Title: Reproductive Health of Syrian Refugee Women in Lebanon: A Descriptive Analysis of
the Sijilli Electronic Health Records Database
Version: 1 Date: 01 Feb 2022
Reviewer's report:
Thank you for the opportunity to review this important study. This study addresses a gap in
refugee health literature in the area of of reproductive health of displaced Syrian refugees.
Specifically, this study examines data among under-resourced refugee communities in Lebanon
and compares pre and post displacement data. As a clinician-researcher, my own research focus
on health services use (women's preventive health behaviors and cancer screening) and mental
health disparities of resettled refugees residing in high-income countries. With this in mind, I
believe this manuscript is timely, and may offer a better understanding of the reproductive health
of this understudied population. Overall, this manuscript has some technical issues (further
described below) and the reporting of the methods and analysis requires substantial clarification.
Key areas that need improvement is overall consistency - in outlining research questions that
match the variables of interest, the description of the methods, the consistency of the analysis
with the comparison groups and variables of interest, and reporting the findings that should not
be introducing new variables or new comparisons not outlined previously in the methods section.
Due to this lack of consistency, I found myself confused about what groups were being compared
and for what reasons. The authors should consider including as much detail and rationale in
the methods section so that readers are not surprised with the mention of new variables and
comparison groups later in the findings section. I provide an important resource (link below) for
reporting statistical data for publication consideration that you may find helpful for this study or
other future studies as well. I think that overall, the information is really important to advance the
literature. However, a more detailed explanation of the variables of interest, statistical analysis,
and the reporting of the findings, will significantly strengthen this paper. The authors provide
a discussion of the claims regarding the younger age of marriage and age of first pregnancy,
pregnancy outcomes, and discussed these in the context of previous literature. I believe that this
manuscript can be revised to address the issues.
Major issues:
First, please write clearly, what your research question is and your hypotheses. I believe you
have multiple aims here - 1: To examine characteristics of female refugees in Lebanon, 2: to
compare characteristics of female refugees who have been pregnant before to all female refugees
over the age of 1 (which I find odd), 3: to compare the pregnancy outcomes of female refugees
who have been pregnant before to pre-displacement pregnancy outcomes of female refugees.
Refer back to these aims to keep the manuscript organized in terms of what methods will be
used to address each aim.
Second, please describe your rationale for choosing your comparison groups in the methods
section. The authors compared all females to females who have been pregnant before. In my
opinion, I think comparing women who have been pregnant before to a group that includes 1
year olds is unnecessary in light of the aim of the study - which is to compare pre- and post-
displacement data of pregnancy outcomes among refugee women. Perhaps a more comparative
group would be an overall sample of women of childbearing age - comparing those who
have been pregnant to those who have not. The authors also compared pregnancy outcomes
to pre-displacement pregnancy outcomes. However, the data source for the pre-displacement
pregnancy data needs to be clarified in the methods section.
In reporting the methods, the authors should consider clarifying which dataset was used for pre-
displacement data and which was used for post-displacement data. Additionally, the study design
should be clearly stated in line 113 - "a secondary analysis of cross-sectional survey data." Is
this dataset publicly available or used in prior literature for research purposes (please cite if so)?
Also, please identify who was responsible for coding or extracting the data. Was this extracted
manually from the dataset prior to uploading into SPSS?
Please list the individual variables that were included separate from the analysis. It should be
clear which variables were included, their type, and how they were categorized. For example,
what are social habits? Were the pregnancy outcomes dichotomized as "yes/no" for previous
abortion, what were the categories for delivery type, and how did you capture breastfeeding
history and duration? Please list every variable that are reported in the findings. These should
match up as you wouldn't want to report on new variables that was not described in the methods
section, or describe variables in the methods section that isn't included in the findings.
In reporting the analysis of the data, was the data cleaned after data extraction? Was there missing
data and how was this addressed?
Multivariate logistic regression was conducted to "assess the independent effect of factors on
pregnancy details before and after displacement per women." The reason why variables should
be detailed out (as requested above) is because as a reader, I would want to make sure the data
analysis is appropriate for the variables that were used.  Also, it is unclear what exactly is being
reported from the logistic regression - adjusted odds ratios? What variables were included in the
model? Or perhaps it was a bivariate analysis?
In reporting the results, please refer this important resource that I use as a guide for reporting
statistical research: https://stats.oarc.ucla.edu/other/mult-pkg/seminars/statistical-writing/
I want to particularly highlight this point from the resource: "The results section usually contains
two parts:  the descriptive statistics and the analyses.  These two parts should be closely
related. Be sure that all of the variables used in the inferential statistics section are included
in the descriptive statistics." When writing out the findings section,  consider first providing
percentages for the entire sample. Then a separate descriptive on the women who have been
pregnant before. Then, the comparison data between the two groups.
Table 1: "The use of p-values should be avoided in this (descriptive) section.  Descriptive
statistics are just that:  they describe your sample of data.  P-values necessarily mean that a
hypothesis has been tested.  When describing data, though, there is no hypothesis to be tested,
so no p-value should be given.  Including p-values in descriptive statistics also contributes to
an alpha inflation problem."
I provide the following suggestions to address minor issues around wording and typos to
strengthen the manuscript:
In the abstract, please include the percentage or N women who delivered based on the 1,942
records. I don't know if reporting that majority of the women were under 18, but rather, a mean
age and standard deviation (if available) may provide a better picture of the sample, unless your
point is to emphasize that there are many children in this sample. If this is a secondary analysis
of de-identified data, then please remove "Information in the database was collected directly
from refugees living in Informal Tented Settlements (ITS) throughout Lebanon in all locations
used by the UNHCR for reporting with proportionate sample sizing to the overall Syrian refugee
population" as this is not part of the research methods. Please include a statement about what
analysis was used (frequencies, chi-square, and logistic regression).
Consider the following phrasing for the Results section in the abstract: "A total of 1,942 female
records were included in this study, with a mean age of __ (SD). Approximately 53.9% were
married (53.9%), and __% had had a delivery. Among women who delivered, 15.5% had a C-
section, 8.7% experienced (specific here) complications, and 10.0% of women did not breastfeed
their children. A prior pregnancy was significantly associated with contraception use. The most
common methods include oral contraceptive pills and Intra-Uterine Device. When compared to
pre-displacement data, the mean spacing between pregnancies was significantly lower and the
number of spontaneous abortions was significantly higher."
The Conclusion section of the abstract should relate back to your own findings relative to
your research aim. Suggest rewording to: "It is necessary to address access to reproductive
healthcare and antenatal care delivery among displaced refugee women living in informal tented
settlements." Consider adding the higher C-section rates in the abstract and the comparable rates
in adverse pregnancy outcomes.
In the introduction, the statement "Lebanon is not a signatory to the 1951 Convention on the
Status of Refugees" please describe what it means to be a signatory to the 1951 Convention
on the Status of Refugees. Very few academics are familiar with the language and history of
displaced populations and a brief explanation of how refugees are typically resettled in higher
income countries, unlike in Lebanon where refugees reside in informal tented settlements, could
be helpful. Additionally, it may be  impactful to add that low-middle income countries host the
majority of the world's population of refugees.
Sentences that need editing:
Line 83. "Being particularly a vulnerable group in times of conflict and migration" - being a
particularly vulnerable group.
Line 85. "Several studies were conducted on the SRH needs of Syrian refugees." Spell out SRH
when abbreviating for the first time. Similarly, see Line 96 to spell out ANC on the first use.
Consider avoiding abbreviations to make it easier for the audience unfamiliar with the language
when it is only used minimally throughout the paper.
Line 114. Needs a period after the sentence.
Line 128. This sentence looks like it may have an extra word.
Line 142. "the majority of whom were One and 18 years of age" - I am not sure what One is
- age 1?
Line 211. Needs a period after the sentence.
Line 216. Extra word.
Finally, it is unclear whether the dataset is publicly available or accessible, or adhere to the
expected standards of ethical data collection. I believe the authors received IRB approval to
conduct a secondary data analysis, but it was unclear whether the data collection process of the
dataset was IRB approved (and if not, consider clarifying for transparency).
Overall, I think your findings are interesting and important. In the discussion section, it would be
great for the authors to elaborate on the following statement on Line 206: "Although this practice
was prevalent before the start of the conflict in Syria(23, 24) , it has now been impacted by several
factors such as safety, economic hardships, and disrupted education (25) ." Are you saying that
more Syrian refugees are marrying younger due to safety issues and economic hardships? If so,
perhaps cite previous literature providing this explanation as this is an important point based on
your findings that there are a large number married before the age of 18.