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We are now satisfied with your revisions and I deem the paper suitable for publication.
Authors made coresponding changes regarding our concerns, the manuscript should be accepted.
Authors made coresponding changes regarding our concerns, the manuscript should be accepted.
Authors made coresponding changes regarding our concerns, the manuscript should be accepted.
Reviewers have again raised major concerns about the methodology employed in the analysis and the transparency in presenting both methods and results. Thoroughly addressing the reviewers' comments will greatly improve the quality of the manuscript.
I find this topic, 'The nexus between geographical distance and institutional delivery trends in Ethiopia: Evidence from nationwide surveys, ' interesting. However, a few suggestions are needed to improve the quality of the manuscript.
1. Distance to a health facility for each respondent is crucial for running logistic regression at the individual (woman) level. However, it's unclear how the authors calculated this distance for each woman. More information on the methodology is needed.
2. When reporting Odds Ratios in the manuscript, authors should also report the corresponding p-values.
3. The manuscript requires thorough language editing. There are grammatical errors and spelling mistakes throughout. Here are some specific examples:
3.1. Line 4 in Abstract: "deliveri" is incorrect (correct: delivery)
3.2. Lines 41-42: The sentence needs rephrasing for clarity. Consider using a tool like Grammarly for assistance.
3.3. Line 102: A full stop is missing after "villages."
3.4. Line 181: "women's life" could be more specific. Authors can rewrite it as "distance between a woman's household and the nearest health facility."
3.5. Line 318 of Conclusion: The word "these" is repeated.
Thank you.
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Now, this manuscript may be published with some minor write-up crosscheck for clear arguments of the study and interpretation of findings and their discussions with apt implications.
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The association of the primary independent variable with the outcome variable cannot be interpreted as useful.
The authors have made efforts to revise the manuscript carefully. However, despite the revision, the likelihood of institutional delivery (ID) remains unchanged (OR: 0.99) with an increase in road network distance (between each EDHS cluster and the nearest health facility), both in 2011 and 2016. Hence, the present study becomes insignificant.
On the other hand, the socioeconomic and demographic covariates demonstrate meaningful association with ID. Therefore, I would like to grant the authors one more opportunity to revise the manuscript with a focus on exploring the aforementioned independent variables associated with ID. I strongly recommend changing the title of the paper to better reflect this shift in the research objective. Furthermore, I would like to see the percentages of ID according to the independent variables included in the manuscript to provide a better understanding of the correlation between ID and those variables.
Strengths:
• The manuscript is well-structured and clearly written, adhering to scientific standards.
• Comprehensive introduction providing a robust background on institutional delivery and geographical challenges in Ethiopia.
• Adequate referencing with relevant literature to support claims.
Areas for Improvement:
• Figures and tables could be better integrated into the text with detailed explanations to enhance readability and understanding.
• The abstract could be expanded to briefly mention key findings and their implications for greater initial clarity.
Strengths:
• The study design is methodologically sound, utilizing data from two rounds of the Ethiopian Demographic and Health Survey, which enhances the reliability of the findings.
• Detailed description of the data sources and statistical methods used, providing a clear path for replication of the study.
Areas for Improvement:
• The sampling strategy and its potential biases could be discussed more thoroughly to address representativeness.
• A more detailed explanation of the methods used to adjust GPS data for privacy concerns could enhance transparency and trust in the data manipulation process.
Strengths:
• Robust statistical analysis supports the conclusions drawn about the impact of geographical distance on institutional delivery.
• The findings are well-linked to the research questions, providing meaningful insights into health service accessibility.
Areas for Improvement:
• Potential confounders and biases could be more comprehensively discussed to strengthen the validity of the findings.
• The impact of the findings on policy and practice could be explored in more depth, providing specific recommendations for healthcare infrastructure improvements in Ethiopia.
The paper provides valuable insights into the relationship between geographical distance and institutional delivery in Ethiopia, which is crucial for policy-making. However, enhancing the detail in the methodology and findings sections could improve the paper’s impact and applicability. Further discussions about implications for future research and policy interventions would also be beneficial.
While there have been notable improvements in the manuscript, substantial further work is necessary. Concerns highlighted by the reviewers regarding the suitability of the primary independent variable (straight-line distance), shortcomings in the introduction and discussion sections, and recommendations to improve the presentation of results and incorporate Chi-squared test results require thorough attention. To facilitate a comprehensive understanding, please furnish detailed justifications for the decisions made in your response letter.
The authors have successfully addressed major issues in the paper. However, a few minor corrections are still needed:
1. The figure orders are not correct. The manuscript refers to figures that are not uploaded (line 167). Please ensure that the numbering and explanations of the uploaded figures align with the manuscript.
2. There is an error in line 214. The year 2011 is incorrect.
3. There is a mistake in line 242. The spelling of "previous" is incorrect.
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Please take care of formatting carefully. The fonts of heading subheadings, and spacing should be appropriate. Read the manuscript multiple times and check whether all tables and figures are uploaded correctly.
Here are your review points rephrased in a more constructive yet straightforward manner:
1. The authors have chosen straight-line distance to the health facility as the primary independent variable affecting institutional delivery in Ethiopia. This choice is problematic because it doesn't account for the geographical complexities of Ethiopia, which includes mountains, plateaus, and rift valleys. People cannot travel in a straight line in such terrain. While the study's main idea is commendable, the choice of the primary independent variable is inappropriate for this context, rendering the study not feasible for further consideration.
2. The authors have not adequately improved the introduction and discussion sections in their revision. Significant revisions in writing are still necessary to enhance the clarity and coherence of these sections.
3. In the results section, it is crucial for the authors to present the results in terms of percentage likelihoods, as guided by the odds ratios. Merely reporting the odds ratios without translating them into understandable percentages may hinder common readers from comprehending the practical impact of specific variables on the outcome. Providing a more meaningful representation of the effects of these variables is essential for a robust reporting of the results.
1. The primary independent variable seems inappropriate. However, the rest of the independent variables provide useful and meaningful assessment of the determining factors of institutional delivery in Ethiopia. The study can be taken into that direction or a better "Distance" or "Accessibility" variable such as road network, transportation means, etc. can be utilised.
1. The authors have not been able to establish the novelty of the study within the "Introduction". However the premise is commendable. the choice of the variable is not.
2. Results reporting can be improved as mentioned earlier.
The revised introduction is not as strong as I expected. It lacks addressing the importance, reasoning, and novelty of the study.
The authors have used 'straight line distance' in the study for their analysis, as mentioned in line no. 144. However, this variable raises concerns regarding its applicability to the geographical context of Ethiopia. The country has a complex topography, encompassing extensive highlands, mountains, and plateaus (spread with the 'Great Rift Valley'). Given this intricate terrain, using straight-line distance may not provide an accurate or meaningful measure for distance-related analyses. It would be more appropriate to consider alternative distance variables for a comprehensive and relevant analysis, even in relatively flat areas, such as transport distance (accounting for road or rail networks) and travel time, often reflecting accessibility and connectivity. These variables play a crucial role in influencing various socioeconomic and environmental outcomes. Therefore, I recommend reevaluating the distance measure used in the study to incorporate more geographically relevant and context-specific findings.
Based on this, as the primary independent variable is inappropriate, I deem this study irrelevant.
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Use of simple sentences and clear English. Easy to read. Grammatical errors corrected.
Methodology is clear after the first revision. Key exposure variable explained.
Data-based significant scientific evidence for public health intervention to increase percentage of institutional delivery.
The authors have demonstrated attentiveness in incorporating the comments provided. Notably, their clarification regarding the distance variable, a key determinant in this study, renders the findings clearer. However, to enhance clarity, a suggested revision for the statement in lines 207-209 could be “A one-kilometer increase in the distance to the nearest health facility reduced the likelihood of delivering at health facility by 21% (Odds Ratio: 0.799, 95% CI:0.71-0.87) in 2011 and 16% (OR: 0.84, 95% CI=0.79-0.89) in 2016” instead of “A one-kilometer increase in the distance to the nearest health facility reduces the likelihood of delivering at health facility with odds ratio of 0.79 (95% CI= 0.71 – 0.87) in 2011 and 0.84 (95% CI = 0.79 - 0.89) in 2016”. Moreover, it is advisable to highlight this significant finding by explicitly mentioning the odds ratio in the abstract.
In addition to these amendments, there are a few points that require clarification before the manuscript could be considered for acceptance:
The abstract still lacks the odds ratios (OR) depicting the relationship between the outcome and exposure variables. It is recommended to include the OR for the primary outcome variable and at least a few important variables for comprehensive insight.
The presentation of the Chi-squared test results (Chi-squared value and p-value) is still missing. Therefore, I do not know which variables were found to be significantly associated with the outcome variable.
If the authors could address these minor yet essential amendments, I recommend the publication of this article.
The manuscript needs significant revisions based on the feedback from all four reviewers.
Reviewer 1 recommends enhancements in multiple sections, encompassing the abstract, introduction, methods, and results presentation.
Reviewer 2 underscores the need for improved theoretical underpinning and clarity about the software used in the analysis.
Reviewer 3 proposes an expanded introduction, more detailed data integration explanations, and discussions on infrastructure quality.
Reviewer 4 has raised methodological concerns, particularly concerning the unclear definition of the distance variable, the absence of p-values, and suggests improvements in statistical methods and variable descriptions. While Reviewer 4 has recommended rejection, the manuscript may be reconsidered if the authors satisfactorily address their concerns.
Reviewer 1 has requested that you cite specific references. You may add them if you believe they are especially relevant. However, I do not expect you to include these citations, and if you do not include them, this will not influence my decision.
**PeerJ Staff Note:** It is PeerJ policy that additional references suggested during the peer-review process should only be included if the authors are in agreement that they are relevant and useful.
**PeerJ Staff Note:** Please ensure that all review, editorial, and staff comments are addressed in a response letter and any edits or clarifications mentioned in the letter are also inserted into the revised manuscript where appropriate.
I congratulate the authors for exploring such an interesting topic, “The nexus between geographical distance and institutional delivery trends in Ethiopia: Evidence from nationwide surveys,” which is based upon a secondary dataset, namely the Ethiopian Demographic and Health Survey (EDHS). The article primarily examines the association of distance to health facilities and institutional delivery among Ethiopian women aged 15-49 who delivered a baby recently (five years preceding the survey). The study utilized the logistic regression method to examine the change in the determinants of institutional delivery, considering the distance to a health facility as a main dependent variable adjusted for individual and household level characteristics. The article identified that the distance to health facilities is significantly negatively associated with institutional delivery even after adjusting for individual and household level characteristics. The association remained unchanged in the period viz., EDHS-3 (2011) and EDHS-4 (2016). The article concluded with the need to reduce the distance to health facilities by constructing more health facilities (health clinics and hospitals) and recruiting adequate health professionals to those newly created health facilities for the purpose of greater gains in institutional delivery and ultimately improved maternal and child health.
This is an interesting article that could be improved further following the section-wise suggestions below.
Abstract
1. Line 9 contradicts line 102 and 103, i.e., here it is mentioned “delivered in past ten years” while in lines 102 and 103 it is “preceding five years”.
2. In line 11, please use consistent words i.e., it would be better to write “institutional delivery” on the place of “facility delivery trends” as it is the main dependent variable and has appeared in the title also.
3. The line 13-14 could be restructured as, “Likewise, at the national level, the average distance to health facilities has decreased from 4.9 km to 4.7 km from 2011 to 2016.
4. In line 18, authors could write “deliver in health facilities” instead of “deliver in facilities”.
5. In line 22: Physical accessibility seems vague which could be replaced with “easily accessible health facility”.
Introduction
1. In line 40: From the words, “this essential goal” it is not clear what goal authors want to point out at. The intext citation in line 42 is also incorrect. The intext citations can be, (Sambo & World Health Organization, 2014) OR (Sambo & WHO, 2014).
2. In line 48: Instead of “maternal institutional delivery” authors can simply write “institutional delivery” adding “maternal” word makes it confusing.
3. In line 61, the meaning of “equity considerations” is not clear. Authors could elaborate it more for clarity. Author could also mention among which groups there is inequitable access to healthcare services.
4. In line 73-74, the research objectives could be refined more. This line could be rewritten as, “Thus, current study primarily focuses on two objectives viz., (1) to assess the trends of distance from health facility and institutional delivery among women aged 15-49 in Ethiopia between 2011 to 2016, and (2) to investigate the association between distance to health facility and institutional delivery among women aged 15-49 in Ethiopia.”
Methods
1. In line 79, the sub-heading “study setting” could be rewritten as “Health care system in the study area”. After that, authors could write first about Ethiopia and then the healthcare system of Ethiopia under this subheading.
2. In line 81, “country” should be written NOT “countries” as Ethiopia.
3. In line 88, “study design” subheading should be rewritten as “data source”. Thereafter, the authors can explain about EDHS, its objectives, and study design in paragraph under this subhead. For formatting of method section of this article I recommend authors to see this paper, https://peerj.com/articles/2675/ and modify their manuscript accordingly.
4. In line 101: Sample selection will go in the “data-source” (which is written as study design in this manuscript)” subheading. There is no need to make a different heading for that.
5. Line 105, table 1 is not needed as it does not provide more information than the information already written between line 104 and 106.
6. In lines 109-111, it is not clear how authors have calculated the distance to health facility. This needs more elaboration. How this variable was created should mentioned in the “outcome variables” which is missing in this paper. Please read article for more clarity, https://peerj.com/articles/2675/.
7. In line 111, a more elaboration is required to make it clear that what was independent variable for bivariate logistic regression and which variables were controlled for multivariate logistic regression.
Result
1. In line 115, this subheading could be renamed as “Socio-demographic and health profile of study participants”.
2. Line 122, the subheading could be renamed as “Trend of distance to health facility in Ethiopia (2011-2016)”. Then the contents under this heading should explain how distance to health facilities has changed between EDHS-3 and EDHS-4.
3. In line 129, the subheading could be renamed as “Trend of institutional delivery in Ethiopia (2006-2016)”.
4. In line 138, the subheading, “Determinants of institutional delivery in 2011”and next subheading namely “Determinants of institutional delivery in 2016” should be merged into one with name, “Change in the determinants of institutional delivery in Ethiopia (2011-2016)”.
5. In line 140-143, I suggest It would be better to run only one model (model 4th) that is adjusted for individual and household level characteristics. Run only model 4th for EDHS-3 and EDHS-4 separately then make a single table showing the Odds ratios of 2011 and 2016. Two tables are not required.
6. In paragraph (line 144-148), the pseudo-r squared or Nagelkerke R-Squared is explained but it is not given in regression table (table 3 and 4). So, I suggest to add a row in the table showing Nagerlkerke R-Squared values as well.
7. Line 151 and entire result section: The reporting of Odd Ratio (OR) values and their explanation needs further refinement, not only here but in entire result section. Please refer to this article to know how to report OR values and how to explain them in your paper. https://peerj.com/articles/592/
Discussion
1. In line 206-207, sentence needs to be rewritten with a refinement.
2. In line 233, the “significant factors” is more correct than “significantly factors”.
3. Line 239, could be written as, “This study has three main limitations” instead of writing “This study has limitations in three main respects”.
4. Line 248, as per my knowledge DHS divert the real location of household to few kilometers to ensure the privacy of study participants. Then why authors are mentioning that this use data on actual location of households.
5. In line 256, it would be better if authors mention how many health workers per 1000 population is WHO’s target.
Conclusion
In line 272-274, this needs to be rewritten so that it could be more meaningful. i.e., “The rate of institutional delivery increased from 10% in 2011 to 26.2% in 2016, accompanied by a reduction in the average distance to health facilities from 4.9km to 4.7km at the national level during the same period.”
Raw data and codes
The raw data was not provided, with the assertion that it is publicly available, which is not entirely accurate. To access the raw data from the DHS website, one needs to create an account and submit a data request application, which can take 24 hours or more. Even if the data can be obtained from online sources, the authors should share the codes used for analysis.
Tables and Figures
In Figure 1, the bars for national average should be shown by different colour to make it look different from others. Altering the pattern of bar rather than changing colour lessens the beauty of the graph. The data labels should be added with bars.
In Figure 3, instead of writing “year of delivery” only “year” is also fine. The axis title for y axis should be written. The full form of N.B should be mentioned. The title of the figure could be revised as, “Trend of place of delivery for most recent birth among women aged 15-49 in Ethiopia (2006-2016)”.
Table 1 is not needed as it does not provide information more than written in the text.
Table 2 do not tell whether percentages are weighted or not. The characteristics should be divided into three broad groups viz., distance to health facility, individual characteristics, household characteristics etc. For instance, in these broad groups, age, education, ANC, health insurance etc will go under individual characteristics, wealth, religion, place of residence etc will go under household characteristics.
In Table 2, in Educational level, 8218 women belongs to “No education” while only 168 belongs to “Higher education”. This creates the problem of sparsity which will give misleading logistic regression output. So, the better way to deal with such a situation is to make only two categories in Educational level such as “Not been to school”, “Been to school”. No education can be coded as “Not been to school” and Primary, Secondary, and Higher can be coded into a single category called “Been to school”.
Health insurance variable should not be kept in the regression model as only 65 was insured against 11,787 women with no insurance in 2011 and only 389 against 10633 in 2016. Including variable in the model will lead to sparsity and misleading regression output. Same is the problem with Religion, Ethnicity, Health insurance, Husband’s educational level, Husband’s occupation, and Current marital status variables which needed to be taken care of by either recoding or removing from the analysis. Authors should revise the entire analysis by using appropriate variables either by transforming them or removing them from the study.
Table 3 and Table 4 have issues. These tables are inaccurate because they do not display the p-value, which is essential for assessing the level of significance. Additionally, the pseudo r-squared value is not included in the table, leading to confusion when it's mentioned in the results section. To enhance clarity, it would be advisable to include a row in the regression table for the pseudo r-squared value if it is discussed in the body text (results section).
Instead of running four models, I recommend running a single model (the 4th model) for both EDHS-3 and EDHS-4. The results can be presented in a consolidated table that includes odds ratios, their 95% confidence intervals, and p-values for both time points. Rather than providing two separate tables (Table 3 and Table 4), the authors can create a single table with five columns. The first column would display the variables or characteristics, followed by two columns for Odds ratios (with 95% CI) and p-values for EDHS-3 (2011). The next two columns would provide the same information for EDHS-4 (2016). Additionally, it is advisable to create this table using MS Excel for easy copying and sharing if needed.
This paper is original and primary, aligning with the aims and scope of the journal. However, there are significant issues. The research question is not adequately defined (Thus, the current study aimed at investigating the role of distance on the trends of institutional delivery over time in line 73-74). The research objectives require refinement to ensure they are properly framed.
The Method section does not offer clear information on the outcome variable, exposure variables, descriptions of variables and their coding, and the software used for analysis. This lack of clarity weakens the replicability of the study.
The data used in the study was robust as it was a nationally representative survey viz., Ethiopian Demographic and Health Survey (EDHS).
I suggest authors provide the dataset they used in their study along with the codes they used for the analysis. Second, I highly recommend authors use English grammar software (i.e., Grammarly) to correct the English before resubmitting.
It is not clear from the manuscript how and from where the data on the distance to the health facility was obtained. Although the author mentioned that it is geographical positioning system (GPS) data, they have not specified the website or source from which one can obtain this data. Additionally, they have not shared the data and codes with the manuscript. Furthermore, there is no mention of how they integrated the GPS data with the Ethiopian Demographic and Health Survey datasets. Since the distance to the health facility varies for each individual surveyed in the EDHS, it raises questions about how the authors acquired these varying distances for each individual and subsequently used them in logistic regression as an independent variable.
Strong points
1. The article explores an intriguing topic, namely the relationship between geographical distance to health facilities and its association with institutional delivery.
2. The study utilizes a nationally representative dataset, the Ethiopian Demographic and Health Survey (EDHS).
3. The authors discover that an increase in distance to health facilities makes Ethiopian women aged 15-49 less likely to opt for institutional delivery, even after adjusting for individual and household-level variables.
Weak points
1. The language in the article is somewhat confusing.
2. The method of merging distance to health facilities with the EDHS dataset raises questions and lacks explanation in the method section.
3. The tables are flawed as they do not display p-values and the coding of exposure variables leads to issues like sparsity, overfitting, and unreliable odds ratios.
1. The introduction lacks proper theoretical underpinning and lacks information on the central theme of the study which appears to be distance to health facility as a major factor in high prevalence of non-institutional delivery in Ethiopia. Authors should mention information from previous such studies in other countries alongside the other major factors of non-institutional deliveries.
2. Missing word on line 31, “An overwhelming amount or number of these cases……”. In the given sentence “amount” or “number” should be added in text.
3. Citation in line 41-42: “(Sambo & World Health Organization. Regional Office for, 2014)” doesn’t appear to be properly formatted. Authors should fix this and other similar cases in the manuscript.
4. Line 79- Is it low level of income inequality in Ethiopia? Please confirm this statement from the source document, as conventionally, LMICs exhibit high levels of income inequality.
5. The Study Setting section of Methods (lines 76-84) lacks substantially. It appears insufficient. Authors are recommended to purposefully provide a sufficiently detailed description of study setting.
6. Under sub section Descriptive statistics of Results, I noticed a sentence – “ less than 70% of women had no education, and roughly 2% had attained higher education” between lines 113-115. Authors should avoid using double negatives like this. From this sentence it is not clear how far less than 70% women had no education? Instead authors probably meant to use “About 70% women reported to have no education” which provides a more proximate assessment.
1, Authors should clearly mention the softwares, applications that were used to perform various analyses exactly where the analyses are discussed. For example- Under sub section Statistical Analysis, between lines 106-107, authors should have mentioned the softwares used to link the spatial data. Methods are also not described in sufficient details and lack mathematical expressions and statement of purpose of choosing the particular method.
2, Multiple independent variables have been utilized in the analysis. However, not all have been reported. Even if some are, it appears very randomly picked to be presented in the text. Authors should either represent all of them or only the main independent variable which appears to be the distance variable or clearly mention why only some confounding variables are hand -picked to be presented in the text.
3, The reporting of results is underwhelming and insufficient. Authors have utilised two rounds of EDHS, hopefully to investigate whether any improvement in these measures have been made in the country. However, the representation of the results does not reflect the aims of the research clearly. The results of logistic regression of the both years have been represented entirely separately where no connection or comparison have been reported. It is recommended to the authors that they must report the changes they found within these two analyses within the Results section.
4. There is also a distinct lack of reporting Odds Ratios within the text or reporting of likelihoods in terms of percentages. It is advised that authors mention ORs and/or percentage likelihoods within the text.
1. Findings appear to be valid and obtained through appropriate statistical methods. However, there are lack of sufficient description on the ways that statistical and spatial data is merged. Authors are advised to put some light on that.
2. Secondly, the discussion section of the manuscript again fails to address the changes that authors must have located- as the utilization of two rounds of data suggest. Not only the changes in non-institutional delivery but also the factors associated to it must have changed. The lack of address to the theme of the study is the major setback of the entire manuscript. Authors are recommended to thoroughly revise the manuscript with this theme in consideration.
There are several spelling, grammatical and typological errors throughout the manuscript which must be addressed during the revision carefully.
The language used in the manuscript is generally clear and professional. However, there are a few instances of grammatical errors that need attention.
The article's literature references are primarily relevant and recent. However, it would be beneficial to include a brief summary or context for readers who may not be familiar with the field. This can be achieved by expanding the introductory section on why this study is needed, as the findings are very generalized, and everyone thinks of and knows that. I mean, how is this study holding novelty?
The article is well-organized, with a logical flow of information. The figures and tables are informative and add value to the content. You can provide more details on the characteristics of women who have not delivered in any health facility in the past five years by adding a column (Table 2) to enrich the information.
You mentioned the spatial database integration with DHS data in this analysis. However, it appears that some of the data details (such as a link to the spatial database) are missing. Please ensure that all raw data is provided to facilitate replication and validation of your results. Also, mention how you calculated the average distance to the health facility, which is a crucial step in this analysis.
The research addresses an original question within the scope of health access. However, it would be beneficial to explicitly state in the introduction how this study contributes to the existing body of knowledge in the field.
As you mentioned, “The mean distance (in kilometers) of the household to their closest public health facility varies across the regions of Ethiopia.” The analysis can be applied at the regional level by taking the distance variable at the regional level.
Clarify whether you used the distance variable at the individual level, as it is the leading independent variable in the analysis.
The methods are adequately described, but more detail is needed in certain areas. For instance, in calculating the distance and integrating it into the analysis, please provide more information to ensure reproducibility.
As the finding of this paper looks pretty general, please specify and discuss the critical issues of infrastructural development, including the quality of the transport (road) and health facilities.
The article would benefit from discussing the potential impact and novelty of the findings within the field. Consider adding a section highlighting how this research advances the current state of knowledge.
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Use of lucid and clear English. Description of data shared. References properly added.
Use of the main outcome variable not clear. Methodologically not sound.
Unclear.
The authors have done a very good job conceptualising the research article. Priority should be given to addressing the factors impeding institutional delivery, particularly in countries such as Ethiopia, where institutional delivery still remains extremely low.
However, I believe the article is lacking in methodological rigour and is written in an unclear manner. I have a few points I would like to bring up.
1. The variables are categorial when we are applying logistic regression. The primary exposure variable in this study, which is geographic distance, is not clearly defined. It is unclear how the authors classified the distance variable. As a result, the entire finding of the article remains unclear.
2. I find the ‘methods’ section very weak. There should have been a paragraph describing the statistical methods in detail. What weight was employed? How was the clustering for the complex survey design was adjusted? Furthermore, I would advise applying pooled analysis when using repeated cross-sectional data.
3. The outcome variable as well as the exposure variables need to be described in detail. Additionally, there must be a rationale for choosing the exposure variables.
4. There is no cross-tabulation which presents the rate of institutional delivery by each categories of the exposure variables. Furthermore, before including in the exposure variables into the regression model, the statistical association of the variables with the outcome variable must be checked with Chi-squared test.
5. P-values are absent in the logistic regression models. P-values are extremely important when we want to examine if the results are significant.
6. It would be good if the authors had included odds ratios in the ‘results’ part of the abstract also.
7. A diagram should be used to show how the sample for this particular study was selected. In this article, sample selection is also not clear.
I apologise that I cannot be more positive on this occasion. Based on these point, especially the use of the main exposure variable (geographic distance) being unclear, I do not recommend that this article be accepted for publication.
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Excellent Review