Title: The severity of menopause and associated factors among middle aged women residing
in Arba Minch, DHSS, Ethiopia, 2022
Version: 4 Date: 22 Apr 2023
Reviewer's report:
Dear Authors ,
Thank you for submitting your manuscript on the prevalence and factors associated with
maternal near misses in Ethiopia for publication.  I appreciate the inclusion of the latest data
on maternal near-miss incidence in Ethiopia, which is essential for policymakers and healthcare
providers to understand the magnitude of the problem and design appropriate interventions.
The identification of various predictors associated with maternal near-miss is also helpful in
identifying high-risk groups and developing targeted interventions.
As a peer reviewer, I have thoroughly analyzed your manuscript and would like to provide my
comments.
1.Some suggestions for more precise and concise manuscript title are:
• Prevalence and predictors of maternal near misses in low- and middle-income countries: a
systematic review and meta-analysis.
• "Systematic Review and Meta-Analysis of Maternal Near Misses: Burden and Associated
Factors in Developing Regions"
• "Prevalence and Predictors of Maternal Near Misses in Developing Regions: A Systematic
Review and Meta-Analysis"
• "Assessing the Burden and Factors Associated with Maternal Near Misses: A Systematic
Review and Meta-Analysis in Developing Regions"
2.The abstract provides a comprehensive review of the current literature on MNM, highlighting
the different factors that contribute to maternal mortality and morbidity.
• Limited search sources: The search for published studies was limited to only a few databases,
and only Google Scholar and Google were used for unpublished studies.
• Limited sample size: The abstract did not provide information on the total number of
participants in the studies included in the review.
• Heterogeneity: There was heterogeneity among the included studies, which could affect the
accuracy of the pooled prevalence estimate.
• Quality assessment: While the paper quality was assessed using the JBI checklist, the abstract
did not provide information on the quality of the studies included in the review.
• Generalizability: The abstract did not mention whether the findings could be generalized
beyond the study population, which was limited to middle-aged women residing in a specific
area.
3. The background section provides a comprehensive overview of the problem of maternal
mortality and the importance of studying maternal near misses. However, there are a few
weaknesses that should be addressed:
• The background section would benefit from a more detailed description of the current state of
maternal mortality in Ethiopia. Although the section mentions that maternal mortality remains a
public concern, it does not provide specific figures or trends. Please consider including the most
recent data on maternal mortality rates in Ethiopia, as well as any progress made in reducing
these rates.
• The section on predictors of maternal near misses could be improved by providing more
information on the methodology of the studies that identified these predictors. Specifically, it
would be helpful to know how the studies defined and identified cases of maternal near miss, as
well as how they controlled for potential confounding variables. Without this information, it is
difficult to assess the quality and reliability of the evidence on which the predictors are based.
• The section on the Sustainable Development Goals (SDGs) could be expanded to provide more
context and clarity. For example, it would be helpful to briefly describe the relevant SDGs and
explain how they relate to maternal health in Ethiopia. Additionally, it would be useful to provide
some information on the progress made in achieving these goals in Ethiopia, if available.
4.Based on the provided methods section, some potential weaknesses or limitations of this
systematic review and meta-analysis include:
• Language and publication bias: The review is limited to studies published in English, which
could lead to language bias. Additionally, the authors only searched for published studies, which
could lead to publication bias.
• Timeframe of search: The authors only searched for studies published between 2015 and 2022,
which may exclude relevant studies published before or after that timeframe.
• Study quality: The authors used a standardized critical evaluation tool to assess study quality,
but it's not clear how they handled studies that scored low on quality assessment.
• Data extraction: Data extraction was done by five authors using an extraction format on
Microsoft Excel, but it's not clear if inter-rater reliability was assessed or if a standardized data
extraction tool was used.
• Heterogeneity: Heterogeneity among included studies was evaluated using Cochran's Q test
and I squared test, but it's not clear if the authors assessed clinical heterogeneity or if they
explored potential sources of heterogeneity.
• Risk of bias assessment: The authors did not mention whether or not they assessed the risk of
bias in the included studies, which is a key aspect of a systematic review.
• Reporting: While the authors indicate that they followed the PRISMA 2020 guidelines for
reporting the study findings, it's not clear if they fully adhered to all the reporting items or if
they used reporting guidelines specific to systematic reviews of observational study.
5.can you confirm? what can I understand from your manuscript results?
“A total of 21 studies with 701,997 pregnant/postpartum mothers from different regions in
Ethiopia were included in the systematic review and meta-analysis. The pooled prevalence of
MNM was found to be 14%. Subgroup analysis based on the region showed that the highest
prevalence was seen in the Amhara region, while the lowest was seen in the Tigray region.
Sensitivity analysis did not show any significant difference after dropping large and small
sample sizes alternatively. Lack of antenatal care, history of cesarean section, and anemia in the
index pregnancy were found to be significantly associated with MNM. However, no association
was found between rural residence and MNM”.
6. The discussion section of this systematic review and meta-analysis provides important insights
into the prevalence and factors associated with maternal near misses in Ethiopia. The authors
have provided a comprehensive overview of the findings and have compared them with similar
studies conducted in other countries.
there are some weaknesses that should be addressed. Firstly, the authors have acknowledged the
considerable heterogeneity across the studies included in the meta-analysis, which may affect
the interpretation of the findings. However, they have not provided any information on how they
addressed this heterogeneity in the analysis.
Secondly, the study does not provide any information on the quality of the studies included in the
meta-analysis, which may affect the reliability of the pooled estimates. Finally, the authors have
not provided any recommendations for future research, which would be useful for researchers
and policymakers in the field.
7. Good references from reputable sources should be used to support the findings and
conclusions and regarding this manuscript  would like to congratulate the authors for thier kind
selection and orientation of these references.
All the best