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. 2024 May 7;19(5):e0302824. doi: 10.1371/journal.pone.0302824

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

Teklehaimanot Gereziher Haile 1,*, Teklehaymanot Huluf Abraha 2, Gebreamlak Gebremedhn Gebremeskel 3, Kidane Zereabruk 3, Tesfay Hailu Welu 4, Teklit Grum 2, Negasi Asres 5
Editor: Renato Teixeira Souza6
PMCID: PMC11075855  PMID: 38713662

Abstract

Background

One of the main factors contributing to maternal morbidity and mortality is induced abortion. The WHO estimates that over 44 million induced abortions take place annually around the world. The majority of these abortions—about 50%—are unsafe, significantly increasing maternal morbidity and contributing to 13% of maternal deaths. Thus, this review aimed to estimate the pooled prevalence of induced abortion and its associated factors in Africa.

Methods

To find literature on the prevalence of induced abortion and its associated factors, a thorough search of the internet databases such as PubMed/MEDLINE, African Journals Online, and Google Scholar was conducted. The data were extracted using a structured method of data collection. Software called STATA 14 was used to do the analysis. funnel plot and Egger regression test were used to evaluate potential publication bias. I2 statistics and Cochrane’s Q were used to measure the heterogeneity at a p-value < 0.05.

Results

976 studies were found through a thorough search of electronic databases. Finally, 46 full-text abstract papers were included in this study. The estimated pooled prevalence of induced abortion was 16% (95% CI: 13%-19%). According to the sub-group analysis, most studies were conducted in Ethiopia, and the pooled prevalence was 19% (95% CI: 10%–30%). Similarly, the subgroup analysis by year of study showed that the prevalence of induced abortion was 39% (95% CI: 17%–64%) among studies conducted in 2019.

Conclusion

The results of this study thus imply that the pooled prevalence of induced abortion is higher than that of earlier studies that were published in some nations. the data from this study are needed to support reproductive and adolescent health programmers and policymakers and to formulate recommendations for future clinical practice and guidelines.

Introduction

Induced abortion is defined as the intentional termination of pregnancy before the 28th week of gestation or before the fetus is born with a weight less than 1000 grams that (i.e., for developing nations) cannot live independently outside of the womb. The World Health Organization (WHO) classifies induced abortion as safe abortion," which is done by a trained health provider and at an appropriate gestational age with services recommended by the WHO [1].

The frequency of induced abortions varies widely. In Western Europe, it was roughly 12 per 1000 women between the ages of 15 and 44, but it was 43 in Eastern Europe [2]. The WHO estimates that over 44 million induced abortions take place annually around the world. The majority of these abortions—about 50%—are unsafe, significantly increasing maternal morbidity and contributing to 13% of maternal deaths [3, 4]. Evidence suggests that induced abortions are more prevalent in nations where abortion is prohibited or regulated than in those where it is permitted [2].

One of the main factors contributing to maternal morbidity and mortality is induced abortion [5]. Six out of ten unplanned pregnancies and three out of ten pregnancies worldwide resulted in an induced abortion [6]. 97% of unsafe abortions take place in developing nations, accounting for around 45% of all abortions [7]. In sub-Saharan Africa, there are approximately 33 unsafe abortions per 1,000 women aged 15 to 49 performed each year [8]. Abortion remains one of the most sensitive sexual and reproductive behaviors because of social stigma, privacy concerns, and the fear of legal sanctions [9].

According to the Human Reproduction Program, there were an estimated 121 million unintended pregnancies in women aged 15–49 years each year between 2015 and 2019, and 61% of these ended in abortion. Moreover, 45% of these abortions were unsafe in 2017 [10]. The poorest women with the fewest resources are the most likely to experience complications from unsafe abortions. Maternal death due to complications of an unsafe abortion was the major cause of hospital admission. Each year, 4.7–13.2% of maternal deaths can be attributed to unsafe abortion [5]. In developing regions, that number rises to 220 deaths per 100,000 unsafe abortions [5, 7, 11].

Induced abortion remains a major public health problem confronting African women [7]. The specific Sustainable Development Goals (SDGs) known as the health goal (goal No. 3) aim to ensure healthy lives and promote well-being for all at all ages, with one of the important targets being to ensure universal access to reproductive health care services, including family planning, information, and education, and the integration of reproductive health into national strategies and programs [12].

To the best of our knowledge, this is the first systematic review and meta-analysis of the prevalence of induced abortion and its associated factors in Africa. Therefore, data on systematic reviews and meta-analyses of induced abortion are needed to support reproductive and adolescent health programmers and policymakers and to formulate recommendations for future clinical practice and guidelines.

Materials and methods

Study design, search strategy and data source

A systematic review and meta-analysis were done using published and unpublished articles on the prevalence of induced abortion and its associated factors in Africa. To find literature on the prevalence of induced abortion and its associated factors, a thorough search of the internet databases such as PubMed/MEDLINE, African Journals Online, and Google Scholar was conducted. Additionally, references in studies that passed screening were checked. Since there is no article published before 1999, we included all articles published from March 1999 to May 1, 2023, in this study.

The following keywords were used in the search: "induced abortion", "abortion", "termination of pregnancy", "prevalence", "incidence", "proportion", "determinants", "criminal abortion", "reproductive age women", "associated factors", "risk factors", "magnitude", and "names of each African nation." The Boolean operators "AND" and "OR" were combined as necessary, and two authors (TGH and THA) independently conducted the search. According to the recommended reporting items for systematic review and meta-analysis (PRISMA) standard, this systematic review and meta-analysis were reported [13] (S1 Table).

Study selection

Studies that were done in each African nation and reported on the prevalence of induced abortion and its associated factors were chosen for the meta-analysis. Duplicate files were removed after exporting all articles read from a few databases to Endnote X8. Three investigators (GGG, TG, and NA) screened the remaining articles and abstracts for inclusion in the full-text appraisal. Before being included in the review, two reviewers (KZ and THW) independently evaluated the publications.

Data extraction and quality assessment

The data were separately extracted by three authors (TGH, GGG, and TG) using a structured method of data collection. Data extraction format made in a Microsoft Excel spreadsheet. Two reviewers (TGH and THA) separately examined the titles, abstracts of each reference obtained, and the full-text search results to categorize possibly qualifying papers. Title, author name, study design, research type, year of study, research base (including population and hospital-based research), sample size, response rate, study area, study quality score, and prevalence contained were all included in the data extraction.

All studies quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale [14]. Assigning a maximum of 10 stars for the risk of bias in three areas—study group selection (4 or 5 stars), group comparability (2 stars), and ascertainment of the result of interest or exposure (3 stars)—is the main method used to create this scale. According to the aggregate quality score, there is a high, moderate, and low risk of bias for ratings of 0–3, 4–6, and 7–10 stars, respectively (S2 Table). The two reviewers’ disagreements were resolved through dialogue and discussion.

Eligibility criteria

The standards used to choose which research will be included in the analysis are based on eligibility criteria for studies. These standards are crucial for guaranteeing that the chosen research is reliable, legitimate, and of a high enough caliber to yield insightful findings (Table 1).

Table 1. Criteria for considering studies for this study.

Eligibility criteria
Inclusion criteria Design: All types of observational study designs
Publication type: Both published and unpublished articles
Population: All reproductive age groups of women
Study Setting: Studies conducted in Africa, which are institutional-based.
Language: Published articles written exclusively in English were considered in this study.
This study was included all published articles from March 1999 to May 1, 2023.
Outcome: Prevalence of induced abortion and associated factors
Exclusion criteria Studies that did not reveal the prevalence of induced abortion and its associated factors
Methodological problems (This including: inadequate sample size, sampling techniques, measurement error, incomplete data, inadequate statistical analysis, or any other relevant methodological limitations identified during the review process).
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Publication bias and heterogeneity

I2 statistics were used to assess the statistical heterogeneity. Heterogeneity was categorized as low, medium, and high heterogeneity, with values of I2 of 25%, 50%, and 75%, respectively [15]. If there is heterogeneity between the included articles. The authors, therefore, will use a meta-analysis of random effects to estimate the aggregate pooled prevalence of induced abortion in Africa. Methods like the funnel plot and Egger regression test were used to evaluate potential publication bias. Significant publication bias was defined as the existence of a P-value of 0.05 [16].

Statistical analysis/ data synthesis and sub-group analyses

Software called STATA 14 was used to do the analysis. The prevalence of induced abortion among reproductive age groups in Africa was displayed using forest plots. I2 statistics and Cochrane’s Q were used to measure the heterogeneity, and a p-value of less than 0.05 was used to proclaim it [15]. A funnel plot and Egger’s test were used to assess publication bias. Different study characteristics, such as study year and study country, were subjected to subgroup analyses. A p-value of less than 0.05 was used to corroborate the publication bias test using the Egger regression asymmetry [17]. Additionally, the ’trim and fill’ method developed by Duval and Tweedie was used to calculate the approximate number of studies that the meta-analysis was missing [18]. Tables and forest plots with 95% confidence intervals (CI) were used to present the results. Due to the significant degree of heterogeneity among the included publications, a random-effects model was adopted [19].

Data management

Based on the standards for inclusion and exclusion, a predetermined framework was developed to direct the screening and selection procedures. Before starting the data extraction, the tool was tested and updated. The search results were first submitted to EndNote 8x software in order to remove duplicates.

Data items

The first author, publishing year, nation, sample size, publication type, study area, study design, and response rate were all included in the data extraction.

Outcomes and prioritization

The primary outcome is the prevalence of induced abortion and its associated factors in Africa.

Results

Articles included in the meta-analysis

At first, 976 studies were found through a thorough search of electronic databases. Titles and abstracts were screened, and duplicated or irrelevant articles were removed using EndNote 8x. Accordingly, we eliminated 587 duplicate articles. After reviewing the remaining 389 publications based on their titles and abstracts, we found that 254 articles were disqualified because the studies in those articles didn’t match the criteria for inclusion or exclusion. Following a second review of 135 articles, 89 were disregarded because 89 of the studies did not focus on induced abortion (n = 19), lack of results (n = 15), or study areas outside of Africa (n = 55).

Finally, 46 full-text abstract papers were included in this systematic review and meta-analysis based on the pre-defined criteria and quality assessment. However, within these 46 studies, there were four studies that had a case-control study design which designed to investigate associations between exposures and outcomes, rather than directly estimating prevalence. As a result, these four case-control studies were still considered in the analysis of associated factors, as their study design allowed for the examination of potential risk factors or predictors. The remaining 42 studies were suitable for inclusion in the meta-analysis of pooled prevalence. A PRISMA flow chart of the study selection shows the specific steps of the screening procedure (Fig 1).

Fig 1. Selection of studies for a systemic review and meta-analysis for prevalence of induced abortion and its associated factors in Africa.

Fig 1

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Characteristics of the study

This systematic review and meta-analysis study include 46 articles with a combined sample size of 195,660. The smallest sample size was 64, which was drawn from Nigerian research [20]. Whereas, the largest sample size was 146,713, according to a study from the African nation of Congo [21]. Different authors conducted induced abortion studies in Ethiopia in different years, with the highest prevalence (68.7%) and the lowest prevalence (1.1%) [22, 23]. The Newcastle-Ottawa Scale quality assessment criteria for each primary study’s quality score indicated no appreciable risk; hence, all the studies were considered in this systematic review and meta-analysis. The detailed characteristics of the included articles are presented in Table 2.

Table 2. Characteristics of studies considered in this systematic review and meta-analysis of the prevalence of induced abortion in Africa.

Authors Study Year Study Area Study Design Sample Size Case Prevalence (%) Quality score based on NOS
Sahile AT et al. [22] 2019 Ethiopia Cross-Sectional 422 290 68.7 8
Mitiku S et al. [24] 2015 Ethiopia Cross-Sectional 461 27 5.9 8
Gebeyehu D et al. [25] 2015 Ethiopia RCS 194 69 35.6 9
Meseret G. et al. [23] 2013 Ethiopia Cross-Sectional 611 7 1.1 9
Denberu B et al. [26] 2015 Ethiopia Unmatched CC 110 cases, 220 controls NM NM 7
Abebe M. et al. [27] 2021 Ethiopia Unmatched CC 103 cases, 309 controls NM NM 8
Megersa et al. [28] 2017 Ethiopia Unmatched CC 147 cases, 295 controls NM NM 7
Tesfaye G. et al. [29] 2010 Ethiopia Cross-Sectional 400 49 12.3 7
Tesfaye B et al. [30] 2017 Ethiopia Cross-Sectional 247 73 29.6 8
Gelaye et al. [31] 2011 Ethiopia Cross-Sectional 493 32 6.5 8
Megersa A. et al. [32] 2018 Ethiopia Cross-Sectional 422 182 43.1 8
Bekele D et al. [33] 2012 Ethiopia Cross-Sectional 340 34 10 7
Senbeto E. et al. [34] 2003 Ethiopia Cross-Sectional 1346 65 4.8 9
Zeleke AM et al. [35] 2018 Ethiopia Cross-Sectional 422 61 14.5 8
Jamie H.A. et al. [36] 2019 Ethiopia Cross-Sectional 611 261 42.7 9
Nigussie et al. [37] 2018 Ethiopia Cross-Sectional 420 79 18.8 8
Lentiro et al. [38] 2017 Ethiopia Cross-Sectional 404 55 13.6 8
Bell S.O. et al. [39] 2020 Burkina Faso Cross-Sectional 1000 40 4 9
Ilboudo et al. [40] 2012 Burkina Faso Cross-Sectional 304 37 12 7
Fatusi A, et al. [21] 2016 Congo Cross-Sectional 146,713 27,590 18.8 9
Geelhoed DW. et al. [41] 1999 Ghana Cross-Sectional 2137 482 22.6 9
Mote C.V. et al. [42] 2008 Ghana Cross-Sectional 408 87 21.32 8
Klutsey EE et al. [43] 2012 Ghana Unmatched CC 76 cases, 304 controls NM NM 7
Ahiadeke C. [44] 1997 Ghana Cross-Sectional 1000 17 1.7 9
Baruwa OJ. et al. [45] 2017 Ghana Cross-Sectional 18,116 3702 20.43 9
Adjei et al. [46] 2011 Ghana Cross-Sectional 2723 101 3.7 9
Simmelink AM et al. [47] 2016–2017 Kenya PC 866 103 11.9 8
Lugaliki AD. [48] 2013 Kenya Cross-Sectional 329 125 38 7
Mohamed et al. [49] 2012 Kenya Cross-Sectional 1000 48 4.8 9
Okereke CI. [50] 2010 Nigeria Cross-Sectional 309 62 20.2 7
Okonofua FE. et al. [51] 1999 Nigeria Cross-Sectional 176 19 11 7
Obiyan et al. [20] 2019 Nigeria Mixed-Study 64 38 59.4 7
Murray N. et al. [52] 2002 Nigeria Cross-Sectional 602 247 41 7
Okonofua F. et al. [53] 2009 Nigeria Cross-Sectional 1842 751 40.77 9
Bankole A. et al. [54] 2012 Nigeria Cross-Sectional 1000 33 3.3 9
Ajayi et al. [55] 2016 South Africa Cross-Sectional 1709 325 19 9
Keogh S.C. et al. [56] 2013 Tanzania Cross-Sectional 1000 36 3.6 9
Kimbwereza FA et al. [57] 2019 Tanzania Cross-Sectional 342 19 5.6 7
Mamboleo N. [58] 2012 Tanzania Cross-Sectional 116 26 22.4 7
Prada E. et al. [59] 2013 Uganda Cross-Sectional 1000 39 3.9 9
Ndari G. [60] 2019 Chad Cross-Sectional 384 112 29.17 7
Polis C.B. et al. [61] 2015 Malawi Cross-Sectional 1000 38 3.8 9
Frederico et al. [62] 2017 Mozambique Cross-Sectional 1076 99 9.2 9
Bell SO et al. [63] 2018 Coˆte d’Ivoire Cross-Sectional 1000 28 2.8 8
Levandowski BA. et al. [64] 2009 Malawi Cross-Sectional 1000 23 2.3 9
Dahlbäck E. et al. [65] 2005 Zambia Cross-Sectional 87 34 39.1 7
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CC: Case Control, PC: Prospective Cohort, NM: Not Mentioned, NOS: Newcastle Ottawa Scale

The pooled prevalence of induced abortion in Africa

In this section of Mata analysis, we included 42 studies, and the estimated pooled prevalence of induced abortion was 16% (95% CI: 13%-19%), but with a significantly high level of heterogeneity among the studies in the random-effects model analysis (I2 = 99.28%, p≤0.000) (Fig 2).

Fig 2. Forest plot for the prevalence of the induced abortion in Africa.

Fig 2

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Publication bias

In this study, to assess and adjust any publication bias, we first applied a funnel plot based on the assumption that the effect sizes of all the studies are normally distributed around the center of a funnel plot in cases where there is no publication bias. When observing asymmetry in the funnel plots, we test using Egger’s bias test and apply the trim-and-fill method to first trim the studies that cause asymmetry in the funnel plot so that the overall effect estimate produced by the remaining studies can be considered minimally affected by publication bias, and then to fill the imputed missing studies in the funnel plot based on the bias-corrected overall estimate.

Therefore, the result shown in Fig 3 seems to have an asymmetrical distribution in the funnel plot. But Egger’s tests for the small study effect were highly non-significant for the presence of publication bias (p = 0.426). This indicates there was no publication bias among the included studies in estimating the pooled prevalence of induced abortion. Additionally, a trim-and-fill analysis for the prevalence of induced abortion was done so as to reduce and correct publication bias in the studies. The result showed no study was imputed for missing studies, and the estimated pooled prevalence was also approximately similar to the unadjusted prevalence.

Fig 3. Funnel plot included distribution of studies in induced abortion.

Fig 3

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Subgroup analysis

In this study, we conducted a subgroup meta-analysis. The studies were grouped based on the study area and study year, and an overall effect size was computed for each group. The aim of this subgroup analysis was to compare these overall estimates across groups and determine whether the considered grouping helps us explain some of the observed between-study heterogeneity. However, the subgroup analysis done does not change the heterogeneity observed (I2>99%, p≤0.000). Further, a meta-regression was run considering the sample size and study year as covariates to check if they were the sources of heterogeneity for the pooled prevalence of induced abortion, but none of them were also significant.

In the sub-group analysis by country (Fig 4), most studies were conducted in Ethiopia, and the pooled prevalence of induced abortion was 19% (95% CI: 10%–30%). Similarly, the subgroup analysis by year of study showed that the prevalence of induced abortion was 39% (95% CI: 17%–64%) among studies conducted in 2019 (Fig 5).

Fig 4. Forest plot for the prevalence of induced abortion in Africa by country.

Fig 4

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Fig 5. Forest plot for the prevalence of induced abortion in Africa by year.

Fig 5

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Factors associated with induced abortion in Africa

The pooled effect estimates of associated factors, including unintended pregnancy (AOR = 9.51, 95% CI: 3.31–27.34), being an unmarried woman (AOR = 4.49, 95% CI: 2.46–8.20), educational status (AOR = 2.63, 95% CI: 1.7–4.06), and substance use (AOR = 2.72, 95% CI: 1.38–5.34), were significant predictors of induced abortion in Africa with a considerable level of heterogeneity (I2 = 76.5%, p≤0.005), (I2 = 61.9%, p≤0.022), (I2 = 51.9%, p≤0.052) and (I2 = 52.3%, p≤0.099) respectively.

Unintended pregnancy and induced abortion

This type of meta-analysis comprised four studies [26, 33, 35, 40]. According to the pooled meta-regression analysis, unintended pregnancy had a statistically significant correlation with induced abortion (AOR = 9.51, 95% CI: 3.31–27.34) (Fig 6). This category of the meta-analysis showed high heterogeneity; hence, a random effect model was produced. Additionally, no evidence of publication bias was found using Egger’s tests, which had a p-value of 0.958.

Fig 6. Forest plot of unintended pregnancy and induced abortion.

Fig 6

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Unmarried women and induced abortion

The correlation between being an unmarried woman and having an induced abortion was evaluated in this review. Unmarried women were positively related to induced abortion (AOR = 4.49, 95% CI: 2.46–8.20), according to the results of a meta-regression analysis that included data from seven studies [28, 30, 36, 42, 44, 46, 48] (Fig 7). This category of the meta-analysis showed moderate heterogeneity. The test for publication bias using Egger’s test revealed no publication bias with a p-value of 0.347.

Fig 7. Forest plot of unmarried women and induced abortion.

Fig 7

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Educational status and induced abortion

Women with primary and secondary education had a considerably higher risk of having an induced abortion, according to the results of a pooled meta-regression analysis of eight studies [23, 28, 31, 32, 36, 44–46] (AOR = 2.63, 95% CI: 1.7–4.06) (Fig 8). There was some moderate heterogeneity across the included studies. The results of Egger’s test for the small study effect and the existence of publication bias were both significant (p = 0.000). Therefore, a trim-and-fill analysis for the educational status was performed in order to lessen and correct the study’s apparent publication bias. The outcome indicated that two studies had now been imputed in place of the missing studies and that, following correction, the estimated pooled odds ratio had marginally changed.

Fig 8. Forest plot of educational status and induced abortion.

Fig 8

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Substance use and induced abortion

Women who used drugs or alcohol were significantly more likely to have an induced abortion (AOR = 2.72, 95% CI: 1.38–5.34) (Fig 9). The four included studies [24, 31, 38, 55] showed moderate heterogeneity, and Egger’s tests for the small study effect revealed a significant small study effect and the presence of publication bias (p = 0.029). As a result, a trim-and-fill analysis for substance usage was carried out in order to lessen and correct the research’s apparent publication bias. No studies were imputed for missing studies, according to the outcome.

Fig 9. Forest plot of substance use and induced abortion.

Fig 9

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Discussion

Induced abortion continues to be a major concern for women’s reproductive health and human rights around the world. To determine the prevalence of induced abortion among reproductive age groups in Africa, a systematic review and meta-analysis were undertaken. According to this study in Africa, the pooled prevalence of induced abortion among reproductive age groups is 16% (95% CI: 13%-19%), or 160 per 1000 reproductive age groups of women.

The result of this study is much higher than the studies carried out in the Globe and Ethiopia with the same study design, which revealed 5.81% and 5.06% [66, 67] respectively. Similarly, studies conducted in East Africa, worldwide in 2010–14, Sierra Leone, Indonesia, Iran, Turkey, Ethiopia, and Australia revealed that 7.79%, 35 abortions occurred annually per 1000 women, 9%, 42.5 abortions per 1,000 women, 3.8%, 10.9%, 23 per 1,000 women and 2.1/100 women [68–75] respectively. The difference might be due to the difference in study design, sample size, cultural, social, religious norms related to abortion, and access to reproductive health service including family planning and safe abortion.

A study conducted in China from in different study year, and Nepal showed that 24.0%, 28.95%, and 21.1% [76–78] respectively, indicated a higher rate of induced abortion than our finding. The possible explanation for the discrepancy might be due to the difference in study design, sample size, data collection methods, type of respondents, and the general public’s level of education. On the other hand, a study was done in China 16.70% [79] and our pooled prevalence (16%), which is what we found, more coincide.

Our study found a strong association between unintended at the time of pregnancy and induced abortion, with women who had unintended at the time of pregnancy being nearly ten times more likely to undergo induced abortion compared to those with intended at the time of pregnancy. This finding is consistent with previous studies from around the world, including Turkey, Iran, and India [6, 73, 80, 81], which have also demonstrated a significant relationship between unintended at the time of pregnancy and induced abortion. These results highlight the importance of addressing unintended at the time of pregnancy through effective family planning programs and education to reduce the incidence of induced abortion and improve women’s reproductive health.

In this study, unmarried women were 4.49 times more likely to develop induced abortion than their counter part. Studies conducted in East Africa, Sierra Leone, and China have reported contrary result [68, 70, 79]. The discrepancy could be the cultural and social norms surrounding marriage and sexuality in these different regions.

Our meta-regression analysis showed that women with primary and secondary education were 3 times more likely to undergo induced abortion than their counter parts. This finding is consistent with studies conducted in East Africa, Sierra Leone, Iran, and Nepal [68, 70, 72, 78]. However, there is a contrary finding from a study conducted in China [79], which reported a lower prevalence of induced abortion among women with higher educational status. The contrasting results could be due to contextual factors, such as cultural and social difference across regions and countries as well as difference in study design and data collection methods.

According to this study, women who used drugs or alcohol were more likely to have an induced abortion than those who did not. This result is consistent with a study conducted in Turkey [73]. This suggests that the association between drug and alcohol use and induced abortion is not specific to a particular region or country. The collective evidence from these studies highlights the importance of addressing substance use disorders and providing appropriate interventions to help reduce the incidence of induced abortion.

Strengths and limitations the study

To the best of our knowledge, this is the first systematic review and meta-analysis of the prevalence of induced abortion and its associated factors in Africa. Therefore, data from this study are needed to support reproductive and adolescent health programmers, administrators, policymakers and to formulate recommendations for future clinical practice and guidelines. In addition to the aforementioned strengths, prior to conducting this manuscript, the protocol was not registered or published online.

Conclusion

The pooled prevalence of this study is 16%. The results of this study thus imply that the pooled prevalence of induced abortion is higher than that of earlier studies that were published in some nations. Because of the social stigma, privacy issues, and worry about legal repercussions, abortion continues to be one of the most delicate sexual and reproductive practices. Induced abortion continues to be a serious public health issue for African women and is one of the main causes of maternal morbidity and mortality.

Any effort to prevent variables like unwanted pregnancy and substance use through educational and contraceptive interventions must focus on eliminating the need for induced abortion, and it is crucial for women of reproductive age to have access to the right options. Safe abortion services should be promptly and easily available to all women who become pregnant unintentionally. Therefore, the data from this study are needed to support reproductive and adolescent health programmers and policymakers and to formulate recommendations for future clinical practice and guidelines.

Supporting information

S1 Table. PRISMA 2020 Checklist.

(DOCX)

pone.0302824.s001.docx (20.8KB, docx)
S2 Table. Newcastle-Ottawa Quality Assessment Scale.

(DOCX)

pone.0302824.s002.docx (25.6KB, docx)

Acknowledgments

We would like to thank the authors of the included studies for their contributions to this systematic review and meta-analysis study.

Abbreviations

AOR

Adjusted Odds Ratio

CI

Confidence Interval

PRISMA

Preferred Reporting Items for Systematic reviews and Meta-Analysis

WHO

World Health Organization

Data Availability

All relevant data are within the paper and its supporting information files.

Funding Statement

The author(s) received no specific funding for this work.

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Decision Letter 0

Johanna Pruller

26 Jan 2024

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.

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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?

==============================

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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: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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

Reviewer #1: 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.

Attachment

Submitted filename: Reviewer Comments for authors.docx

pone.0302824.s003.docx (14.6KB, docx)
PLoS One. 2024 May 7;19(5):e0302824. doi: 10.1371/journal.pone.0302824.r002

Author response to Decision Letter 0

12 Feb 2024

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.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0302824.s004.docx (20.1KB, docx)

Decision Letter 1

Renato Teixeira Souza

27 Mar 2024

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.

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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.

PLoS One. 2024 May 7;19(5):e0302824. doi: 10.1371/journal.pone.0302824.r004

Author response to Decision Letter 1

6 Apr 2024

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.

Attachment

Submitted filename: Response to Reviewers.docx

pone.0302824.s005.docx (14.9KB, docx)

Decision Letter 2

Renato Teixeira Souza

15 Apr 2024

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.

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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

**********

Acceptance letter

Renato Teixeira Souza

26 Apr 2024

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

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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

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Table. PRISMA 2020 Checklist.

    (DOCX)

    pone.0302824.s001.docx (20.8KB, docx)
    S2 Table. Newcastle-Ottawa Quality Assessment Scale.

    (DOCX)

    pone.0302824.s002.docx (25.6KB, docx)
    Attachment

    Submitted filename: Reviewer Comments for authors.docx

    pone.0302824.s003.docx (14.6KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0302824.s004.docx (20.1KB, docx)
    Attachment

    Submitted filename: Response to Reviewers.docx

    pone.0302824.s005.docx (14.9KB, docx)

    Data Availability Statement

    All relevant data are within the paper and its supporting information files.

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