore, we only used the age-aggregated variable (V013). 5- line 165: education and literacy are different concepts; therefore, I advise including literacy. It has been shown that women with literacy even with no formal education have a better pregnancy outcome. Some of those with no education still have literacy of reading and writing Response: Thank you for the suggestion. We have included the variable literacy. 5- another important variable could be the husband or partner's age, education, and employment. I suggest to include it. Response: Thank you for the suggestion. We have included the variable partner’s age. 6- how the missing data were handled? Response: Thank you for seeking clarification. Data were missing at random, which were not evident across all observations, but only within sub-samples of the data. Those missing data in variables of interest that have low percentage (<5%) were dropped, while those with high percentage (>5%) were retained for final analysis. This is reflected in the results (table 1 and Table 2). 7- the analysis strategy for multivariate analysis including the choice of the independent variables that included in the models and the technique that has been used to do so as well as the strategy to construct the final optimal model should be explained Response: Thank you for the suggestion. The independent variables were selected based on their availability in the dataset, practical significance, and relevance reported in the literature about pregnancy termination. Since the study used data collected by a cluster sampling technique, a complex sample analysis was deemed a suitable technique. Also, complex sample analysis provides valid estimates of parameters because, during analysis, it accounts for sample weighting, clustering, and stratification. Thus, a complex sample logistic regression was used to perform a multivariable analysis of predictors of pregnancy termination. This is explained in the methods. Reviewer #2: Thank you dear editor for inviting me to review this manuscript which provides interesting findings for policy makers in the respective country. I have provided the following comments for the author. Response: Thank you for your time in reviewing our manuscript. Your comments and suggestions are taken into consideration to improve our paper. We have looked through the areas and sections highlighted and made the necessary changes and corrections, and are all reflected in the manuscript. 1. Prevalence of pregnancy termination and associated factors among married women in Papua New Guinea- the tittle is informative and clearly understandable however the focus of your study is on induced abortion particularly unsafe abortion so why did you used the general term ‘’pregnancy termination’’? Response: Thank you for seeking clarification. We have used the term “pregnancy termination” throughout this analysis, as this is probably the softer and more non-discriminatory way of describing the issue (euphemism).We have therefore included an operational definition as suggested. 2. What do you think about the non-response rate which is very high in this study so how did you manage it? Response: Thank you for seeking clarification. The design weights were adjusted for individual non-response to get the sampling weights for women. Non-response is adjusted at the sampling stratum level. After adjusting for non-response, the sampling weights are normalized to get the final standard weights that appear in the data for analysis. 3. On the conclusion part you said the prevalence of pregnancy termination among married women remains high in PNG. What was your reference to say it is high? Response: Thank you for highlighting this to seek further clarification. We acknowledge the statement as on oversight. The sentence has been revised and corrected. It is reflected in the conclusion: Pregnancy termination is performed among married women in PNG. 4. On the data source line number 149 you said that the extracted data on these women included information on their socio-demographic characteristics and the history of termination of pregnancy within the three years preceding the survey. You did not exclude those mothers without the history of pregnancy within the three years. I raised this issue because it has no importance of including them in this study since they were not pregnant within the three years. Response: Thank you for highlighting this oversight. We have revised and dropped those married women who have no history of pregnancy in the past 3 years. It has been corrected and is reflected in the text. 5. The line umber 159 …. Women were asked whether they had ever terminated a pregnancy. The response was coded as “0” for “No” and “1” for “Yes” for pregnancy termination. For this study, the terms pregnancy termination and induced abortion are used interchangeably. This part should be written in the operational definition. Response: Thank you. Yes, we have included it as operational definition for this study. It is reflected in the manuscript. Attachments Attachment Submitted filename: Cover letter - Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0309913.r002
21 Aug 2024 Decision Letter - Amos Buh, Editor Prevalence of pregnancy termination and associated factors among married women in Papua New Guinea: a nationally representative cross-sectional survey PONE-D-23-24906R1 Dear Dr. Maviso, 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, Amos Buh, BSc., MPH, PhD 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: No ****** 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: 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 #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 #2: Yes: Yosef Haile Gebremariam ******** https://doi.org/10.1371/journal.pone.0309913.r003
Formally Accepted
26 Aug 2024 Acceptance Letter - Amos Buh, Editor PONE-D-23-24906R1 PLOS ONE Dear Dr. Maviso, 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. Amos Buh Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0309913.r004

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