Reviewer ’s report  
 
Title: Use of contraceptives, high risk births and under -5 mortality in Sub Saharan Africa: 
Evidence from Kenyan (2014) and Zimbabwean (2011) Demographic Health Surveys  
 
Version: 1 Date: 17 Feb 2018  
 
Reviewer: Marshall Makate  
 
Reviewer's report:  
 
The paper uses cross -sectional level data from the Kenya and Zimbabwe Demographic and 
Health Surveys to examine the factors associated with high -risk births, under -five mortality and 
contraceptive use among women who have experienced high -risk births or under -five mortality. 
The pa per tackles an important public health issue in the case of developing countries. I have few 
comments that might improve the quality of the paper.  
 
Comments  
Background  
 The contribution of this paper to the literature is not very clear to me. The findings of the 
paper are not at all new. The authors should be clear about the nature of their contribution to 
the literature. Is it just using a different dataset specific to some country? Also, several key 
literature for the countries under study have been omitt ed (see comments below).  
 
 The authors should discuss the rationale for restricting the analysis to women who are at 
higher risk of having a high -risk birth and those who have experienced an under -five death. 
This is a major limitation of this paper. Just focusing on these subsamples creates whole lot 
of econometric problems e.g. small sample bias, self -selection problems. Also, the authors 
should ask themselves the question whether the factors influencing contraceptive use among 
high-risk women are differe nt or similar to those influencing contraceptive use among low -
risk women. If they are different, they should show the results for both sub -samples. This is 
not explored in the paper. For example, the finding that highly educated women and those 
from high -wealth households, are more likely to use modern contraceptive methods is not 
new at all, see e.g. (Muhwava, 2003); Zanin et al. (2014).     
 
 The background can be improved greatly. At the moment, it lacks fluidity, and appears to 
have several disjointed statements.  
 
 The authors appear to have omitted much more recent literature for Zimbabwe that examine 
the underlying causes of under -five mortality in the country. See for example, Makate et al 
(2017) who single -out the important role played by prenatal q uality on child survival. This 
present study does not even provide a discussion on the possible impact of prenatal care on 
child survival. Also, check Grépin and Bharadwaj (2015).  
 
 There is no clear justification on why the authors pick Zimbabwe and Keny a for the analysis. 
Was it an arbitrary choice? To what extent are these countries comparable? These issues 
should be adequately discussed in the paper.  
 
 If the goal was to show differences in factors influencing contraceptive usage among high vs 
low risk , then the current analysis does not answer that research question.  
 
 Just as a note, the 2011 DHS for Zimbabwe is not the most recent survey data, I think the 
authors should revise the statement on page 5, lines 9 -11 to reflect this. They don't have to 
change the analysis, but rather include something like "at the time of  writing this paper…."   
 
 On page 4, line 6…"less than 70 what? I think it should be written in full as 70 deaths  
 
 On page 4, please revise lines 8 -16, they don't read very well.  
 
 Page 4, line 33. Did the authors mean "represent increased risk/chances of mortality" instead? 
Otherwise, increased mortality appears to suggest a direct causal relationship. Please clarify.  
 
 Page 4, lines 44 -48 should be revised to clearly indicate that, the findings from previous 
studies have shown that…(not just say availa ble data from…).  
 
 The authors should also explicitly state the community -level variables of interest, upfront in 
the background section and justify why the community context is important for these 
countries. Why should we care about the community context ? See for example, the paper by 
Chitalu and Koch (2015) on the role of community -level factors on maternal healthcare use 
in Zambia.   
 
Methods  
 On page 5, the authors describe the datasets used including the sample sizes. There is no 
mention of how missin g observations were addressed, a common problem with this data.  
 
 The authors should clearly define how the outcome variables are measured here. Are they all 
binary variables? This needs to be clarified for the reader.  
 
 Also, how is under -five mortality  defined in this case? Does it include children who were 
alive at the survey date but had not reached 5 years of age? If so, we might have a censoring 
problem here, something not addressed in the paper.  
 
 It will be nice for the authors to provide a brief justification of why the explanatory variables 
chosen matter for contraceptive use, and child mortality outcomes etc.  
 
Modelling approaches  
 The authors should be clear on what kind of regression model they are using, which I 
presume is a two -level logisti c regression. This is missing on line 60 of page 7.  
 
Results.  
 The interpretation of results section can be improved.  
 
 The authors report the AIC of the models but do not interpret them or at least alert the reader 
which model was chosen and why it was s elected as appropriate.  
 
 Looking at the adjusted odds ratios across tables, what main message can the reader get from 
the results?  
 
 There is no discussion on the policy implications of this study. Why should we be interested 
in the results of this study ? 
 
References used  
Marshall Makate, Clifton Makate; The impact of prenatal care quality on neonatal, infant and 
child mortality in Zimbabwe: evidence from the demographic and health surveys, Health Policy 
and Planning, Volume 32, Issue 3, 1 April 2017, Pag es 395 -404, 
https://doi.org/10.1093/heapol/czw154   
Chitalu M Chama -Chiliba, Steven F Koch; Utilization of focused antenatal care in Zambia: 
examining individual - and community -level factors using a multilevel analysis, Health Policy 
and Planning, Volume 30,  Issue 1, 1 February 2015, Pages 78 -87, 
https://doi.org/10.1093/heapol/czt099   
Grépin, K.A., & Bharadwaj, P. (2015). Maternal education and child mortality in Zimbabwe. 
Journal of Health Economics, 44, 97 -117. 
Muhwava, W. (2003). Patterns of contraceptive u se at the edge of fertility transition in 
Zimbabwe.  
Zanin, L., Radice, R., & Marra, G. (2014). A comparison of approaches for estimating the effect 
of women's education on the probability of using modern contraceptive methods in Malawi. The 
Social Science Journal, 51, 361 -367. 
Are the methods appropriate and well describe d? 
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 suppo rted 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 s pecify what aspects require further  
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
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 al l 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  
 
I agree to the open peer review policy of the journal. I understand that my nam e will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made availabl e under an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will no t be published.  
 
I agree to the open peer review policy of the journal