Reviewer’ s report  
 
Title: Intimate  partner  violence  against  women  and its association  with pregnancy  loss in 
Ethiopia:  Evidence  from a national  survey  
 
Version:  1 Date:  21 May 2020  
 
 
 
Reviewer's  report:  
 
The authors  of this submission  have  used a secondary  analysis  of cross -sectional  survey data from 
the 2016 Ethiopian  DHS  to show  a statistical  association  between  intimate  partner  violence  and 
pregnancy  loss, and also an association  between  multiple  acts of controlling  behaviour  and 
pregnancy loss, all in married  couples. Although not unexpected, this may be useful  information 
on which  to base further  more  focused  research.  It is also of value  with its subject  matter  based in 
Africa.  
 
To tighten  up the submission, I suggest  the authors  cut the introduction  by more  than 50%. 
Informed and interested readers will not need  reminders  on the burdens  and definitions  of 
pregnancy  loss, and also don't  need  an introduction to Ethiopia's  health  service and the state of 
unmet  need  for contraception.  
 
There  are significant  limitations  to the interpretation  of the results.  While  limitations  have  been 
acknowledged to a degree,  there  remains  a sense that the authors  believe in a causal  relationship, 
with pregnancy loss labelled  as the as the 'outcome  variable'. The authors  have  not adequately 
acknowledged the limitations.  The results  as they stand  cannot  be used to make  any statement 
about  causation.  They  can only serve to generate  hypotheses.  First,  the outcome  of pregnancy loss 
is a broad  category that includes  both spontaneous  losses and deliberate  terminations.  The need  to 
merge these two quite  different  phenomena  suggests  that the authors had a sample size problem. 
Ideall y, the effects on the 'outcomes'  of pregnancy loss from  intended termination  of pregnancy 
and pregnancy loss from accidental  stillbirth  or miscarriage should have  been  examined  in 
separate analyses.  Second, so-called  reverse causality  is a real and even  likely  possibility here. 
Third, the authors  were  faced  with secondary data and could not design the research  to include  all 
ideal  covariates for analysis,  hence the likelihood  of residual  confounding, which  can easily 
explain the low derived effect sizes (adjusted  odds  ratios  less than 2). And so it is not appropriate 
for the authors  to write,  on page  12, that 'this study  provides  insights  into the potential role of IPV 
and partner  controlling  behaviour  in maternal  mortality'.  That statement  is not supported by the 
data provided. The  matter  is far more  complex than can be explained by  speculation on 'potential 
direct and indirect pathways'.  
 
The conclusion as submitted goes far beyond  what  can be supported by the data.  But I do agree 
with the important public  health  message,  as given  in the abstract,  that 'there  is a clear  need  to 
develop IPV  prevention strategies'.  This is supported by the descriptive  data from  the 2016 DHS. 
Whether  intimate  partner  violence  causes pregnancy loss or maternal  death  is irrelevant - intimate 
partner  violence  remains unacceptable.  The study provides  some  foundation for further research 
on the how and why of pregnancy  outcomes  in association  with intimate  partner  violence.  
Are the methods  appr opriate  and well described?  
If not, please specify  what  is required  in your comments  to the authors. 
Yes 
Does  the work  include  the necessary  cont rols? 
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. 
No 
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 am able to assess the statistics  
 
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. Have  you in the past five years received  reimbursements,  fees, funding, or salary  from  an 
organisation  that may in any way gain or lose financially  from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks  or shares in an organisation that may in any way gain or lose 
financially  from  the publication  of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently  applying for any patents relating  to the content  of the 
manuscript?  
 
4. Have  you received reimbursements, fees, funding, or salary  from  an organization that holds 
or has applied for patents relating  to the content  of the manuscript? 
 
5. Do you have  any other  financial  competing interests?  
 
6. Do you have  any non-financial  competing interests  in relation  to this paper?  
If you can answer  no to all of the above, write  'I declare  that I have  no competing interests'  below . 
If your reply  is yes to any, please  give details below. 
 
I declare that I have  no competing interests  
 
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