Reviewer ’s report  
 
Title: Women’s empowerment is associated with maternal nutrition and low birth weight:  
Evidence from Bangladesh Demographic Health Sur vey 
 
Version: 0 Date: 03 Oct 2019  
 
Reviewer: Mian B. Hossain  
 
Reviewer's report:  
 
Journal name: BMC Women's Health  
 
Manuscript Number: BMWH -D-19-00617  
 
Title: Women's empowerment is associated with m aternal nutrition and low birth weight: 
Evidence from Bangladesh Demographic Health Survey  
 
Study on nutritional or health status especially among married women in reproductive age is 
particularly important for developing countries like Bangladesh where health and medically 
related reforms are being actively implemented. In this aspect I think th is is an important study. 
However, there are some issues would be considered to improve this study.  
 
General comments/quarries  
1. Authors extracted data from BDHS -2-11 and BDHS -2014 datasets, these were 
household studies overall Bangladesh. BDHS applied probability sampling for selecting their 
sample; most probably some same households had been selected for BDHS -2011 and 2014. How 
authors overcame the overlapping problem?  
2. There is some important health or nutritional indicators such as household wealt h 
index, female education level have been changing (increasing) during the last decades. These 
types of health indicators also can able to put contribution to change women's empowerment, 
their nutritional status as well as birth weight status of children i n a particular country. The 
behaviour of these indicators was different for 2011 and 2014 datasets. There was a great chance 
to get misleading results for considering 2011 and 2014 datasets together.  
3. BDHS selected samples from overall Bangladesh using two-stage stratified cluster 
sampling. Samples came from the different levels of hierarchy [clusters (enumeration areas)], 
Bangladesh is developing country, sample was not homogeneous on the basis of health or 
nutritional status as well as birth weight, an d this a large number of samples collected from 
whole country. There is a great chance to get cluster effect of selected variables in any health 
study using such kind of dataset. If have cluster effect and use single level traditional model, 
most probably to get misleading results.  Already some studies [1. Islam et al. (20190 Prevalence 
and factors associated with early initiation of breastfeeding among Bangladeshi mothers: A 
nationwide cross -sectional study. PLoS ONE 14(4): e0215733. 
https://doi.org/10.13 71/journal.pone.0215733. 2. KAMRUZZAMAN et al. (2016) 
MULTILEVEL LINEAR REGRESSION ANALYSIS OF FACTORS INFLUENCING BODY 
MASS INDEX AMONG BANGLADESHI MARRIED NON -PREGNANT WOMEN. J. Biosoc. 
Sci., page 1 of 11 © Cambridge University Press, 2016 doi:10.1017/S0 021932016000572. 3. 
Khan MHR, Shaw JEH (2011). Multilevel logistic regression analysis applied to binary 
contraceptive prevalence data. J Data Sci. 2011; 9:93 -110] have been done on anemia and 
nutritional status using same datasets, they got cluster effect  and they used multilevel model to 
overcome this problem. How authors overcame this problem if they have?  
4. Authors considered only under nutrition but the over -nutrition also focusing issues for 
developed and some developing countries. In Bangladesh, th e prevalence of over -nutrition 
among married women in reproductive age has been rapidly increasing during the last decade 
[NIPORT, 2014].  It is possible to get the significantly impact of WEI on over nutrition among 
women in Bangladesh. Why authors did no t consider over nutrition?  
 
Comments/questions  
Abstract:  
1. It should be better to put "under nutrition" instead of "malnutrition" throughout the 
manuscript.  
2. Page 2, Line 34: Authors analyzed 27357 women and 9,234 mother -child pairs.  
Did authors consi der same mothers who were in mother -child pairs and also in women?  
3.    Page 3, Line 52: It is better to write  "public health" instead of "population health".  
Background:  
1. Page 4, Line 85: .....and health of their family. [20], it would be ...... an d health of their 
family [20].  
Methods:  
1. Page 6, Line 128: Authors mentioned that they considered 2011 and 2014 datasets to 
maximize the sample size. I don't understand why they need to maximize the sample size. I think 
the sample in 2014 dataset is en ough for their study.   
2. Page 6, Line 131 -134: On average,.......(.....census in 2011). May be this statement for 
2014 survey, if yes, it should be mentioned.  
3. Page 7, Line 160 -161: ...on a Likert -type scale, it is not Likert -type scale, it is categor y. 
Please write "Education was classified into four groups/categories" instead of  Education was 
classified at a 4 -point scale.  
4. "Point scale" would be "groups/categories" throughout the manuscript.  
5. The classifications of WEI should be mentioned in m ethods section.  
6. Page 9, line 205 -208: Our hypothesis.........of low birth weight babies. These two 
sentences should be moved from here to Background.  
 
Results  
1. Table 2: Please describe very clearly about Wealth quintile 1,  Wealth quintile 2, 
Wealth quintile 3 and Wealth quintile 4, Wealth quintile 5 in methods section, otherwise very 
difficult to understand in here. Did authors apply z -proportional test to find the significance 
difference between two proportions? If yes, please mention in Methods Sec tion (Statistical 
analysis).  
2. Table 3: I think no need to apply any test for getting trend in significance (p -value). 
&lt;0.139 would be 0.139.  
 
 
 
Suggestions  
1. Authors can consider only 2014 BDHS dataset.  
2. Authors need to check the variation of their outcome variables among clusters 
(enumeration areas), if they get variation, they should apply multilevel model to remove the 
cluster effect.  
3.  If possible they can consider three categories of nutritional sta tus; (i) under nutrition, 
(ii) normal (healthy) and (iii) over nutrition.   
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, pl ease specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscr ipt or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written E nglish  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
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