Title: Impacts of inequalities in utilization of key maternal health service on fertility Preference
among high parity women in four selected regions of Ethiopia
Version: 1 Date: 01 Feb 2024
Reviewer's report:
Title
There is a clarity issue in the title (need some editorials). The title seems mixing of the inequality
in maternal health service utilization with fertility preference. How this two words related.
Fertility preference vs MHS utilization seems unarelted.  Since key maternal health services
utilizations are more related with service during pregnancy and fter birth within 6weeks such as
ANC, delivery & PNC. MHS use is one time use of service but fertility preference is different
issue with include culture, religion, family influence. How recent use of MHS influence fertility
preference. Is gap in information is the only reason for high fertility in developing countries?.
• Other issue, including two words of  “Utilization “, better if remove one “Impacts of inequalities
in utilization of key maternal health services utilization on fertility Preference among high parity
women in four selected regions of Ethiopia”
• Inequality vs inequity: can we use interchangeably.
• Is it possible to use “key reproductive health service” than “key maternal health services” to
include contraceptive use, since contraceptive can be used by any women with in reproductive
age group
• Why fertility preference if they are already with high fertility. The women have five and more
children now, why you need to assess on fertility preference. As justification not stated in the
background section also.
Abstract
• Methods: assumptions is limited
• Line 30-31 (first section of the conclusion): Better if you make it more clear. It is difficult to
understand easily.
Background
• Why fertility preference if they are already with high fertility. The women have five and more
children now, why you need to assess on fertility preference. As justification not stated in the
background section also.
• This study include inequality in the title, but does not stated anything about inequality in MHS
use in the background section
• Those recent articles are not included. All are talking about equity/equality in MCH in Ethiopia.
Better if stated any in the background section, to strengthen the gaps in Ethiopia.
• Alem Desta Wuneh, et al, Wealth-based equity in maternal, neonatal, and child health services
utilization: a cross-sectional study from Ethiopia. International Journal for Equity in Health
volume 18, Article number: 201 (2019)
• Alem Desta Wuneh, et al. Wealth and Education Inequities in Maternal and Child Health
Services Utilization in Rural Ethiopia. Int J Environ Res Public Health. 2022 May; 19(9): 5421.
• Alem Desta Wuneh, et al. “If I Was Educated, I Would Call the Ambulance and Give Birth
at the Health Facility”—A Qualitative Exploratory Study of Inequities in the Utilization of
Maternal, Newborn, and Child Health Services in Northern Ethiopia. Int. J. Environ. Res. Public
Health 2022, 19(18), 11633; https://doi.org/10.3390/ijerph191811633.
-Editorial issue, to long and many paragraphs need to be reduced
-Using data from EDHS 2019 in the background section for MHS use but not using for analyses
(ref=13) why?
Methods
• I appreciate the authors in focusing in those four regions. They are more agrarian, nomadic
regions in Ethiopia with deep harmful cultural, religion and traditional practice takes place
such as early marriage, dowry, FGM, polygamy, under-education of women etc. how those
characteristics can be included in this study.
• Is it possible to use the recent EDHS-2019 (mini), the data is accessible in DHS program online
than using old data. You can have adequate variables for this study.
• PAFs its assumptions not clearly described
• Inequality measurement missed?
• It is not clear the measurement for in0065quality in the methodology in this section. Better to
state something.  How do you measure inequality in MHS utilization.
Result
• Most women (>70%) included in this study are uneducated, with no job, poorest, and from
rural residence.  Do you think this may affect the analysis. To relate fertility preference with one
time use of MHS than the socio-cultural, religion issues in the four regions ?
• Sub-title is needed for this next paragraph that describe table 4 line 229
• Sub-title is needed for this next paragraph that describe table 5. To reduce long paragraphs
and sentences. Line 241
•
Discussion
• The discussion is more focused on factors associated with fertility preference than the aim of
the study “the impact of inequality in MHS use on fertility preference”. How this study differ
from “factors associated with fertility preference” study
• Analysis related limitations are not stated
Conclusion
• The conclusion is different from the title. In the title stated the influence of inequalities in MHS
use on fertility preference but the conclusion is on “the influence the inequalities in fertility
preference”