Reviewer ’s report  
 
Title: MATERNAL AND NEONATAL SERVICE USAGE AND DETERMINANTS IN 
FRAGILE AND CONFLICT -AFFECTED SITUATIONS: A SYSTEMATIC REVIEW OF 
ASIA AND THE  MIDDLE -EAST  
 
Version: 0 Date: 06 Aug 2016  
 
Reviewer: Brett Nelson  
 
Reviewer's report:  
 
I commend the authors on their significant work. The topic of maternal -newborn health in 
disrupted settings is of paramount importance. A systematic and thoughtful review of the 
existing literature is very much appreciated.  
 
Title:  
1. Since Ir aq and the Palestinian Territories are often considered part of the WHO "Middle East 
and North Africa" (MENA) region, I wonder if the authors would want to consider using a 
term that is broader than just "Asia" in their title and throughout the text?  "Asi a" may be too 
limiting geographically to your included countries.  
 
Abstract:  
2. Objective section: change "it's" to "its"  
 
3. Methods section: literature from "development agency websites" would likely not be "peer -
reviewed" by external reviewers; these agency reports are useful but are rarely peer -
reviewed.  So, more correctly, the authors searched the peer -reviewed literatu re in the listed 
databases and also searched select gray literature from development agency websites, 
correct? I would recommend re -wording this in the Abstract and in the Methods.  
 
4. Methods section: the use of a quality evaluation tool is a terrific str ength of this paper. Meta -
analysis of the service -usage determinants is another great strength that is not always 
included in literature reviews. I congratulate the authors on their work.  
 
5. Results section: it is useful that the authors organized determi nants by demand - and supply -
side determinants. Very helpful.  
 
Background:  
6. Lines 9 -12: the authors refer to MDGs 4 and 5 in present tense ("4 and 5 cannot be achieved 
globally"). Since the MDGs have passed and been replaced with the SDGs, I would re -word 
and consider removing MDGs altogether from this paragraph - or at least discuss them in 
historical terms.  
 
7. Lines 17 -19: this may be more of a stylistic approach, however, the authors have included 
their study objective in the first paragraph of the pa per. Instead, we often see that an 
introduction provides background, describes what is known about the topic, describes what is 
not known about the topic, and then gives the study objective at the end of the Introduction - 
immediately prior to the Methods.  Since the authors discuss the study objectives again at the 
end of their Introduction, I would remove their mention in the first paragraph of the paper.  
 
8. Line 9: change "two thirds" to "two -thirds" (with hyphen)  
 
9. Line 22 (and elsewhere): change "low  and middle -income" to "low - and middle -income" 
(with hyphen)  
 
10. Line 27: as above, I would remove or re -word discussion of MDGs since they have passed.  
 
11. Line 29: hyphenate "Long -term"  
 
12. Lines 39 -41: could you perhaps also include the NMR for Afgh anistan here? For readers 
familiar with newborn rates, it would be interesting to see the specific rate for Afghanistan 
here.  
 
13. Any particular reason why the authors wanted to focus only on Asian FCS and not on FCS 
globally? Are there suspected differen ces in terms of determinants/interventions/culture that 
would justify looking at Asia individually? If there's some logical justification for limiting 
the study geographically, I would consider mentioning this to readers. Without this 
explanation, it seems  like the study is unnecessarily limited in its geographic inclusion 
criteria.  
 
Methods:  
14. Great use of PRISMA and other standards for systematic reviews.  
 
15. Page 6, Line 49: I note (but completely understand) that the literature search is slightly date d, 
having been conducted in April 2014 (and covering articles through 2013). However, this 
would not prohibit its publication.  
 
16. Page 6, Line 58: Forgive my confusion, but are the authors reporting they only hand -searched 
articles (which were found throu gh review of the bibliographies) in "the Journal of Health, 
Population Nutrition, and American Journal of Public Health"? Certainly there were relevant 
articles identified in the bibliographies that were outside of these journals?  If bibliography 
articles  were truly limited to just these journals, this would represent a notable study 
limitation.  
 
17. Page 7, Lines 7 -17: the search terms look appropriate. I would have just also included a 
search term for "newborn/neonatal/perinatal health/care" since this is  a key topic of the 
article, including being listed in the article title. Do the authors believe that newborn -related 
studies were adequately identified without including this search term(s)?  
 
18. Page 7, Line 37: the authors mentioning excluding "evaluatio n studies." Could you please 
clarify? Studies that evaluate MNH or MNH programming in FCS would be excluded? Any 
particular reason why? These evaluation studies would seem to be useful in identifying 
challenges, successes, etc.  
 
19. Page 7, Line 49: change  "till" to "until"  
 
20. Page 8, Line 12 (and elsewhere in the paper): change "Data was" to "Data were" ('data' is 
technically a plural noun)  
 
21. Strong data analysis approaches.  
 
Results:  
22. Figure 1 and articles found: I would personally start by reportin g the number of articles 
found AFTER duplicates were removed. I think it is a little misleading to report in Figure 1 
and in the text that 21,893 articles were found when the vast, vast majority of these articles 
were duplicates (only 1,319 articles remain ed after duplicates were removed). Reporting 
21,893 initial articles can give readers the wrong impression that there is much more written 
on this topic than there actually is. However, I will defer to the editors if they suggest 
otherwise. Also, the numbe r 1,319 is an important number that should probably be in the text 
instead of the 21,893 number. I would also recommend clarifying in the Figure 1 and/or in 
the text how many of the articles were found in the peer -reviewed literature and how many 
were foun d in the agency websites (presumably not formally peer -reviewed by external 
reviewers?).  
 
23. Throughout all of the Results, when reporting numbers (e.g., of 18 studies, 8 were from 
Nepal….), it would be useful to include the percentages after the numbers ( "….8 (44%) were 
from Nepal…").  
 
24. Page 9, Line 44: The authors do not specifically mention how many studies received a low 
score and were eliminated from the study. This may be useful to include.  
 
25. Pooled odds ratios and Figure 2 are useful. Thank you.  
 
26. Figure 2: Again, forgive my ignorance here, but I am confused by the p -values listed in 
Figure 2. In the three categories, for each of the three subtotals, it appears from the diagrams 
(i.e., diamond does not include the zero -line) and from the confide nce intervals (i.e., do not 
include 0) that these three subtotals are all statistically significant, correct? However, the p -
value for the first subtotal is listed as p=0.947. Should there not be a statistically significant 
p-value here? Or is this non -significant p -value referring to something different than the 
diagram/CIs? Perhaps you could clarify this for readers.  
   
Discussion:  
27. Page 14, Lines 14 -22: This is just a comment and not necessarily a suggestion for change. 
But I found it interesting in y our results that the presence of a female TBA or CHW (and at 
least one female doctor, etc.) was associated with INCREASED SBA usage. We often fear 
that TBAs may reduce SBA usage as these 'unskilled' providers conduct deliveries in the 
community; it is enco uraging that TBAs may be facilitating/encouraging SBA usage.  
 
28. Page 14, Line 44 (and elsewhere): change "demand and supply -side" to "demand - and 
supply -side" (with hyphen also after 'demand').  
 
29. Page 14, Line 49: I would also add "transportation" to th is list of service facilitators. 
Transport availability has been shown to be a big challenge in rural areas.  
 
30. Page 15, Lines 70 -10: "no commensurate improvement in living and health standards is 
visible" is a rather strong statement, and it may be accur ate. However, unless the provided 
references suggest that there is absolutely "no" appreciable improvement, I would re -word 
this statement - e.g., qualify it a bit by saying that "there is OFTEN no commensurate 
improvement…"  
 
31. As discussed above, I think  it would be useful for the authors to explain why they limited this 
review to Asia and what the implications might be: are findings expected to be similar in 
other FCS regions? What have other studies found? I realize that this is beyond the planned 
reach  of this study, but briefly relating your findings to the broader context (other studies) 
may further increase these paper's already important relevance.  
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 sp ecify which controls are required in your comments to the authors.  
 
Unable to assess  
 
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 m anuscript 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 wri tten English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
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