Reviewer’s report
Title: Women’s empowerment and fertility preferences in high fertility countries in Sub-Saharan Africa
Version: 0 Date: 04 Jul 2018
Reviewer: George Odwe
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Women's Empowerment and Fertility in Sub-Saharan Africa
General comments
The relationship between women empowerment and fertility is an important topic that has received  
attention in the recent past. I agree with the authors that fertility remains high in a number of SSA  
countries and that high fertility is evidently sustained by high demand for children which dents the  
prospect for fertility decline. The linkage between women empowerment and fertility is, therefore,  
important in understanding factors that sustains persistently high fertility in SSA region. This study  
tries to explore on the one hand the relationship between women's empowerment and ideal number of  
children and their ability to have only the number of children they want on the other hand. Using a  
multidimensional empowerment index, the study employs linear regression and logistic to model the  
effect of empowerment indicators on fertility variables. It is noteworthy that the relationship between  
women empowerment and fertility is bi-directional, that is, on the one hand, women's empowerment  
may  cause  changes  in  fertility  outcome,  and  on  the  other  hand,  may  affect  changes  in  women  
empowerment. The study, therefore, has a limitation in using a cross-sectional data to establish the  
effect of women empowerment on fertility.  Due to the cross-sectional nature of the data used, the study  
can  only  attempt  to  explore  the  relationship  between  women's  empowerment  (measured  using  
empowerment proxies) and fertility outcome but cannot establish the causal effects.
The rationale for the study is still not clearly stated in the background section and the discussion  
section does not help in linking the results to other studies' findings as well as policy and program  
implications, save for a few references 21, 29-33. 
I feel the paper may need to be revised before being considered for publication. The following specific  
comments should be addressed to improve on the manuscript:
Background (pages 3-5)
1)It is still not clear about what new knowledge the study is contributing. I find the background is  
lacking information on the current knowledge and gaps on the topic in the Sub-Saharan Africa settings  
and how the current study will fill this gap.  A broad body of research exists on women's empowerment  
and reproductive outcomes (fertility, contraceptive use, etc.) in low-income countries.  It is surprising  
that the authors completely ignored highlighting the current debates on this topic. The authors need to  
include relevant literature on women's empowerment and fertility so that one can understand the  
nuances of the topic.
2)Whereas decision-making power is just one aspect of women empowerment the study included  
other dimensions of women's empowerment—economic, socio-cultural, and familial/interpersonal. We  
don't see clear research questions/hypothesis.
3)The  study  hypothesizes  that  "the  degree  of  women's  decision-making  power  and  choice  
compared to men's in matters of fertility varies inversely with the importance of women's socio-
demographic  characteristics  and  their  position  in  the  economic  structure".  However,  testing  this  
hypothesis will need comparative analysis between women and men. However, the analysis does not  
take this into account. There is need to rephrase the hypothesis to be consistent with the analysis.
4)The  concept  of  women  empowerment  is  varied  depending  on  the  context  and  may  be  
challenging to measure. However, the authors should not assume that every reader understands the  
concept. Therefore, it would be important to define the concepts in the background so that readers can  
understand what the study is all about. Include a theoretical framework underpinning the study. There is  
also need to include a conceptual framework that may be helpful in showing the relationship between  
women empowerment, intermediate and the outcome variables. 
5)In addition to fertility and contraceptive status, the authors should provide in the introduction a  
better understanding of the context in terms of social, economic, cultural differences in any. 
I have some specific comment on the Methods
1)Data Sources: the study uses most recent DHS dataset for the respective countries, however, it is  
not clear which particular dataset was used i.e. whether individual women, couples or birth recode files.
2)The ideal number of children per married woman is treated as a continuous numerical variable  
in this study. However, such questions elicit both numeric and non-numeric responses. Thus, it is  
important for the authors to indicate how non-numeric responses were handled.
3)As already pointed out, it is rather challenging to measure the concept of women empowerment  
without taking into consideration the local context. In some context having many children may be  
preferred as a way of gaining recognition/status which may also be interpreted to mean empowerment.  
The authors  need to indicate what  informed the inclusion  of the variables  used to construct  the  
empowerment index. 
4)The DHS provides key domains such as decision-making powers, autonomy, and ownership of  
goods that are often used to measure empowerment. I would advise the authors to stick to available  
standardized measures of women's empowerment. It would be helpful if the authors cited in each  
measurement section where the items came from, so we know which came from the standard and  
which the authors created themselves. 
5)It is unclear how the frequency of listening to radio or reading newspaper of hearing about  
family planning on TV/radio in the last few months is related to empowerment. Also, if the authors  
created the measure themselves, please justify. Or if the items were adapted, please explain how they  
were adapted and cite if this has been elsewhere.
Analysis/Result
1)It is not clear from the analysis why two models (I and II) were used. The authors need to 
provide a sentence or two explaining why the two models are used. This should also be clear in the  
results as well as in the discussion.
2)The  sub-titles  under  result  section  is  misleading.  Consider  removing  them and  only have  
univariate, bivariate and multi-variate sub-sections
3)Review the section on multivariate results to make clear the result of the two outcome variables.  
Also, indicate the direction and the magnitude including the confidence intervals for the association  
between independent and outcome variables
4)Indicate  which variables were controlled for in the analysis
Discussion 
The discussion should be clear, systematic and focused in line with the objectives of the study to allow  
readers to follow and understand the new knowledge the study is contributing.  As currently written, the  
article discusses broad issues some of which cannot be implied by the results and lack clarity on the  
main findings of the study.
Specific comments 
1)Provide examples of social traits on page 11 line 15
2)Page 13 … Increased 2 empowerment of women in Chad and Burkina Faso can be linked to  
changes in national and local legislation…indicate national and local legislation you refer to.
3)Women in the cities are more advantaged in terms of socio-economic diversification and the  
multiplication of services, facilities, and activities which make women more open to working. On the  
contrary, many cities  in low-income countries are characterized by informal settlements/slum and  
sometimes far much worse off than their counterparts in the rural settings
4)Line 12 page 15- the sentence is not clear: While fertility is under control in some countries, it  
is a factor that influences women in other countries where high fertility is regarded as particularly  
valuable.
Appendices 
1)Show the reliability test for each of the empowerment dimensions 
2)Include religion in Table 2
3)Include totals (Ns) in table 2
4)The titles in Table 4 and 5 are incomplete. For example, rewrite the title table 4 as 'Beta  
coefficients from a linear regression of women empowerment on the ideal number of children' 
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.
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:
Needs some language corrections before being published
Declaration of competing interests
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