Reviewer’s report
Title: 
Association between intimate partner violence and the use of maternal
health care services among married Malawian women
Version: 
0 
Date: 
15 Feb 2021
Reviewer's report:
This paper uses multivariable logistic regression to determine whether intimate
partner violence (IPV) predicts MCH service utilization in Malawi using data
from the 2015-16 Demographic and Health Surveys. Overall, I believe the
authors need to provide more justification for the research question and conduct
a broader literature review. I also think the Methods could be more robustly
described, particularly when it comes to the timing of exposure/outcome
measurement. I recommend the following to improve the manuscript's clarity.
Abstract
Line 32: Please change "multivariate" to "multivariable" here and throughout the
manuscript. This is not a multivariate analysis.
Background
The Background could use some restructuring. Much of this section it is
descriptive (about MCH service utilization and IPV) but there is little motivation
regarding the research question. Readers of this journal will be familiar with
much of the Background included here (defining MCH health care and its
importance, much of lines 7 to 41); these sections could be shortened. Instead,
the authors should discuss: Why do the authors believe that IPV might be
associated with MCH service utilization? What research gap is being filled with
this study?
A brief review of the literature reveals several studies that are not
referenced/discussed in the Introduction and Discussion but should be, for
example:
Sripad P, Warren CE, Hindin MJ, Karra M. Assessing the role of women's
autonomy and acceptability of intimate-partner violence in maternal health-care
utilization in 63 low- and middle-income countries. Int J Epidemiol. 2019 Oct
1;48(5):1580-1592. doi: 10.1093/ije/dyy299. PMID: 30753484.
Shamu S, Munjanja S, Zarowsky C, Shamu P, Temmerman M, Abrahams N.
Intimate partner violence, forced first sex and adverse pregnancy outcomes in a
sample of Zimbabwean women accessing maternal and child health care. BMC
Public Health. 2018 May 3;18(1):595. doi: 10.1186/s12889-018-5464-z. PMID:
29724216; PMCID: PMC5934870.
Metheny N, Stephenson R. Intimate Partner Violence and Uptake of Antenatal
Care: A Scoping Review of Low- and Middle-Income Country Studies. Int
Perspect Sex Reprod Health. 2017 Dec 1;43(4):163-171. doi: 10.1363/43e4917.
PMID: 29596048.
Methods
Page 5, Line 25: the final N included in the analysis should be in the Results.
The definition of IPV should come before the definition of the outcomes
(exposure should be defined first).
Dependent variables (page 5, Line 38): it is unclear which birth these variables
correspond to. The woman's most recent birth, or all of her births in the previous
5 years? Are all of these variables self-reported?
Definition of dependent variables: The authors provide a citation for the
definition of ANC visits, but not for the definitions of the other outcomes
considered in this analysis. Were these variables defined previously in the
literature or by the DHS?
Definition of dependent variables: for "Institutional deliveries" the authors do not
adequately define the variable. They state that "Institutional deliveries defined as
births that occurred at any level of health facility", versus what? Home
deliveries? Please give the full definition here. The same goes for "Skilled
assistance during delivery."
Page 6, line 41: The specific dimensions of IPV included in each domain of IPV
(emotional, physical, and sexual) could be put into an appendix for the sake of
space. The authors should also mention that they considered emotional, physical,
and sexual violence as independent variables (in addition to the composite "any
IPV" measure).
I do not recommend including Cronbach's alpha for the IPV measures as this is
not really a measure of reliability in this case, it just implies that the dimensions
of IPV are (unsurprisingly) correlated.
What is the recall window for IPV? Ever? In the past 12 months?
Page 7, line 17: The authors state that the covariates were selected based on their
"importance in the literature." Please provide citations for this.
Page 7, line 24: Did the authors use the wealth index that was calculated by the
DHS or did they perform their own principal components analysis? If so, why?
Page 7, line 50: The sentence starting with "Adjusted odds ratios" is not a
complete sentence.
My major comment about the Methods is in regards to the timing of these
measurements. If the authors include births that happened in the past 5 years for
the outcome, and the exposure is any IPV, how can we be certain that the
exposure preceded the outcome? For example, a woman may have given birth 5
years prior and her questions about MCH service utilization were regarding that
child. However, instances of IPV may have occurred more recently (and
therefore the outcome precedes the exposure). This seems problematic,
particularly in terms of understanding the findings. If this can't be addressed,
please put this in the Limitations.
Results
Page 8, line 19 (population characteristics): The authors describe the
inclusion/exclusion criteria in the methods, but more on who was excluded from
the final sample would be great. Some sort of flow diagram would be ideal.
Figures 1 & 2: Including a "Yes" and "No" bar is redundant and distracting since
all variables add up to 100%. Consider dropping the "No" bar or showing the
prevalence of IPV and MCH service utilization differently.
Page 8: Like in the Methods, please describe IPV before the MCH service
utilization variables.
Page 9: It would be helpful to see the unadjusted odds ratios somewhere
(perhaps in an appendix).
Discussion
The second paragraph of the Discussion should not be on the prevalence of IPV
in Malawi. While this is of course important (and could be briefly mentioned
later in the Discussion), it is not a key finding of this paper. 
The Discussion should focus more on the findings of this paper, contextualizing
them in the literature (with a broader literature review as mentioned in my
comments for the Introduction). Why do the authors hypothesize these
relationships were observed? I would also like to see some discussion the
particulars of the findings. Why do the authors hypothesize that the associations
were observed for the institutional deliveries and skilled birth assistant
outcomes, but not for the ANC or PNC outcomes?
Page 10, line 51: What are TBAs?
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes