Reviewer ’s report  
 
Title: The relationship between under -five child death and maternal mental distress in G amo 
Gofa Zone, Southern Ethiopia: A community based comparative cross -sectional study  
 
Version: 0 Date: 09 Jan 2017  
 
Reviewer: Catherine M. Herba  
 
Reviewer's report:  
 
Review of manuscript submitted to BMC Women's Health. Title: The relationship between 
under -five child death and maternal mental distress in Gamo Gofa Zone, Southern Ethio pia: A 
community -based comparative cross -sectional study. .  
This study aims to examine the associations between maternal mental distress and child death 
(under age 5 years). A cross -sectional study was conducted, including 356 mothers who had lost 
their children versus 712 mothers with live children. While the study is interesting, and 
conducted within Ethiopia, there were a number of methodological issues that limit the possible 
conclusions of the study. This manuscript would also benefit from re -reading  and editing for the 
English writing as there were a number of errors throughout the manuscript.  
 
Abstract:  
The first sentence of the abstract is long and lacks clarity. Further, in the conclusion, it is noted 
that women experiencing child loss had high er rates of suicide attempts. As far as I could see 
from the manuscript and the measure, it only seems that suicide ideation and not attempt was 
assessed.   
 
Introduction:  
Page 4 (line 62): Sentence: 'For example, studies have shown  ... is independently associated with 
depression in mothers'. Independent of what?  
Page 5 (line 74 -76): The reference to the greater burden of child loss on the mother could use a 
reference rather than referring to carrying the child in the womb and the pain of labor.  
Page 5 ( lines 81 -88): The long -reaching effects of child loss is indicated. However, it would be 
helpful to be more precise in terms of the settings of these studies (i.e. high -income countries vs. 
low and middle -income countries). This becomes a bit more clear on  the following page, but this 
information could be included here to clarify.  
Page 6 (line 94): It is noted that the situation in developing countries in general and in Ethiopia 
in particular needs to be investigated. Why Ethiopia in particular (compared t o other low -income 
and middle -income countries)? This could be clarified.  
 
Methods:  
Page 7: The sample is described. However it is not too clear exactly who was recruited - was this 
a sub -sample of a larger population? Did many women refuse  to participate? How was this sub -
sample (if it is a subsample) defined (for instance how were the controls selected and matched to 
the child loss group)? Also, what are the inclusion vs. exclusion criteria? how many of these 
children would have been still -births versus children who died after a few months compared to a 
few years? Was this difference ex amined in relation to maternal mental distress?  
Page 8 (line 146): It is noted that 362 women exposed to child loss were compared to 724 
unexposed women. These numbers do not match up to what was presented in the abstract.  
Further -was any child loss expe rienced in the groups of 'unexposed' women (i.e. a death of 
another sibling either before 2011 or older than age 5 years)? was this used as an exclusion 
criteria?  
Page 9 (line 171 -173): The SRQ is described and the subscales for the 25 -item version is 
described. The 20 -item version was used. Were similar subscales available in this 20 -item 
version (as to the 25 -item version that is described)?  
Page 9 -10 (lines 175 -176): It is noted that the cut -off score of 6 on the SRQ is shown to have 
good validity. What  is considered 'good validity'? To what percentage of women does this cut -off 
correspond to?  
Page 10: References to support the indices of wealth index and maternal power should be 
included.  
Page 10: Religion is briefly mentioned, but rather in relation t o broader categories (as is also 
presented in the table at the end of the manuscript as well as on page 13, line 236). However, is 
there any information on the degree of religiosity? This could be more likely associated with 
coping with child loss rather t han the category of religion per se.  
Page 12 (line 222): It is noted that the VIF factor more than 10 was taken as an indicator of 
multicollinearity. However, what was done in that case? was that predictor then removed from 
the regression? It is also not clear exactly which variables were used as predictors or covariates 
in the models that were run.  
Page 14 -15: Section on association between child death and maternal mental health: Did the 
authors control at all for the age of the child at death or the tim e passed since the death of the 
child? There is some reference to this in the conclusion, but I do not see anywhere in the text or 
analyses of how this was dealt with.  
Further, was there any investigation into the cause of death? For instance, still birth , versus 
illness (ex. infection, malnutrition) vs. accident? At different points in the text, it is not clear 
whether there is any separation of concepts for stillbirth vs. the loss of a child after some months 
or years of life. This also becomes less clea r with the discussion of results relating to antenatal 
care (age 15).  
 
Discussion  
Page 16 (line 293): Wording 'unleashed this gab' is unclear.  
Page 16 (line 303): The authors note that 'The effects of the child loss on maternal CMD was 
greater during the  earlier period within 6 months of child death'. In the paper and analyses 
description, there is no clear indication of how this was assessed and the description of these 
results on the timing of child loss.  
Page 17 (lines 316 -320): There is a paragraph d iscussing the importance of screening women for 
mental health problems during pregnancy. While this is indeed something that could prove quite 
important, it does not really seem to be tightly linked to the focus of the paper. The inclusion of 
this paragrap h further makes it less clear whether pregnancy loss and stillbirth are included in the 
child loss group or not.  
Page 17 (line 328 -332): The paragraph linking maternal CMD to physical health, while 
interesting, seems misplaced in this paper given that the  paper does not focus at all on the 
physical health of the mothers.  
Page 18 (line 336 -341): Again, there is a discussion of antenatal care, where it becomes unclear 
whether the focus of the paper is on perinatal loss (or pregnancy/stillbirth) vs. postnata l loss of 
the child. How many babies in the child loss group were due to pregnancy complications/still 
birth vs following birth?  
 
Conclusion  
 Page 19, Line 344: Reference is made to suicide attempt (as was also done in the abstract). As 
far as I can see i n the paper, only suicide ideation and not attempt was assessed.  
Page 19 (lines 350 -352): While the importance of antenatal care is highlighted, including the 
relevance of screening for common mental distress in women, the screening itself is not able to 
reduce the impact of mental health problems. The appropriate follow -up and care of these 
identified women also needs to be a priority.  
Page 29; Figure 1: Figure 1 shows the time since the child death (in months) in relation to the 
proportion of mothers w ho score above the SRQ cut -off. As I noted in an earlier comment, there 
is not a sufficient description of this analysis in the manuscript. Further, it is not clear whether 
this could be longitudinal or not. I assume it is just cross sectional, but then ho w many women 
fall into each category? Finally, as also raised in a previous comment, did any of the women in 
the ' no child death' experience a child loss at a previous time point (i.e. with another 
child/sibling)?  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Unable to assess  
 
Does t he 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.  
 
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 reco mmend additional statistical review  
 
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 i nterests, 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  
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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 t he 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?  
 
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below.  If your reply is yes to any, please give details below.  
 
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