Title: Exposure to different types of mass media and timing of antenatal care initiation: Insights
from the 2016 Uganda Demographic and Health Survey
Version: 0 Date: 19 Sep 2021
Reviewer's report:
This manuscript explores the association between mass media exposure and the timing of
antenatal care initiation among women in Uganda. While the subject of the research (antenatal
care initiation) is very interesting, particularly in Uganda, there are major flaws in the
conceptualisation of this paper that makes it unsuitable for publication in BMC Women's Health
in its current form. I have outlined many of the major and minor flaws below and hope that they
will help the authors advance their work.
Major Comments:
The result in the supplementary file appears to be more suitable for this work than the one
currently presented in this work, as it's the actual media exposure. The current measure could
almost be easily passed for the ownership of assets which has already been captured in the wealth
index.
- The background is supposed to provide some contextual information about the state of ANC
in Uganda. Unfortunately, this section mostly speaks to ANC in sub-Sahara Africa, South Asia
and the broad importance of ANC with very limited information about ANC in Uganda.
- What is the state of maternal and child mortality in Uganda, levels of ANC and actual findings
of previous studies about the subject focusing on Uganda?
- Towards the end of the background, the authors attempted to summarise previous work on the
topic and gaps, but the actual findings of these works are not highlighted. For example, "Bbaale
analysed the 2011 UDHS and only looked at exposure to radio as one of the variables but did
not pay attention to exposure to TV and newspapers [12]." What did Bbaale find in their work,
and why do you think their approach is limited? I don't think it's enough to just say Bbaale did
this, but we will do that. Perhaps the author could clarify why their proposed method is a much
better approach and how they think their proposed approach could illuminate the problem better.
Unfortunately, I'm not able to find anything like this or close in the introduction.
Please provide additional information about your sample. The authors mentioned that "we
included women aged 15-49 years who had a live birth within five years preceding the survey
and had given informed consent". However, the inclusion of partner's education in the model
with 2109 missing responses suggests that the models may have been based on the complete
case sample. That is, those who were currently in a union. Also, Not all women who had a birth
in the last five years would have complete information about the timing of the first ANC visit.
It will be important to clarify how many missing responses were observed and how these were
dealt with - imputation or list-wise deletion?
Analytic Approach: What is Complex sample analysis? Also, please revise lines 176-179. There
appear to be some repetitions.
Results: "Almost a third of the women (2953/10,152, 29.1%, 95% CI: 27.9-29.6) initiated their
first ANC contact in the first trimester."  This isn't very clear. I don't think you need to repeat
all the numbers on the table. 29% might just be fine.
Discussion: I think the overall discussion of findings needs to be reviewed to ensure they are
supported by the findings of previous studies. I see a general link between each covariate and
mass media despite no evidence to support those. To make these claims, the authors will need
to fit a model that looks at the association between media exposure and sociodemographic
characteristics or at least cites studies examining the same in Uganda.
LN 234, please describe in detail what new/rigorous interventions the government has been
putting in place.
LN 249-251, the interpretation of the relationship between radio and ANC initiation is incorrect.
The result suggests that those who can access newspapers have similar outcomes as those who
don't. The link with residence is weak, at least as suggested by this study. Those in rural and urban
areas have the same ANC outcomes. This pattern is also similar across the levels of educational
attainment except for secondary education. Those with no education and primary education have
a similar ANC outcome as those with tertiary education.
LN 283-286, there's no finding in this work suggesting that young women are more likely to
listen to the radio and watch TV than older women. And if this is a plausible explanation, even
younger women 15-24 years are equally perceived to watch TV more than older women. Still,
they do not have a significantly different outcome from older women.
Limitation: This study examined exposure to mass media, not the actual health information
disseminated on mass media. As a result, the links are with just watching mass media, assuming
that those who watch a lot may have seen some health promotion campaigns compared to those
who don't.
Conclusion: "For a stronger effect, CHW outreach programs can contribute to identifying and
getting women into hospitals in remote and inaccessible areas focusing in the Eastern region."
There is no finding in this work that supports this conclusion.