Reviewer’s report
Title: 
Changes in the prevalence and trends of female genital mutilation in Iraqi
Kurdistan Region between 2011 and 2018
Version: 
0 
Date: 
20 Apr 2020
Reviewer's report:
Dear authors, Thanks for your manuscript. I believe it is of interest as it
contributes to filling a gap on knowledge about FGM/C in areas that are often
under-researched. Please find some suggestions below, which I hope might help
in improving the manuscript and making it acceptable for publication. I hope you
will find them useful. 
Page 4: Please also refer to medicalisation as a raising trend. 
Page 5: could you specify here where that region is situation in Iraq? 
Page 5: please also refer to the year instead of saying 'recent', in order for the
reader to compare to 2010
Page 6: Please specify that this is about Iraqi Kurdistan; there is also a typo
(studied)
Page 6: Please specify that this has not been done in Iraq until now, or if it has
been done, specify where the gap in knowledge is in Iraq specifically; on page 6
also specify with what the factors are associated. 
Page 7: Please specify what secondary analysis you did, and what the primary
analysis consisted of; make it clear to the reader what you did in the secondary
analysis
Page 9: it should be specified clearly what the primary analysis consisted of and
what exactly the author did as a secondary analysis. In my view the methods
section should clearly distinguish between primary and secondary analysis
Page 10: please use 2011 and 2018 instead of first time and last time. it is
remarkable to note that there's an increase in the more wealthy group; it should
be discussed in the discussion. is it possible that the more wealthy group is
increasingly using medicalised FGM?
Page 11: same comment as above (use 2011 and 2018)
Page 12: I do not really see the added value of comparing with Kenya or BF; it is
much more interesting to compare with Yemen eg, or explain why the
prevalence in Iraq and Yemen went up from 1997 to 2013 (change in survey
sample?)
Page 12: typo: in
Page 12: please add some more in-depth discussion on this issue (continuous
reduction of the practice), see eg recent publications by Shell-Duncan, or Cappa
or others 
Page 12: can you provide reference for this (line 53-54)? is this relevant to Iraq,
could you provide more context on what has been done in Iraq to sensitise
communities? Please also add a section to discuss medicalisation, especially in
Iraq. Also on page 12, you did not survey changes in people's awareness, so
please provide a reference that this awareness increased in the Kurdish regions in
Iraq. Please also provide a reference to the law, when it was implemented and
what campaigns were implemented. 
Page 13: line 11: why was this not included in your secondary analysis, i.e. to
see if there is a correlation between the increase in education level and change in
prevalence? in any case, it would be good to have a reference for the statement
that education level increased in the region under survey in this study
Page 13: line 53-54: this is a remarkable finding, ie. that the highest decline was
in poorest area, this might be discussed more in depth, as it is indeed contrary to
what is 
generally assumed. could you provide more detail or evidence that access
to education and awareness was increased among the poorest? 
Page 14: lines 21-24: am 
not sure whether this is relevant here; there is also no
discussion about the role of religion in the regions, could this be added in the
dsicussion? 
Page 14, lines 7-9: also, this remarkable finding that the prevalence increased in
the wealthierst group should be discussed much more in detail; medicalisation is
surely one explanation and it should be explained here (those with more financial
might choose to medicalise, or is it that they have easier access to hospitals, or?);
also, the statement about 'becoming very rich rapidly', needs more explanation,
as well as the cosmetic purpose of FGM in the regions under study. 
References should include recent literature on prevalence (see previous
comment), and should also be checked (see eg ref 24, which has some errors?). 
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the
authors.
Unable to assess
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Unable to assess
Are 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 further assessment in your comments to the editors.
I recommend additional statistical review
Quality of written English
Please indicate the quality of language in the manuscript:
Acceptable
Declaration of competing interests
Please complete a declaration of competing interests, considering the following
questions:
1
. 
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salary from an organisation that may in any way gain or lose financially
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Do you hold or are you currently applying for any patents relating to the
content of the manuscript?
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Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
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Do you have any other financial competing interests?
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paper?
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interests' below. If your reply is yes to any, please give details below.
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