Safe abortion service utilization and associated factors among insecurely housed women who experienced abortion in southwest Ethiopia, 2021: A community-based cross-sectional study.

BACKGROUND: Insecurely housed women are more vulnerable to physical and mental health issues than the general population, making access to a safe abortion more difficult. Though Ethiopia has a penal code regarding safe abortion care, there has been a dearth of studies investigating the safe abortion care practice among those insecurely housed women. Thus, this study aimed at assessing the magnitude of safe abortion service uptake and its determinants among insecurely housed women who experienced abortion in southwest Ethiopia.
METHODS: A community-based cross-sectional study was conducted in three towns in southwest Ethiopia from May 20-July 20, 2021. A total of 124 street-involved women were included in the study. They were selected by snowball sampling technique and data was collected through a face-to-face interview. The data were entered into Epi-data Version 3.1 and exported to SPSS 21 for analysis. A bivariable and multivariable logistic regression analyses were performed to determine the association of independent variables with the outcome variable. The level of significance was determined at a p-value <0.05. To determine whether the model is powerful enough in identifying any significant effects that do exist on the dependent variables, a power analysis was performed via a Post-hoc Statistical Power Calculator for Multiple Regressions.
RESULTS: The magnitude of safe abortion service utilization among insecurely housed women was found to be 27.9% [95% CI: 20.1, 34.2]. Average daily income [AOR:3.83, 95% CI: 1.38, 10.60], knowledge of safe abortion services [AOR:3.94; 95% CI: 1.27,9.24], and affordability of the service [AOR: 3.27; 95% CI:1.87, 8.41] were identified as significant predictors of safe abortion service among insecurely housed women. CONCLUSION AND RECOMMENDATION: The magnitude of safe abortion service utilization among insecurely housed women in the study area was low. The respective town health offices and health care providers at the facility level should strive to improve awareness about safe abortion service's legal framework, and its availability. In addition, a concerted effort is needed from local administrators, NGOs, and healthcare managers to engage those insecurely housed women in income-generating activities that allow them to access safe abortion and other reproductive and maternal health services.

Introduction

According to the World Health Organization (WHO), abortion is considered safe when performed using a method that is appropriate for the gestational age and by trained health professionals in a safe and clean environment [1, 2]. Unintended pregnancy as a result of unmet contraceptive needs and limited access to safe and legal abortion are two major reasons that contribute to unsafe abortion [3]. Insecurely housed women, or those who do not have a definite, regular, and suitable place to sleep at night, are the most vulnerable group to unwanted pregnancies [4]. This is mainly because they are subjected to sexual violence, rape or harassment, and a low level of contraceptive utilization [5].

Despite their clear desire to avoid pregnancy, Insecurely housed women face hurdles to accessing reproductive health care [6]. Furthermore, the majority are unaware of the availability of safe abortion care options, and the fear of stigma and discrimination prevents them from accessing these services [7]. As a result, they frequently exposed unsafe abortions, such as self-induced abortions, to avoid the perceived shame and stigma associated with seeking abortion care [8].

Unsafe abortion is one of the leading causes of maternal mortality, accounting for 4.7 to 13.2 percent of all maternal deaths worldwide, leaving 220,000 children without a mother each year [9]. According to data, 30 women die per 100,000 unsafe abortions in developed countries, while 220 women die per 100,000 unsafe abortions in developing countries annually. In addition, over 7 million women are treated in health facilities each year for consequences of unsafe abortion, including bleeding and sepsis [1, 10]. As a result, having access to a safe and high-quality abortion service is crucial in reducing the number of unsafe abortions and the accompanying maternal deaths and complications [2].

Between 2015 and 2019, 73.3 million induced (safe and unsafe) abortions were performed annually on a worldwide scale. Induced abortions occurred in 3 out of 10 (29%) of all pregnancies and 6 out of 10 (61%) of all unwanted pregnancies and among these, 1 out of 3 was carried out in the least safe or dangerous conditions [11]. Unsafe abortion is responsible for between 4.7–13.2% of maternal deaths per year [10]. According to estimates from 2010 to 2014, over 45% of all abortions were unsafe, with nearly all of these unsafe abortions occurring in developing countries [12]. The highest incidences of unsafe abortion occur in Latin America, Africa, and Southeast Asia [13]. In Africa, the chance of dying as a result of unsafe abortion was the highest [12].

Abortion has been legalized in Ethiopia since 2005 in cases of rape, incest, fetal impairment posing a life-threatening risk to the mother or her child, or if the mother is unable to raise her child due to physical or mental incapacity. Despite the law, many Ethiopian women have difficulties accessing safe abortion [9, 14]. In 2014, the national estimate of induced abortion was 620,300, with an annual abortion rate of 28 per 1,000 reproductive-age women [15]. Despite advances in the availability of safe abortion services, about half of all abortions continue to take place outside of health facilities [16].

As compared to the general population, those pregnant women who are insecurely housed are more vulnerable to physical and mental health issues that affect both the mother and the baby, and access to a safe abortion becomes more difficult [17]. Furthermore, insecurely housed women seek abortion care later in pregnancy, leading to a higher likelihood of abortion complications [18]. In general, due to limited access to routine health care, the risks of all pregnancies are increased in those groups [19].

According to studies, the use of safe abortion services by insecurely housed women is quite low. Only 19% and 10.4% of them in the United States and Brazil, respectively, accessed safe abortion services [18, 20]. In the Democratic Republic of Congo (DRC), 24.5% of prior pregnancies resulted in induced abortion, with the proportion among the youngest street girls (50%) being the highest [21]. A study on the reproductive health of insecurely housed women in Addis Ababa found that almost all (96%) of pregnancies were unwanted, with 59.4% of these pregnancies ending in abortion [22]. Safe abortion services should be easily accessible and affordable to all women, according to the WHO [2]. However, evidence suggests that even in countries with liberal abortion laws, impediments to safe abortion, such as legal, health-care, socioeconomic, and stigma-related barriers, hamper access to safe abortion services [23].

Women who are insecurely housed are usually underrepresented. In Ethiopia, the number of insecurely housed women is rising rapidly, yet their problems are not being addressed in government plans [24]. Furthermore, just a few studies on their reproductive health issues have been conducted in Ethiopia [22, 25, 26]. Even though insecurely housed women have a higher risk of unwanted pregnancies than the general population, the majority of studies have focused on the use of safe abortion services by the general populace and students [27-29]. This study is therefore important in identifying the level of and factors related to safe abortion service utilization, and also providing information that will aid in addressing the reproductive health needs of insecurely housed women in the study area.

Methods and material

From May 20 to July 20, 2021, a community-based crossectional study was conducted in three purposively selected towns in southwest Ethiopia: Jimma, Bonga, and Mizan-Aman. Jimma town is the capital of the Jimma zone in the Oromia region of Ethiopia, which is located 345 km from Addis Ababa, the capital city of Ethiopia. The town has 17 kebeles (13 urban & 4 rural) and based on the 2007 national census, the estimated population of Jimma town in 2020/21 is 220,609. Bonga town, the capital of the Kaffa zone, is 105 kilometers and 465 kilometers away from Jimma town and Addis Ababa, respectively. The town has three administrative kebeles and a total population of 27,634 people, with 13624 men (49.3%) and 14010 women (50.7%). Mizan-Aman is the capital of the Bench-Sheko zone and is located 651 kilometers southwest of Addis Ababa. The total population of the town is estimated to be 48,934, with 24,956 women (51%) living in all five kebeles.

Populations of the study

All insecurely housed women with abortion experience living in three selected towns of southwest Ethiopia (Jimma, Bonga, and Mizan Aman) were the source population. The study populations were those selected insecurely housed women with abortion experience residing in the towns. All insecurely housed women with a previous history of abortion were eligible to take part in this study. Participants who were seriously ill during the data collection period were excluded from the study.

Sample size determination

The sample size for the study was determined using the rule of thumb of 10 participants per measurement variable [30-32]. The number of explanatory variables after an in-depth review of the literature was 11, and thus the minimum sample size required for this study was (10 x 11 = 110). After accounting for a 10% non-response rate, the final sample size was 124.

Sampling technique and procedures

A snowball technique was used to choose study participants. The data was collected from the first group of eligible insecurely housed women who experienced abortion and agreed to participate in the study. These women were then used as a reference for recruiting another respondent who could be included in the study. The data collection proceeded until a large number of women had been identified and the required sample size had been met.

Data collection tool, methods, and personnel

Data were collected using a pre-tested structured questionnaire that was prepared after reviewing relevant literature in trying to attain the study’s objectives [1, 2, 20, 24]. The tool had six sections: Background characteristics, obstetric characteristics (pregnancy and abortion experiences), individual factors (knowledge of safe abortion services), health system-related characteristics, and utilization of safe abortion services. Four BSc midwives collected data through face-to-face interviews under the supervision of three public health officers. Before data collection, the respondents were informed of the study’s purpose and asked if they were willing to take part in it.

Data quality management

The questionnaire was translated from English to Amharic, and then English language instructors will translate it back into English. Cross-cultural and conceptual translations were prioritized during the translation process over terminological literality or linguistic equivalence. Furthermore, the questionnaire was pre-tested on 5% of the total sample size in Serbo town, outside the study area. The internal consistency between the items in the knowledge and practice assessment questions was evaluated, and the corresponding Cronbach’s alpha values were 0.83 and 0.87, respectively. The overall internal consistency composite score was 0.85, which indicates that 85% of the variance in the scores was found to be reliable and deemed to be good. Both data collectors and supervisors got a one-day intensive training on the objectives of the study, data collection techniques, and procedures. Finally, supervisors reviewed and checked questionnaires for completeness at the end of each data collection day, and appropriate feedback was given to data collectors the very next day. The privacy of study participants was maintained to encourage genuine participation and information sharing as sources for the study.

Measurement of variables of the study

The outcome variable was the use of safe abortion services. Those who have terminated their pregnancy in a health facility by a certified health care provider were considered to have had a safe abortion (YES = 1), while those who sought abortion outside of a health facility were considered to have had an unsafe abortion (NO = 0).

Insecurely housed (street) women: Women who live or spend most of their time on the street and rely on it for their livelihood [33, 34].

On-the-street women: were those women who had no formal homes (insecurely housed) and sleep on streets, verandas, balconies, etc. at night [34, 35].

Off-the-street women: are those women who have houses to go to for sleep at night while making their lives on the street life [34, 35].

Knowledge of abortion service: Eight questions were used to assess respondents’ level of knowledge of abortion services, and those who scored at or above the mean were considered knowledgeable unless they were not [36].

The perceived waiting time for abortion services: is the average time from initial referral to procedure reception, and it is considered prolonged if it exceeds 2 hours and short if it is less than 2 hours.

Data analysis

The data were entered into EpiData version 3.1 and exported to SPSS version 21 For further analysis. Inconsistencies, completeness, and outliers were checked using running frequency, cross-tabulations, and sorting. To check for the distribution of variables throughout the population, descriptive statistics such as frequency distribution, proportion, mean, and standard deviation were computed. A binary logistic regression analysis was used to find factors associated with safe abortion service utilization. A bivariable logistic regression was used to assess the relationship between each explanatory variable and the response variable. As a result, with a P-value <0.25, eight of the eleven variables showed an association and were entered into a multivariable logistic regression model. Finally, multivariable logistic regression was performed, and three statistically significant variables at p-value <0.05 were identified. The adjusted odds ratio (AOR) of each significant variable with the corresponding 95 percent confidence interval was used to report the strength and direction of the association.

To determine whether the model is powerful enough to identify any significant effects that do exist on the dependent variables, a Post-hoc power analysis was performed by using a Post-hoc Statistical Power Calculator for Multiple Regression. The following parameters were considered during the calculation: the number of predictors in the final model = 3, observed R2 = 0.28, probability level = 0.05, and a sample size = 122. Finally, the observed statistical power was found to be 0,9998, which is much greater than the minimum requirement of 0.8. So, enough statistical power existed to detect a significant effect.

To assess model fitness, the effect size of the final model was estimated by correlating the predictive probabilities of each case (explanatory variables) with the outcome of interest. By doing so, the correlation value(the predicted probability) was 0.575, possibly an indicator of a good model fit. Furthermore, model fitness was assessed using the Nagelkerke R Square and the Omnibus test, the results of which were 0.466 and 0.001, respectively, indicating a good model fit. Multicollinearity between independent variables was also checked by estimating the variance inflation factor and no multicollinearity was detected (VIF<10).

Ethical consideration and consent to participate

Ethical clearance was obtained from Jimma University Health Institute’s Human Research Ethics Committee. A letter of cooperation was also obtained from the Epidemiology department for the health offices of three selected towns. A letter of permission was obtained from each health office to proceed with the study. The participants were informed about the purpose of the study, and their right to refuse participation and discontinue the interview. Written Informed consent was obtained from each participant before the interview. By avoiding any identifiers of the study participants, the information obtained from them was kept confidential throughout the study. Personal protective equipment was provided for data collectors because the study takes place amid a global pandemic, COVID-19.

Results

Socio-demographic characteristics of the respondents

A total of 122 insecurely housed women with abortion experience were interviewed, yielding a response rate of 96.0%. Regarding the place of residence, 96(78.7%), 17(13.9%), and 9(7.4%) were from Jimma, Bonga, and Mizan-Aman towns, respectively. the majority, 90 (73.8%) of the study participants were “off-the-street”. The mean(±SD) age of respondents was 26.14(±6.71) years. Seventy-one (58.2%) of respondents had ever been married, and more than half (51.6%) had no formal education. The average(±SD) daily income of the respondents was 21.35(±6.79) ETB. The majority of respondents (84.4%) relied primarily on panhandling (“begging”) for a living, with the remaining 19 (15.6%) working part-time jobs in addition to panhandling (Table 1).

Table 1

Socio-demographic information of insecurely housed women in southwest Ethiopia, 2021.

Variables	Safe abortion		Total(%)
	Yes(%)	No(%)
Age category in years
<25	18 (31.1)	40 (68.9)	58(47.5)
≥25	16 (25.0)	48 (75.0)	64(52.5)
Marital status
Un married	15 (29.4)	36 (70.6)	51(41.8)
Ever married	19 (26.7)	52 (73.2)	71(58.2)
Religion
Orthodox	13 (25.5)	38 (74.5)	51(41.8)
Muslim	11 (28.2)	28 (71.8)	39(32.0)
Protestant	10 (31.2)	22 (68.8)	32(26.2)
Ethncity
Oromo	14(35.0)	28(65.0)	42(34.4)
Dawro	7 (21.2)	26(78.8)	33(27.0)
Amhara	9(30.0)	21(70.0)	30(24.6)
Yem	2(28.6)	10(71.4)	12(9.8)
Others	2(40.0)	3(60.0)	5(4.1)
Educational level
No formal education	13 (20.6)	50 (79.4)	63(51.6)
Primary school	21 (35.6)	38(64.4)	59(48.4)
Insecurely housed women by type
Off-the-street	25(27.8)	65(72.2)	90(73.8)
On-the-street	9(28.1)	23(71.8)	32(26.2)
Daily income
Below average (<21.35ETB)	16(19.3)	67(80.7)	83(68.0)
Average and above(≥21.35ETB)	18(46.2)	21(53.8)	39(32.0)
Source of income
Begging (Panhandling)	27(26.2)	76(73.8)	103(84.4)
Begging+other work	7(36.4)	12(63.2)	19(15.6)

Individual and health system-related characteristics

Nearly three-fourths, 90 (73.8%) of respondents were not knowledgeable about abortion. Regarding stigma, 37(30.3%) of respondents reported that they have ever faced stigma/discrimination from health care providers. Thirty-five(28.7%) respondents reported that they had been counseled at a health facility to continue the pregnancy. More than one-third, 43(35.2%) of study participants responded that they have waited a long time at a health facility and 41 (33.6%) reported that the cost of abortion services at a health facility was affordable to them (Table 2).

Table 2

Individual and health system-related characteristics of insecurely housed women in southwest Ethiopia, 2021 G.C.

Variables	Safe abortion		Total (%)
	Yes(%)	No(%)
Perceived stigma and discrimination from HCPs
Yes	15(22.3)	52(77.7)	67(54.9)
No	19(34.5)	36(65.5)	55(45.1)
Ever faced stigma by HCPs
Yes	7(18.9)	30(81.1)	37(30.3)
No	27(31.8)	58(68.2)	85(69.7)
Knowledge of safe abortion services
Poor	18(20.0)	72(80.0)	90(73.8)
Good	16(50.0)	16(50.0)	32(26.2)
Counseled to continue the pregnancy
No	22(25.3)	65(74.7)	87(71.3)
Yes	12(34.3)	23(65.7)	35(28.7)
Perceived time for abortion care
Long (>1hr)	9(20.9)	34(79.1)	43(35.2)
Short(<1hr)	25(31.6)	54(68.4)	79(64.8)
Affordability of cost for abortion services
Unaffordable to me	17(21.0)	64(79.0)	81(66.4)
Affordable to me	17(41.5)	24(58.5)	41(33.6)

Safe abortion service utilization

Thirty-four, 27.9% [95% CI: 20.1, 34.2] of insecurely housed women in the study area got a Safe abortion service. The majority(72.1%) of total abortion takes place outside health institutions under unsafe conditions. The commonest health facility visited by 15(44.1%) of safe abortion users were health centers followed by private clinics, 10 (29.4%), and public hospitals, 9(26.5%) (Fig 1). Of the 88 women who seek abortion outside of a health facility, 29 (32.9%) and 59 (67.1%) initiate abortions on their own (self-induced) and in an informal setting by a traditional provider, respectively. Fifty-two (42.6%) respondents said they knew women who had had abortions, while the remaining 72(57.4%) said they didn’t.

Fig 1

The list of health facilities visited by insecurely housed women for safe abortion service in southwest Ethiopia, 2021.

Determinants of safe abortion service utilization

In a multivariate logistic regression analysis, three variables were found to be significantly associated with safe abortion service utilization among insecurely housed women: knowledge of safe abortion care, average daily income, and affordability of safe abortion services at the health facility. Women with at least a daily average income had 3.83 times more chances of having a safe abortion than those with a daily income below the average [AOR:3.83, 95% CI: 1.38, 10.60]. Those insecurely housed women who had good knowledge of safe abortion services were 3.94 times more likely to receive one than those who had poor knowledge of safe abortion services [AOR:3.94; 95% CI: 1.27,9.24]. The odds of safe abortion service uptake were 3.27 times higher among women who reported that the service is affordable to them versus women who reported that the service is not affordable to them [AOR: 3.27; 95% CI:1.87, 8.41] (Table 3).

Table 3

Factors associated with safe abortion service utilization among insecurely housed women in southwest Ethiopia, 2021.

Variables	Safe abortion care		COR (95% CI)	AOR(95% CI)	P-value
	Yes	No
Educational level
No formal education	13 (20.6)	50 (79.4)	1	1
Primary school	21 (35.6)	38(64.4)	2.13(0.94,4.78)*	1.72(0.64,4.59)	0.282
Age category
<25	18 (31.1)	40 (68.9)	1
≥25	16 (25.0)	48 (75.0)	1.35(0.61,2.98)
Marital status
Un married	15 (29.4)	36 (70.6)	1
Ever married	19 (26.7)	52 (73.2)	1.14(0.51,2.54)
Daily income
Below average	14(16.9)	69(83.1)	1	1
Average and above	20(51.3)	19(48.7)	3.59(1.56,8.26)*	3.83(1.38,10.60) **	0.010
Counseled to continue the pregnancy
No	22(25.3)	65(74.7)	1
Yes	12(34.3)	23(65.7)	1.54(0.66.3.60)
Knowledge of the safe abortion
Poor	18(20.0)	72(80.0)	1	1
Good	16(50.0)	16(50.0)	4.00(1.68,9.49)*	3.94(1.27,9.24) **	0.018
Affordability of safe abortion service
Unaffordable for me	14(17.3)	67(82.7)	1	1
Affordable for me	20(48.8)	21(51.2)	2.67(1.17,6.05)*	3.27(1.87.8.41) **	0.034
Perceived time for abortion care
Long (>1hr)	9(20.9)	34(79.1)	1	1
Short(<1hr)	25(31.6)	54(68.4)	1.75(0.73,4.19)*	2.35(0.79,6.06)	0.073
Perceived stigma and discrimination from HCPs
Yes	15(22.3)	52(77.7)	1	1
No	19(34.5)	36(65.5)	1.83(0.82,4.07)*	1.68(0.65,4.38)	0.274
Ever faced stigma by HCPs
Yes	7(18.9)	30(81.1)	1	1
No	27(31.8)	58(68.2)	1.99(0.78,5.11)*	1.83(0.61,4.50)	0.130

1: Reference category, AOR:Adjusted Odds Ratio,COR: Crude Odds Ratio

* significant at p-value< 0.25

** significant at p-value< 0.05

Discussion

The purpose of this study was to estimate the magnitude and factors that influence the use of safe abortion services among insecurely housed women in Southwest Ethiopia. According to the findings, just 27.9% of insecurely housed women in the study area had a safe abortion, implying that nearly three-quarters of abortions among insecurely housed women were unsafe. This figure is significantly lower than the national estimate of safe abortion in 2014, which indicated that 53% of abortions were performed in health institutions under safe conditions [15]. The finding is also lower than those studies conducted in Addis Ababa (59.4%) and Gondar(55.5%) [22, 25]. The disparity could be owing to variation in the study subjects, as this study focused on insecurely housed women of reproductive age, whereas the studies in Addis Ababa and Gondar focused on street children aged 10–18 and 10–24 years old, respectively [22, 25]. This suggests that a higher number of insecurely housed women terminate their pregnancies outside of health institutions, potentially exposing them to increased risks of morbidity and mortality from unsafe abortion complications.

Safe abortion service utilization among insecurely housed women was significantly associated with variables such as knowledge of safe abortion care, average daily income, and affordability of safe abortion services at a health facility.

Insecurely housed women with higher average daily incomes were more likely to utilize safe abortion care. This finding is consistent with studies conducted in Chili and Northern Ethiopia, indicating that women with higher average daily incomes were more likely to utilize safe abortion [7, 37, 38]. Even though abortion was given freely in a semi-liberal approach in Ethiopia, insecurely housed women with low income may have been unable to access service delivery points because of some additional costs of transportation and medication, leading them to undergo unsafe abortion services [39]. Women with low incomes, on the other hand, may face challenges related to the fate of their newborns while growing up in a fatherless environment and may be afraid to raise their newborns independently in such an environment, which may impede the uptake of safe abortion services [40]. As a result, a concerted effort is needed from local administrative and healthcare managers to engage those insecurely housed women in income-generating activities that allow them to access safe abortion and other reproductive and maternal health services. This could also imply that health care providers should offer outreach activities aimed at the most vulnerable segments of the population who are unable to access health care due to financial constraints.

Knowledge of safe abortion services was also identified as a significant determinant of safe abortion services. This finding was supported by studies conducted in Ghana, and northern Ethiopia [25, 41]. This could be attributed to a high likelihood of utilizing safe abortion services due to knowledge of safe abortion services, such as the legal framework of abortion at the national level and the place where safe abortion services are provided.

Finally, the study revealed that those insecurely housed women who could afford the cost of abortion services had a better chance of having a safe abortion than those who couldn’t. One of the barriers to safe abortion service use for insecurely housed women was the costs spent for an abortion before and at a health facility, which may encourage them to seek traditional providers even though the service is free at public health facilities [14]. This finding is consistent with the study conducted in the Democratic Republic of Congo (DCR) which indicated that high costs inhibit access to safe abortion [21]. As a result, health care providers in the township needed to place a strong emphasis on raising awareness about the provision of safe abortion services without financial restraints.

The study focuses on the most vulnerable and neglected segments of the population, for whom knowledge on sexual and reproductive health issues is scarce, and the findings are important in developing essential policies, strategies, and programs, as well as planning interventions for these groups. Furthermore, unlike the majority of studies, the current study was conducted among women who have had abortions, which may provide a more accurate picture of safe abortion services. Because the overall number of insecurely housed women with abortion experience in the study areas was not statistically documented, probability sampling procedures were not applied, which could raise the generalizability issue. Even though respondents were given as much time as they needed for a good recall of long-term memory, inquiries were made following an ordered sequence of events; starting with the present and thinking back to a point the likelihood of recall bias should be considered. The study relied on self-reports, and the sensitive nature of the issue may have contributed to social desirability biases.

Conclusion

The magnitude of safe abortion service utilization among insecurely housed women in the study area was low. Average daily income, knowledge of respondents on safe abortion services, and affordability of the service were identified as significant predictors of safe abortion service utilization. Respective town health offices and health care providers at the facility level should strive to improve awareness about safe abortion services, their legal framework, and their availability. The magnitude of safe abortion service utilization among insecurely housed women in the study area was low. The respective town health offices and health care providers at the facility level should strive to improve awareness about safe abortion service’s legal framework, and its availability. In addition, a concerted effort is needed from local administrators, NGOs, and healthcare managers to engage those insecurely housed women in income-generating activities that allow them to access safe abortion and other reproductive and maternal health services.

The data collection tool used to assess the magnitude of Safe abortion service and its determinants.

(DOCX)

Click here for additional data file.

The minimal data set that supports the findings of the study.

(SAV)

Click here for additional data file.

6 Jul 2022

Safe Abortion Service Utilization and Associated Factors among Homeless Women Who Experienced Abortion in Southwest Ethiopia, 2021: A Community-Based Cross-Sectional Study

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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

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

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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: Thank you for the opportunity to review this manuscript. The manuscript reports the findings of a study of safe-abortion services use among reproductive-age street-involved insecurely housed women in Southwest Ethiopia. The authors explored the prevalence and predictors of accessing safe-abortion services by insecurely housed women by surveying a convenience sample of 124 women and conducting a multivariant logistic regression with use of safe abortion services (yes/no) as the binary outcome variable. The surveyed insecurely housed women were found to be significantly less likely to access safe abortion services than the general population in Ethiopia, while income, knowledge of available safe-abortion services and perceptions about the cost of such services being the significant predictors of not accessing safe-abortions.

The manuscript reports the findings of an important and interesting study on an extremely marginalized and understudied population with important implications for our understanding of reproductive health behaviors and the barriers marginalized populations navigate as they try to access reproductive health services. Most importantly the findings show that the choice is between safe and unsafe abortion services, and that insecurely housed women on the margins of the Ethiopian society, are not utilizing safe and freely available abortion services due to lack of knowledge and misconceptions about costs.

However, the manuscript requires some significant revisions before it will be ready for publication.

1. The manuscript requires careful language editing. At times the inconsistent language, grammatical errors, and some (not many) typos prevents from fully understanding the authors’ intentions.

2. The terminology used is not consistent with current conventions of writing about people experiencing insecure housing and homelessness. Though the authors refer to their sample as homeless women, at least 26% of them were street-involved in that they were panhandling (the authors term this ‘begging’) however they slept indoors. The authors (p.13) differentiate between on-the street and off-the street women with ‘off-the-street” women defined as those sleeping in the street. This may be a typo and the authors meant that the other way around, in which case 70% of the sample were street-involved but insecurely housed rather than homeless. I would suggest terming the sample insecurely housed women rather than homeless women. The terms ‘street girls’ and ‘street women’ (p.10) should be replaced with street-involved

3. The quantitative analysis requires significant revisions. Rather than a proper statistical power analysis the authors used a thumb rule (10 participants – not ‘samples’ as the authors write – per predictor variable) this should be replaced by a post-hoc power analysis reporting the power provided by the 124 participants when running a multivariate logistic regression with 3 predictors (the final model). Reliability of measures is not well reported, Cronbach’s alphas for each scale used should be reported both for the sample and from previous validation studies if available as well as some details about who developed these measures and why these were chosen. The authors state (p.12) they have committed some questions due to low reliability score – the full details of the process need to be provided including which questions were omitted, which scale thy belonged to originally and what were the scores. The process by which the multivariate logistic regression model was developed is not well described, how were the original predictors chosen and how were some of them omitted and the rest retained? The Hosmer-Lemeshow test of goodness of fit reported is usually not recommended due to low reliability. Providing a more fulsome description of the logistic regression conducted and the model fit indices is needed.

4. It is not clear why knowledge about safe-abortion services and the misconception about their cost are distinct factors – surely thinking a free service is unaffordable constitute an example for lack of knowledge – a better explanation as to why this were deemed distinct is needed.

5. The association between higher daily income and access to safe abortion services found is more perplexing than the discussion accounts for. Given the services are provided free of charge, is higher daily income a proxy for some other characteristic (e.g., higher executive functioning; greater autonomy in decision making)?

In sum I wish to reiterate that the manuscript is interesting and the study highly important and I hope some of my suggestions will prove helpful in revising this manuscript and resubmitting for publication.

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Reviewer #1: Yes: Jonathan Alschech

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Submitted filename: Thank you for the opportunity to review this manuscript.docx

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13 Jul 2022

Attached as "Response to Reviewers" in the submission system

Submitted filename: Response to Reviewers.docx

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1 Aug 2022

Safe abortion service utilization and associated factors among Insecurely housed women who experienced abortion in Southwest Ethiopia, 2021: A community-based cross-sectional study

PONE-D-21-36728R1

Dear Dr. Habte,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Dylan A Mordaunt, MD, MPH, FRACP

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for your resubmission. This is a simple but interesting and an important piece of work. The reviewer previously identified a need for major revisions. I've subsequently taken over editing this, but I can see that these issues have been addressed.

With regards to the criteria for publication:

1. The study appears to present the results of original research.

2. Results reported do not appear to have been published elsewhere.

3. Experiments, statistics, and other analyses are performed to a high technical standard and are described in sufficient detail.

4. Conclusions are presented in an appropriate fashion and are supported by the data.

5. The article is presented in an intelligible fashion and is written in standard English.

6. The research meets all applicable standards for the ethics of experimentation and research integrity.

7. The article adheres to appropriate reporting guidelines and community standards for data availability.

Furthermore, following internal discussion on the article, we have decided that the single reviewer secured for the mansucript was able to provide a thorough evaluation of the study and the addition of another reviewer would have yield minimal incremental value.

Although the study may have benefited from an additional qualitative approach, to provide an exploratory element given the research question. The quantitative approach adopted by the authors is acceptable, as it yielded  numerical data. Numerical data may be beneficial for some policy questions where hard numbers are more useful than painting exploratory pictures.

Furthermore the result should also be interpreted with the limitations of the  statistical analysis, given issues in the sub-group comparisons. These issues arise due to a poor overall understanding of what the whole population cohort is characteristics, as a result of both the problem area but specifically related to the sampling approach.

Overall the mansucript satisfies PLOS ONE’s publication criteria and we have decided that it is suitable for publication

Reviewers' comments:

2 Aug 2022

PONE-D-21-36728R1

Safe abortion service utilization and associated factors among Insecurely housed women who experienced abortion in Southwest Ethiopia, 2021: A community-based cross-sectional study

Dear Dr. Habte:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Associate Professor Dylan A Mordaunt

Academic Editor

PLOS ONE