Title: Women Empowerment and Access to Maternity and Reproductive Healthcare in Pakistan:
Cross-validation of a Survey-based Index in Afghanistan (SWEI-A)
Version: 0 Date: 09 Oct 2022
Reviewer's report:
There is a need for English language proofreading. For example, see Introduction, paragraph 2,
first sentence: “Although gender-based issues are widespread global concerns, in some poor-
resourced countries such as Pakistan and Afghanistan, it turned into a humanitarian crisis
and undermine the current efforts to achieve equal sharesfor both genders in the country’s
socioeconomic development (4, 5)”. I think it should be changed to “Although gender-based
issues are widespread global concerns, in some poor-resourced countries such as Pakistan and
Afghanistan, they have/these issues turned into a humanitarian crisis and have undermined
the current efforts to achieve equal shares for both genders in the country’s socioeconomic
development” (4, 5). There is a problem in the next sentence as well; it is ending with a comma
not a full-stop.
In the Methods section, a lot of information is given about PDHS 2017-18, which could be
shortened. It would be better to provide reference of the report where all these details are
mentioned instead of rewriting them. More focus should be paid here on the sample size that
was used in this study and sample sizes with respect to selected variables. This will help the
readers to have an idea of missing values. Further, it would have been helpful if a note related
to how missing values were treated would have been added in the methods.
There was no table of descriptive statistics in the results section. It would be desirable if a table of
descriptive statistics could be added (highlighting frequency, percentage, sample sizes for each
attribute and variable. In Table 1, AVE for each construct should have been added. This would
have helped to assess convergent validity for each construct. In Table 2, the Cronbach’s alpha
for Labor Force construct is higher than 0.95 which suggests redundancy. It is quite possible two
variables added in the construct might be highly correlated. There is a variable related to Intimate
Partner Violence (IPV) in PDHS dataset. If the variable related to attitude towards violence was
added to construct the index, why wasn’t IPV added in the index. With respect to empowerment,
this could have been a major dimension of empowerment particularly for married women
In the data analysis section, it is mentioned “The categories (low, medium, high) for
women empowerment domains were obtained by pooling the individual indicators’ scores and
approximating the terciles as the cutoff points (20, 41)”. Keeping in view this, each domain
was recoded into three categories and one of the categories was the reference, shouldn’t the
results be displayed for remaining two groups/categories instead of one. In Table 4, the results of
attitude towards violence and adequate ANC show that with higher attitude towards violence, the
PRR of adequate ANC increases? Or does higher score on attitude construct shows unfavorable
attitude towards violence? A lot of studies have suggested to only going for correlation analysis
to assess convergent validity, why was poisson regression used? I will suggest not using the term
association when using poisson regression as statistically there is a difference between tests of
association and tests of causality. I would also recommend providing the pooled score (range) of
the domains (e.g. Labor Force participation, decision-making etc). Also, I feel that the variables
related to property ownership and sexual health, are key variables in measuring empowerment
but they had to be excluded for the sake of model fitting. This is one of the reasons that majority
studies have not used variables given in PDHS to construct an index of women empowerment
and have treated these variables as independent variables.
One of the logic behind creating indexes is to create a mechanism for summing all the constructs
in the index to create an index of let’s say 0 – 1 or 0 -100. This was not done. Please discuss
why this was not done. There have been studies in Pakistan that have included almost all of
these variables as proxy variables for women empowerment. Please review these studies and add
them in your study by discussing what these studies lacked with respect to their measurement
of women empowerment.
Doi: 10.1186/s12889-021-11376-6
Link: https://jass.pk/downloads/dec-2018/10th03.pdf
Doi: 10.1177/0886260520980380