Reviewer’ s report
Title: Intimate partner violence against women and its association with pregnancy loss in
Ethiopia: Evidence from a national survey
Version: 0Date: 26 Mar 2020
Reviewer: Caroline Ackley
Reviewer's report:
Intimate Partner Violence against Women and its Association with Pregnancy Loss in Ethiopia:
Evidence from a national surveySummary of the manuscriptThe paper identifies an association between intimate partner violence (IPV) and pregnancy lossthrough a retrospective analysis of 2016 Ethiopian Demographic and Health Survey data. Itbegins by describing the different 'types' of pregnancy loss and gives global data figures tocontextualise the reported rates of abortion and stillbirth. It also links pregnancy loss to maternalmortality and provides more in-depth contextualisation of social determinants of abortion andstillbirth in Ethiopia.The paper provides a description of the study variables and the methods used to determine if thereis an association between IPV and pregnancy loss.The study found that there is a correlation between different forms of IPVand pregnancy loss. Theresults suggest that 2 in every 3 women have experienced at least one form of IPV in their lifetime,which is a significant finding on its own. But the study goes further in its detail to show that theodds of pregnancy loss are higher among women who have experienced multiple acts of partnercontrolling behaviour.
The paper concludes by providing several recommendations related to the SDGs and improving
maternal health outcomes. It identifies key sectors and actors needed to address IPV and healthstrengthening strategies.
Overall strengths and weaknesses
This is an important study that lays the foundations for further studies on pregnancy loss and IPVin Ethiopia. The authors did an excellent job of conducting a meta-analysis on EDHSS data andhave significant findings that have the potential to shape research and public health agendas. Ienjoyed the straightforward nature of the article, however at times I was left wanting moredescription. I acknowledge that the data set and methods do not necessarily allow for furtherdescription, and appreciate the authors acknowledging the limitations of this. There are severalplaces where I feel the authors can be more direct in their writing and employ simple tools to guidethe reader. I have noted these in the section 'minor issues to consider'. Overall, this is a paper withhigh national impact that many authors will cite in the future; myself included.
Recommended course of action
I suggest publication with minor revisions.
Minor issues to consider
*It would be helpful to have some sort of general introduction to Ethiopia in terms of health
policy, health systems, and demographics. This is important because later in the paper youprovide minimal contextualisation of the demographics, but do not account for potential regionalvariations in findings. I wonder about demographic variation because I am familiar with theEthiopian context, but you have yet to provide that context in the introduction.*A 'road map' in the introduction would help your main points flow a bit better, and not leavingthe reader to discover your connections at the end of the section. This could be included after thefirst sentence in the introduction where you foreshadow your points to come.*At times you make generalizations or use terms that could be better refined. For example, on line
78 you write 'Ethiopia is a country with inadequate contraceptive use'. The use of 'inadequate'
should be contextualised to help the reader understand as compared to where or when? And,according to whom? Additional phrases that merit more critical engagement:oLine 232 'social autonomy of women'oLine 254 'high gender inequality and male dominancy' (I know this data comes from the CSA,but you can be more critical in your use of powerful phrases).*You introduce partner controlling behaviour on line 83 and define much later in the paper. Iwould like for it to be defined earlier.*You define the sub-variables of IPV on line 131 and I would have liked those introduced earlier,perhaps in the introduction.*In your results you briefly describe the general characteristics of respondents. I feel that this issomewhat lacking in greater contextualisation because Ethiopia such an ethnically and religiouslydiverse country. Can you go deeper in this section and provide insight into different regions?*You briefly mention a habit of substance abuse on line 189. Can you provide more descriptionhere? Khat is widely used in Ethiopia and is most likely included in your statement on substanceabuse but a general reader would not be familiar with this.*In the results and discussion if there are any places to provide further description it would be verynice. I know this is beyond the remit of your data set and methods, but as a reader and researcher
who has conducted qualitative work on stillbirth I want to know more.
*In your limitations section it might be helpful to also include the potential for conceptual andlinguistic misalignment in terms used in the EDHSS. For example, many women might notconsider some controlling behaviours to be controlling and therefore might not report them, etc.This misalignment is quite common in research on FGM and I suspect it is possible in othersensitive topics like IPV.*Your recommendations are good, but also read a rather general. I wonder if you could make useof key approaches to help this section have more impact. For example, health systemsstrengthening, multi-sectorial approaches, etc.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
YesDoes the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Yes
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
YesAre you able to assess any statistics in the manuscript or would you recommend an
additional statistical review?If an additional statistical review is recommended, please specify what aspects require furtherassessment in your comments to the editors.
I recommend additional statistical review
Quality of written English
Please indicate the quality of language in the manuscript:
AcceptableDeclaration of competing interests
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