Title: Female Genital Mutilation and Skilled birth attendance among women in sub-Saharan
Africa: evidence from demographic and health surveys
Version: 3 Date: 11 Sep 2021
Reviewer's report:
Comments to the authors
Thank you for asking me to review this manuscript that investigated association between
prevalence of female genital mutilation (FGM) and presence of skill birth attendant (SBA)
during the childbirth.
General comments
Much as presence of SBA is associated with safe childbirth, it is not clear to me how presence of
SBA could be link to an event or action taken on a woman before age of puberty.  Which of the
childbirth(s) did the authors considered for the presence of SBA?  Was it the last or first or ever
had childbirth that was considered in this analysis? The rationale for picking the 10 countries
out of many countries in sub-Saharan African region is not clear. What is the common reason
for all the countries selected? There are other countries in SSA with similar FGM practice
Specific comments
Introduction
The rationale for considering 10 countries out of the other SSA countries is missing here. The
specific objective should be clearly described. It is difficult to understand the intention of the
authors with this statement “we examined the link between FGM and skilled birth attendance
(SBA) in SSA.”
Methods
Why were 10 countries selected? Some countries have high prevalence while others are not.
Besides the data were collected at different periods (2010 to 2018). What about the policy
changes within and between these countries over this period?
This information on outcome is not clearly described. Which of the childbirth(s) did the authors
considered for the presence of SBA?  Was it the last or first or ever had childbirth that was
considered in this analysis?
Data analysis – The author did not provide reason for using fixed effect in building their model.
I think a descriptive table on individual country level prevalence of FGM and SBA attendance
at the delivery to be used for this analysis will be an important information.
Discussion
I think the discussion should be on profiling women with previous FGM that are not considering
using SBA for their delivery. It is also important for authors to highlight key public health issues
that might be considered to improve SBA attendance at the SSA subregion and specific countries
instead of repeating results of their findings that were earlier presented in result section.
In the discussion, I do not understand “Optimal ANC visits increased SBA”  - what does this
mean?  The discussion here is over summarised. I do not think all the 10 countries were operating
the same MNCH policy and programmes. I think the authors will have to improve on the and
justify why a woman with previous history of FGM will consider SBA or not.
I think the authors did not consider differences in MNCH policy, education, cultural differences,
and existing interventions that could have confounded their results. This is a big limitation that
must be discussed.
References
The style of these references are different from others
1. Akin-Tunde A. Odukogbe, Bosede B. Afolabi, Oluwasomidoyin O. Bello, Ayodeji S.
Adeyanju. Female genital mutilation/cutting in Africa. 2017. Doi:  10.21037/tau.2016.12.01.
PMCID: PMC5422681. PMID: 28540220
2. Ganiyu O Shakirat, Muhammad A Alshibshoubi, Eldia Delia, Anam Hamayon, Ian H
Rutkofsky. Overview of Female Genital Mutilation in Africa: Are the  Women Beneficiaries or
Victims? 2020. PMCID: PMC7536110
Assessment - Major Revision  Required– the authors will need to attend to all issues raised.
Please present a clear rationale for this analysis including why the 10 countries were selected,
feasibility of pooling data collected over 10 years together and an individual country level
descriptive analysis of FGM and SBA prevalence. The discussion should involve interpretation
of results within the context of each country policies and programme. The limitation of pooling
results collected 8 years apart would be important.