Title: Examining the unfair concentration of non-institutional deliveries among poor households
in India: A study of predictors and wealth-based inequality
Version: 3 Date: 16 May 2024
Reviewer's report:
BMC- Non institutional deliveries – Revised Manuscript – Reviewer’s comments
This is an important topic and a timely analysis particularly taking into account the trend over
last 5 NFHS rounds. However, the analysis overlooks certain important aspects that need to be
flagged before it becomes a self-contained paper. These aspects relate to analysis of the NFHS-5
data itself, comparison between the NFHS-4 and NFHS-5 data and the issue of the sample size
across the time series data. My observations are given below.
1. The strong increase in the Institutional deliveries between NFHS-3 and NFHS-4 is
noteworthy. But the sample size difference between the two rounds needs to be flagged. As such
Figure-1 should incorporate the sample size of total deliveries. It will also show that NFHS-4
and NFHS-5 sample size is comparable.
2. Likewise the gap between the two rounds NFHS-4 and NFHS-5 is much lower than that
between earlier rounds. This needs to be flagged while asserting that the rate of decline in the
NIDs is tapering off.
3. The tapering off is may also considerably vary by regions. As such the Table-2 should have
the corresponding numbers of NFHS-4. At the least, the authors should provide the region table
for NFHS-4 and NFHS-5 separately. One can safely guess that the decline in the southern and
the western region may have been very sharp, and not so sharp in the Central, Eastern and the
N-E region, but instead of readers speculating about it a clear table is warranted.
4. This becomes clear if we see the following visualization. The disproportionate contribution
of the NE region needs to be flagged.
Region Total Deliveries Non-Inst Deliveries NID as %
Northern 28908 1775 6.1
Central 50275 7274 14.5
Eastern 35111 6503 18.5
Western 15220 949 6.2
Southern 21590 416 1.9
North-eastern 24465 7133 29.2
175569 24050 13.7
[See attached file for the two pie charts]
5. Once this is accepted, a similar table and pie chart is warranted for the NFHS-4 data.
6. A separate analysis for the NE region (30% of the NIDs) and the rest of the regions becomes a
logical next requirement. This is because of the sharply differing parameters for the NE region in
terms of very sparce habitations, high female literacy, non-proximity of the infrastructure among
others. If the model still shows same correlates to be important, it will be a counter intuitive
story. If it shows that different correlates are at play in the two regions, it tells a story not reported
in the literature so far. In either of the cases this makes a unique contribution to the literature.
7. We also need a region wise break up for the Christian community. Chances are that the NE,
the central and the rest of the regions will show a strongly different % of NIDs, but the authors
will do a big service if they do it for NFHS-4 and NFHS-5.
8. Authors may consider geospatial mapping of NID rates across the state along with their
corresponding concentration index. This can reveal how clusters of low and high NID rates
correlate with clusters of low and high inequality, thereby enhancing the value of the results.
Additionally, they may consider estimating the index at the district level and identifying clusters
within states, which would further contribute to the existing literature [This is optional].
9. Finally, since the authors have flagged the issue of NID, it is important to look at the
assisted NIDs vs unassisted NIDs. Chances are that certain regions may reveal disturbingly large
proportion of unassisted NIDs. That will be an excellent contribution to the literature and add
value of this paper.
Most of my suggestions do not involve complicated number crunching, but offer low-hanging
yet important additions to the value of the paper. Running the model for the NE region and rest
of the country separately will also not be a time taking for them. I hope the authors take it in the
right spirit. In case they work out the odds ratios for the NFHS-4 sample as well, that will be an
icing on the cake, but I will leave it to their best judgement and the ‘fatigue factor’.
Reviewer-1 (Revised Manuscript)