Reviewer ’s report  
 
Title: MATERNAL AND NEONATAL SERVICE USAGE AND D ETERMINANTS IN 
FRAGILE AND CONFLICT -AFFECTED SITUATIONS: A SYSTEMATIC REVIEW OF 
ASIA AND THE MIDDLE -EAST  
 
Version: 0 Date: 27 Jun 2016  
 
Reviewer: Cheryl Moyer  
 
Reviewer's report:  
 
The authors have conducted a systematic review of the literature regarding maternal and neonatal 
service usage and determinants in fragile and conflict -affected situations in Asia. The topic is 
extremely important, and this is an area that is not well -researched. That said, my reaction to this 
manuscript is as follows:  
1) The authors describe on pages 9 and 10 the significant limitations of all included studies - 
making the reader wonder why a synthesis of such marginal -quality literature is worthwhile. 
It would be preferable to describe the strengths of the studies (are there strengths?) if making 
the case that a systematic review of the literature is go ing to yield useful findings.  
2) At a macro level, I am not entirely sure what I learned from this paper. Yes, there are limited 
data from FCS. And yes, MNH service utilization is often low in FCS. Is this a surprise? (But 
note that institutional delivery  ranged from 85% in Nepal to 97% in Palestine - numbers that 
would be considered a huge success in most LMICs.) The determinants of utilization also 
look very similar to non -FCS settings - it is not unusual that education and wealth were 
strong drivers. So  what's the take -home message here? What have we learned that we didn't 
know before?   
3) The paper looks across a variety of countries, across a variety of indicators, and concludes 
that "poor MNH status in FCS is a leading contributor to the burden of maternal and neonatal 
ill-health in Asia."  But the paper looked at determinants of utiliz ation and utilization itself - 
NOT health status, nor how MNH status in FCS compared to the rest of Asia. So such a 
conclusion can't be reached based on the data presented. This gets back to my main concern 
about this paper: What is the main message? And h ow do these wide -ranging studies 
contribute to that single message?  
4) I get the sense that the point of this paper is to show how poor the evidence is in FCS r.e. 
MNH service utilization. But making the reader go through an entire systematic literature 
review to reach the conclusion that the research literature is too sparse to learn much doesn't 
seem fair. It seems to me that it would be better positioned as a commentary than a 
systematic review.    
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, pl ease explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require furth er 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publi cation of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you curr ently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any  other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
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below.  If your reply is yes to any, please give details below.  
 
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