Title: The association of parity number with multimorbidity and polypharmacy among
Iranian women in the Azarcohort: A cross-sectional study
Version: 1 Date: 03 Jan 2023
Reviewer's report:
I consider that the manuscript " The association of parity number with multimorbidity and
polypharmacy among women in the Azarcohort" focuses on an interesant issue, factors
associated with multimorbidiy and polypharmacy, in this case parity number. The article is not
currently suitable for publication. Major revision is recommended in order to be considered as
publishable.
TITLE:
Indicate in the title that it is a cross-sectional cross-sectional study (as it may later lead to
confusion as it is a cohort-based study). It could be interesting to add that it is in Iran.
ABSTRACT:
Do not use abbreviations or acronyms without first including the full word (WC, WHR....).
METHODS:
- Design: include at the beginning that this research is based on baseline data collected from
the Azar cohort Study.
- Population: the population is not clearly described, as it is not clear which part of the data
refer to information on the complete population of the Azar cohort or whether this particular
investigation has its own selection criteria (e.g., lack of menstruation). For example, to clarify
the exclusion criterion "suffering from serious illness": it is not clear whether this criterion is
from the Azar cohort or from this study, while there is another exclusion criterion "lack of
menstruation" which would be only from this study. And it appears that in total only 4 women
are excluded, so it seems to be only women without menstruation. Review the term "Lack of
menstruation" which can be confusing, better as it appears in section 2.5 "had never experienced
menstruation".
- In relation also to this exclusion criterion "serious psychiatric or physical illness": it should
be clarified what it refers to because serious illnesses can be cardiovascular diseases or cancer
or depression for example, and these diseases appear within the diseases included as part of the
definition of multimorbidity (section 2.3) which is a main outcome variable of this study.
- Indicate whether a classification system (e.g. O¨Halloran) has been used to decide which
chronic diseases are included in the definition of multimorbidity or whether it is the decision
of the researchers and they are exclusively those that appear in section 2.3. It is not clear when
using the wording "such as obesity, diabetes, hypertension... Also define which diseases are
included in disease. Eliminate the definition of obesity in section 2.3 as it is repeated in section
2.4 (anthropometric measurements).
- Variables: Justify the choice of the 6 parity categories used.
It is possible to have information on the moment of "multimorbidity or polypharmacy". There
may be multimorbidity that is prior to different parity periods in the reproductive history, there
will not have been time for all the women that occurs in time...
- Statistical analysis: It is not clear why they say that ordinal regression analysis was used if
the outcome variables are dichotomous (multimorbidity, polypharmacy, hypertension ....). No
stratified analysis or sensitivity analysis was performed to take into account aspects such as
the fact that, being a cross-sectional study, there are women who have not yet completed the
reproductive cycle and others who have. Nor is it clear whether the multimorbidity or disease
variables are dated after the birth of the last child or whether they could not be considered and
therefore multimorbidity could be pre-birth, during or after. This is key because it would not be
appropriate to talk about risks but simply to explore associations if we are not clear about the
time frame of occurrence of the variable under study (parity) with respect to the multimorbidity
outcome.
RESULTS:
- Model 3 (Table 3) adjusts for the use of contraceptives or Hormone therapy, this variable we
do not know how it is distributed in the cohort, it would be interesting to know it in table 1. Also
indicate whether contraceptives or hormone replacement therapy can be counted as drugs in the
variable "polypharmacy", if this is the case repeat the analysis without taking this into account
as it should not be as an adjustment variable and at the same time as a result variable in table 3.
- Avoid the use of the term risk, better to use terms such as association or in the following
sentence change it to OR "Interestingly, after adjusting for confounding facotrs, the OR (RISK)
of depression in women with ....".
DISCUSSION:
- This section should be deeply revised in terms of order, clarity and meaning of various
sentences. Moreover, the discussion does not focus on the objective of the study (to study the
relationship between parity and multimorbidity and polypharmacy) but discusses mainly other
associations that are already better known. And giving much space to studies on mortality and
parity that are not addressed in this research.
- Here are some examples of sentences to be clarified, improved, but I recommend a global
review of this section:
- It is not clear what the authors mean by the following sentence "As limited information exists
regarding theirmechanisticassociation, our discussion considers studies on all-cause mortality."
- On which references is the following sentence based: The findings of mortalities maybe
explained by the depletion of nutrients with multiple pregnancies, especially if the time between
the pregnancies is short.
- Limitations: this study has other limitations already discussed throughout this review that
should also be included in the discussion.
CONCLUSIONS:
Not to speak of risk but of association given the type of design.
Other aspects that I recommend to be improved:
- Though I am not a native English speaker, I would recommend to review thoroughly and check
the English wording and editing (spaces between words, type-size of letter...), references along
the text