Reviewer ’s report  
 
Title: The associations betwee n Intimate Partner Violence a nd maternal health care service 
utilization: A systematic review and meta -analysis  
 
Version: 0 Date: 08 Aug 2018  
 
Reviewer: Abigail Hatcher  
 
Reviewer's report:  
 
The manuscript syste matically reviews the literature about an important topic, namely the 
association between experience of intimate partner violence and antenatal healthcare utilization 
outcomes. However, there are a number of considerations that may strengthen the paper for  
publication:  
 
Introduction  
1. There is no need to capitalize "antenatal care" or "skilled delivery care". I also don't 
believe it's necessary to use an acronym for either term.  
 
2. What does "inadequate ANC" mean? Inadequate attendance (not enough clinic v isits) or 
delayed entry, or something else?  
 
3. Page 4, line 55 should be toned back from "However, there has been no systematic 
review and meta -analysis that have explored the…" since multiple systematic reviews 
have been conducted (and should be cited). T he gap in literature could perhaps be the 
addition of the meta -analyses:  
 
a. Pratley (2016) SS&M  
 
Methods  
4. On page 5, please define the IPV exposure by type (e.g. physical, sexual, and/or 
psychological) and cite the relevant definition.  
 
5. Was antenatal ca re usage defined by the studies themselves or as a universal definition of 
4+ clinic visits?  
 
6. It feels like the search terms are lacking. What about "spousal abuse" or "antenatal 
services" or "skilled birth attendance"? I'm concerned that the authors mis sed some 
important papers, including:  
 
a. Rurangirwa AA, Mogren I, Ntaganira J, et al. Intimate partner violence among pregnant 
women in Rwanda, its associated risk factors and relationship to ANC services 
attendance: a population -based study. BMJ Open 2017 ;7:e013155. 
doi:10.1136/bmjopen -2016 - 013155  
 
7. Poor quality is not typically a reason for exclusion. The authors do say that they excluded 
based on the NOS Scale, but more typically these scores are reported in the table and 
studies are still included re gardless.  
 
Results  
8. On page 8, before you dive into the meta -analytic findings, it is important to characterize 
the included studies. Instead of Table 1, which combines antenatal and skilled delivery 
outcomes, I would rather split this into two tables. These are the tables  that should be 
written about in the text.  
 
9. I would likely only use Figures 1, 3, and 6. I'm not sure the geographic differences are as 
important as the measurement distinctions. Please present the I2 value for Figs 3 and 6 
for each type of violence on i ts own, then an overall estimate of heterogeneity. That the 
heterogeneity is high is rationale for dropping Figs 2 and 5.  
 
10. The rule tends to be that high heterogeneity means that one cannot trust the meta -analytic 
findings…so the authors need to find an y way possible of reducing heterogeneity.  
 
11. On page 9, instead of "50% less likely…" the terminology should be "had half the odds" 
or "had 50% decreased odds…"  
 
12. The other factors related to antenatal care use and skilled delivery can be summarized in 
the Discussion, but do not belong in the Results unless the authors intend to conduct a 
meta -regression.  
 
Discussion  
13. On page 13, the discussion about "Women who have experienced physical violence that 
resultedresulted in injury may refrain…" needs to be  its own paragraph. This paragraph 
should hypothesize pathways linking IPV experience to poor maternal healthcare usage 
based on the extant literature. Consider, for example, partner controlling behaviors that 
limit women's ability to seek healthcare aroun d the time of pregnancy and considerations 
around HIV that intersect with IPV victimization (for both topics, see Hatcher (2014) 
JIAS).  
 
14. The finding that most extant literature is cross -sectional is not a limitation of the study, 
but an important findin g. This needs to be brought up towards the top of the Discussion.  
 
15. Can you please say more about the reporting of hetergeniec findings? The authors cite the 
Higgins BMJ paper, but I'm unfamiliar with this approach.  
 
16. More limitations: only reviewed p apers in English, timeframes, etc.  
 
17. In Conclusion, could also cite Pallitto (2016) BMC Health Services Research as a 
promising intervention strategy.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
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.  
 
Yes 
 
Are you able to assess any statistics in the manus cript 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 manuscri pt: 
 
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 financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either no w 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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