Title: Healthcare Disparities in Gynecological Health Services for Women with Disabilities: A
Cross-Sectional Study from Iraq
Version: 3 Date: 23 Apr 2025
Reviewer's report:
Dear authors,
Thank you for this interesting article, which provides important insight into the gynecological
health service access of women with disabilities in Iraq. While the article itself is well-written,
it does require some major revisions, in order to bring out the full potential and impact of the
research.
The major points that need to be addressed are the following:
1) Page 2, first line: You are using the medical definition of disability, which in disability
research is very rarely used. This has been replaced by the social model of disability, that states
that “persons with disabilities include those who have long-term physical, mental, intellectual
or sensory impairments which in interaction with various barriers may hinder their full and
effective participation in society on an equal basis with others”. This is stated in the Convention
on the Rights of Persons with Disabilities (CRPD) (https://social.desa.un.org/issues/disability/
crpd/convention-on-the-rights-of-persons-with-disabilities-crpd), which Iraq signed in 2013.
2) There seems to be a confusion or a mix-up with the type of disabilities mentioned. For
example, page 3, first paragraph, you mention “women with developmental disabilities”.
Developmental disabilities include people with autism, ADHD, learning disabilities, etc., and
do not include people with intellectual disabilities. I understand that it is a reference to an article
that uses this term. I do not have full access to this article, but in the abstract the authors mention
“cognitive and physical abilities”, which make me believe that they themselves have used this
term incorrectly. If you have access to this article, please check, otherwise it would be better
to remove it.
3) Page 4: purpose of article. Please include here any other articles on the topic (or similar topic)
that has been done in Iraq, in order to showcase the importance of your work. If there are none
or very few, this could be the value of your research, which should be added here.
4) Associations between disability type and reproductive health factors: there is no mention
here of disability type. Also, there is no association or correlation (as mentioned later on). With
hypothesis testing, the only thing that can be assessed is whether there are (or not) statistically
significant differences between groups. Associations can be made with inferencial statistics,
such as regressions.
5) Discussion: I would like to see more discussion of the results of the survey and the possible
reasons behind such results in the Iraqi context. For example, it would be interesting to see the
results of Question 16 of the survey.
6) Implications for policy: It is necessary to add that Iraq has signed the CRPD, so the
government has an obligation towards people with disabilities to provide the same level of
healthcare as with the general population, and according to their needs.
7) Limitations: Sample size is small (not relatively). The conclusions cannot be generalized to
the entire female population with disabilities, because the sampling was not probabilistic.
8) Table 4: It is not clear what the types of disabilities included were. Did you use the
classification of Figure 3? In such cases, and since the n is small, the type of each disability
should appear. For example: Column 1: Accessibility to Gynecological Clinics. Column 2:
Physical disability (10, 34%), Column 3: Sensory disability (35, 28%)…Column X: p value. I
also assume that since the number in some cells will be less than 5, Fisher’s exact test should
be used in those cases. I suggest that for this table, the disability classification includes as
few categories as possible, i.e. developmental disabilities (check comment below), sensory
disabilities (visual and hearing), physical disabilities, and intellectual disabilities.
9) Figure 3: Related to the above comment, the classification of types of disability should be:
Developmental disability (includes speech and language disorders, autism, learning difficulties),
visual disability, physical disability, hearing disability, intellectual disability, and multiple
disabilities. I have concerns about the inclusion of diabetes and short stature. Which type of
disability does diabetes cause in this particular case? And which type of disability does short
stature cause here? These two cases should be included in the corresponding category.
10) Survey, question 13, type of disability. Here, you have included the category of
psychological disorder. However, in the text you mention that “the study targeted women with
physical, sensory, or cognitive disabilities”. Psychological or mental health disability is not
among “physical, sensory, or cognitive disabilities”. Please address this issue.
Some other points are the following:
1) Within the text (not the tables), the total n of the women is 68 or 69. Please clarify.
2) Please check the text for some minor typos or grammatical errors (for example, p.5, last
paragraph “Figures 1 and 2 presents…”).
3) Page 6, first paragraph: Please check the range of the weight, as it cannot be 10 to 85 kg (this
should include the values of the 25th and 75th percentiles).
4) Page 7, second paragraph: Please provide references for the statement that “These findings
align with existing literature that underscores the systemic neglect of reproductive health
services for disabled women, particularly in developing countries.”
5) Table 1: in the % column, please leave the number with only one decimal.
Thank you. I look forward to reading a revised version of this article.