The prevalence of suicidal behavior and its associated factors among wives with polygamy marriage living in Gedeo zone, southern Ethiopia, 2020.

INTRODUCTION: Polygamy is a trend of marriage characterized by having two and more wives or husbands at the same time. In low and middle-income countries including Ethiopia, polygamy has a significant negative effect on the social, economic, physical, and mental well-being of women. Therefore, this study aimed to assess the prevalence and associated factors of suicidal behavior among wives with polygamy marriage living in the Gedeo zone, Southern Ethiopia, 2020.
METHODS: A community-based study employing cross-sectional design and systematic sampling technique was used to select wives with polygamy marriage who are residents of Gedeo Zone from November to December 2020. The World Health Organization Suicidal Behavior Questions (SBQ-5) was adapted to explore the outcome variable. The Logistic regression at 95% CI, p<0.05 was used to identify factors associated with suicidal behavior.
RESULTS: This study enrolled 423 respondents. The study revealed that, the overall prevalence of suicidal behavior was 157(37%). Illiteracy, being a wife of a husband with three and more other wives, current history of depression, intimate partner violence, and poor social support were significantly associated with suicidal behavior at 95% confidence interval, p < 0.05.
CONCLUSION: This study found that one-third of the respondents had suicidal behavior. Different significant socio-demographic and psychosocial variables were identified. Thus, due attention should be given to minimize the practice and its effect on the mental wellbeing of a mother and their children.

Introduction

Suicidal behavior is a pattern of thinking or predispositions that situated an individual at risk of committing suicide. Suicidal behavior has three categories; suicide ideation, suicide plan or intent, and suicide attempts which are the leading cause of harm and end of life [1]. Suicide is one of the complications of a psychiatric disorder and affecting all individuals irrespective of their nation, culture, religion, gender, and class [2]. Currently, Lithuanians rank first for a suicidal rate, which accounts 31/100k [3]. Globally, while over 16,000,000 people attempt suicide, and 800,000 commit a suicide every year, other 3000 individuals also commit suicide in a daily base. The case is more prevalent among youths and women [4].

Polygamy is a state of marriage in which a husband marries more than two wives at a time and remains one of the hotly contested and acceptable practices. It is a misunderstood topic in the traditional and modern society of Africa and Ethiopia. It is acceptable in most cultures and religions, particularly in Muslim [5-7]. It is a very problematic and well-buried practice against freedom, equality, and human rights of a woman [8]. It has also a burden on husbands to care for all their wives and children in terms of social, economic, psychological, and physical needs [9].

Psychological and social factors such as jealousy, intimate partner violence, lack of social support, and economic dependency on their husband were contributing factors for having mental disorders among women with polygamy marriage [10-12]. Several studies have documented that woman with polygamous marriages were reported of having repeated physical and psychological violence from their husbands and thus, children expressed their feelings through pain, hurt, and anger. Moreover, in low and middle-level countries, it has a risk for having sexually transmitted diseases, including HIV/AIDS which also contribute for mental health problems on wives with polygamous marriage, their family and society at all [13, 14]. Psychiatric problems such as mood, anxiety, and psychosis were documented among woman with polygamy marriage in particular among senior wives and their family members [15, 16]. Developed countries such as Canada, USA and Australia were launched human and legal rights to prevent any forms of women abuse and violence happened during marriage [17]. This resulted in reduction of polygamy marriage. However, in Ethiopia polygamy cultural practices accounts 12.1% and its effect on the mental and psychological health of wives is not well-studied [18]. Therefore, this study aimed to assess the prevalence and associated factor of suicidal behavior among wives with polygamy marriage living in Gedeo zone, southern Ethiopia, 2020.

Methods

Study design, setting and period

This study was a community-based cross-sectional design conducted among wives with polygamy marriage and lives in Gedeo zone. The data collection period was from November to December 2020. Despite being unlawful and excluded from family and criminal code of Ethiopia, polygamy is quiet practiced due to the cultural and religious (Muslims and pagans) acceptability [19]. In Ethiopia, there are 86 nation and nationalities that have unique attitude and norm towards different social circumstances. polygamy is the most acceptable social norm among Oromo, Somalia, Sidama and Gedeo nations [20]. In Gedeo people, there was ancient ancestor called ‘‘Daraso” who practiced polygamy in the first time and starting from that a man with polygamy marriage was considered as rich, famous and acceptable by the community [21]. The zone has a population of 850, 534 and 500,000 of them were females. The fertility rate in this study area was higher as compared to other parts of the country [22]. The area located in the southern part of the country and 359 KM far from the capital city of Ethiopia, Addis Ababa.

Study participants

The inclusion criteria were women who are presently in polygamous marriage and age 18 and above years old, while the exclusion criteria were women who presented themselves with acute or severe illnesses and not present during the data collection period.

Sample size determination

The sample size of the current study was calculated using single population proportion formula,

Where, n = required sample size, z is reliability coefficient at 95% confidence interval (1.96), p = 0.5 (proportion for unknown prevalence of outcome variable, q (1-p) = 0.05, d (margin of error) = 0.05

= (1.96) (1.96) (0.5) (0.5) / (0.05) (0.05) = 384, 10% non-response rate = 38.4

The total sample size was, 384+ 38.4 = 423

Sampling technique

This study used a systematic random sampling technique. To get the sampling frame of the sample, we gave coding for each number households practicing polygamy marriage. There were 1692 households who practiced polygamy and living in the Gedeo zone. To calculate Kth interval, we used the formula (N/n), where N = Total number of population and n = required sample. Kth interval = (1692/423 = 4th) and include all samples by counting every 4th interval.

Study variables

Dependent/out-come variable

Suicidal behavior (Yes/No)

Independent variables

Socio-demographic variables. Age, educational status, employment, residence, husband work, wife’s house and religion.

Marriage and psycho-social variables: Duration of marriage, number of wives at a time, distance of the two wife’s house, family size, social support, and duration of marriage.

Data collection and instruments

The data was collected by ten health extension staffs who are working in the zonal health center. The data collection method was structured interview technique. The first part of the questionnaire was about the socio-demographic characteristics of the respondents. The second part of the questioner was suicidal behavioral revised questionnaire (SBQ-R) used to assess suicidal behavior of the respondents related to polygamy marriage, and a score ≥ of 7/18 considered as suicidal behavior [23]. The tool has 93% sensitivity and 95% specificity. The third part of a questionnaire was Intimate Partner Violence (IPV) used to measure intimate partner violence and score > 10/25 classified as intimate partner violence [24]. The fourth part of the questionnaire was the Patient Health Questionnaire (PHQ)−9 tool used to assess depression, and a score > 10/21 said to have depression [25]. The final part of the questionnaire was the Oslo social support scale (Oslo -3) used to measure social support levels from participants friends, neighbors and bloody families. This measurement has been used in both clinical and population-based studies with good internal consistency. In the present study, the tool has Cronbach alpha of 0.87. The total score ranging from 3 to 14 and classified as poor (3–8), moderate (9–11), and strong social support (12–14) [26].

Data quality control

This study used reliable questionnaire which has been translated to Amharic and Gedeoffa local languages and showed good internal consistency. The issues written on the questioner were easily understandable by respondents and finished on planned time duration. The validity of the questioner was checked during pretest on 5% of respondents before two weeks of the actual data collection period. The data collected from each respondent has been putted keeping confidentiality/security. The respondents have informed about the purpose and objective of the study before the actual data collection. The collected data checked at daily basis for its completeness.

Data management and analysis

Data was entered into the Epi-Data version 3.4 software package and exported to the Statistical Package for Social Sciences (SPSS) version 22. Descriptive statistics; frequency, percentage, mean and standard deviation were used to describe the socio-demographic characteristics of respondents. A logistic regression analysis at p ≤ 0.05 of the 95% CI was used to interpret the association with the independent variables.

Ethical consideration

Ethical clearance was obtained from the ethical review board of Gedeo zonal women and child health beauro. Each participant has given written informed consent to participate in the current study. The study ensured issues of voluntary participation and confidentiality throughout the data collection period.

Result

Socio-demographic results of respondents

The response rate for this study was 100%. The mean (SD) age of respondents was 30 (±6) years old and more than half of the respondents were living in rural areas. Nearly two-thirds of them have no formal education. More than two third, 329(77.8%) of them were protestant religion followers. Regarding to wives work, 250(59%) of them were house wife. Among 423 respondents, 182(43%) of them had poor social support. Of them, 212(50%) of the respondents were living with their husband for at least 6 years (Table 2).

Table 2

Variables associated with suicidal behavior, Dec, 2020 (N = 423).

Variables	Category variables		Suicidal behaviour		X2	Adjusted odds ratio (AOR), 95% CI	P-value
			Yes	No
Age	Below 30	135	94	41	3.1205	1.48(0.96, 2.29)	0.43
	Above 30	288	175	113		1
Educational status	Non formal(illiterate)	309	211	98	34.7904	3.83 (2.44–6.02)	0.001*
	Primary school (grade 1–8)	114	41	73		1
Residence	Urban	42	19	23	3.22	0.53(0.28,1.01)	0.13
	Rural	381	232	149		1
Religion	Protestant	329(77.7%	172	157	1.6788	1
	Orthodox	64(15.1%)	29	35		1.32(0.77–2.26)
	Muslim	30(7.09)	14	16		1.252(0.59–2.64)
Husbands work	Farmer	313	140	173	0.83	1
	Merchant	110	43	67		0.79(0.51,1.24)	0.24
Wives work	House wife	250	134	116	5.71	1
	Farmer	89	39	50		0.68(0.41,1.10)	0.10
	Merchant	84	52	32		1.41(0.85, 2.33)	0.37
Number of wives at a time	Two	300	132	168	13.4	1
	Three	123	79	44		2.29(1.48,3.53)	0.01*
Distance of the two wives house	< 20 km	148	94	54	0.67	1.21(0.80,1.83)	0.15
	>20 km	275	162	113		1
Family size	<3	157	95	62	0.56	1.17(0.78,1.74)	0.17
	>3	266	151	115		1
Depression	Yes	237	132	105	17.6	2.37(1.60–3.52)	0.001**
	No	186	65	120		1
Intimate partner violence	Yes	144	90	54	30.4	3.18(2.09,4.83)	0.02*
	No	279	96	183		1
Social support	Poor	182	106	76	24.7	3.02(1.92, 4.75)	0.01*
	Moderate	89	36	53		1.47 (0.85,2.54)	0.29
	Strong	152	48	104		1
Duration of marriage	< 3 year	63	38	25	1.27	0.94(0.53, 1.67)	0.11
	3–6 year	148	99	49		1.25(0.80, 1.94)	0.14
	>6year	212	131	81	3.1205	1

(1, reference category, * p< 0.05, **, p<0.01), model fitness = 78%)

Psycho-social variables

According to this study result, 237 (56%) of respondents had depression and 186 (44%) intimate partner violence (Fig 1).

Fig 1

Descriptive psycho-social results of respondents Dec, 2020 (N = 423).

Prevalence of suicidal behavior

Among 423 respondents, 157(37%) of them scored 7/18 for revised suicidal behavior scale and considered as having suicidal behavior (Table 1).

Table 1

Suicidal behavior items response of respondents Dec, 2020 (N = 423).

Serial no.	Question items	Response	Frequency	Percentage
1.	Life time suicidal ideation, intent, and/or attempts	Never	199	47%
		Suicidal ideation	114	27%
		Suicide plan	42	10%
		Suicide attempt	68	16%
		Overall suicidal ideation and attempt	224	52.9%
2.	Frequency of suicidal ideation in the past one year	Never	218	51.5%
		Rarely (1 time)	112	26.4%
		Sometimes (2 times)	51	12.1%
		Often (3–4 times)	25	6%
		Very often (5 or more times)	17	4%
		One year all suicidal ideation	205	48.4%
3.	Threat of suicidal attempt	Never	322	76%
		Once	59	14%
		Two and more	42	10%
4.	Likelihood of suicide behavior in the future	Never	164	38.7%
		No chance at all	47	11.2%
		Rather unlikely	41	9.7%
		Unlikely	18	4.3%
		Likely	72	17%
		Rather likely	51	12%
		Very likely	30	7.1%
5.	Overall prevalence of suicidal behavior	Yes	157	37%
		No	266	63%

Factors associated with suicidal behavior

During multivariable logistic regression analysis, at 95% CI (p< 0.05), the independent variables such as educational status, number of wives, history of depression, intimate partner violence, and poor social support were associated with the outcome variable (Table 2).

Discussion

This community-based cross-sectional study design aimed to assess the prevalence of suicidal behavior and its associated factors among wives with polygamy marriage living in the Gedeo zone. This study found that 157 (37%) of the respondents had suicidal behavior, which was consistent with a study done in South Africa 39% [27], whereas this figure was higher than study conducted in Peru (22.6%) [28], Thailand (17.6%) [29], and Ethiopia (14%) [30]. This discrepancy could be explained by the difference in the character of study participants. Hence, the previous studies were conducted among pregnant, ante-natal and post-natal women. In-addition, polygamous marriage is related to a lack of emotional support, economic dependency, and burden in the care of children, which could be the contributing risk factors to the higher suicidal behavior [31].

The current study has also identified variables such as non-formal educational status, more than two wives, current depression, intimate partner violence, and poor social supports which were associated suicidal behavior.

The respondents with no formal education/ illiterate had AOR 3.83;95% CI (2.44–6.02) more likely to develop suicidal behavior as compared to those with primary education, which was supported by the study conducted in the United States [32] and meta-analysis done in five low and middle income countries (India, South Africa, Nepal, Uganda, and Ethiopia) [33].

Illiteracy is related with lack of awareness, knowledge, and understanding regarding the women’s rights, family, and marriage law of a country, which are vital to prevent intimate partner violence and abuse. Moreover, there is a tendency to be culturally more influenced in sharing their feelings frankly, opinions, and doubts happening in their marriage [34].

According to this study finding, being a wife of a husband with three and more other wives were AOR 2.29 95% CI (1.48, 3.53) more likely to experience suicidal behavior as compared to those with two wives, which was similar with studies done in Norway [35], Syria [36] and Turkey [37].

As the numbers of wives increase, the challenges of polygamy marriage such as social, emotional, economic crises become significant, which are common reasons for low self-esteem, helplessness, hopelessness, and thoughts of harming self [38].

Those respondents with a current history of depression had AOR 2.37 95% CI (1.60–3.52) more likely to show suicidal behavior, which was in- line with the previous studies conducted in Germany [39], South Africa [40], and meta-analysis done in Sub-Saharan African countries (Tanzania, Ethiopia, Nigeria, Uganda, Ghana and Burkina Faso) [41].

Depression is a common psychiatric disorder characterized by loss of interest, negative attitude for self, others, and the future, which all lead to the thoughts and actions of harming self [42].

According to this study result, respondents with a history of intimate partner violence had AOR 3.18 95% CI (2.09, 4.83) more likely to experience suicidal behavior. The finding in agreement with studies conducted in Thailand [29], Korea [43] and Sub- Sharan African counties (Angola, Burundi, Ethiopia, Uganda, Malawi, Mozambique, Zambia and Zimbabwe) [44].

Intimate partner violence has negative health consequence on the physical, emotional, psychological, and mental health of married women, which gradually cause serious psychiatry emergency conditions such as suicidal behavior [45].

The last predictor variable related to suicidal behavior was women’s social support. Those with poor social support had AOR 3.02 95% CI (1.92, 4.75) more likely to develop suicidal behavior. Congruent findings were reported from the studies conducted in 23 European countries [46], South Africa [47] and Ethiopia [48]. Social support is a pillar for filling the gap of economic, social, and emotional crisis observed on women with polygamy marriage. Having no support results in helplessness, worthlessness, and low self-esteem, which are the main entry symptoms of depression and suicidal behavior [49].

Strength and limitation of the study

This study tried to address very interesting issue regarding women’s burden due to polygamy marriage. Moreover, the current study was conducted within traditional and cultural influenced community. Despite with the above strength, this study has also the following drawbacks. The cross-sectional nature of the study design constraint the cause effect relationship of the independent and outcome variables. In addition to this, some important variables such as husband’s educational status, income, current wives pregnancy and health status were missed which might have correlation with polygamy marriage.

Conclusion

This study found that more than one-third of wives with polygamy marriage had suicidal behavior. The most affected groups were those with no formal education, triple polygamy, current history of depression, intimate partner violence, and poor social support. Therefore, this harmful traditional and cultural practice should be avoided and reduced through the collaborative work of traditional and local community leaders, local and international women’s rights association organizations, human rights associations, religious leaders, community mental health workers, and country ministry of health. In addition, empowering women with education and encouraging them in community affairs is an essential weapon to stop this type of marriage. Mental health professional should work in collaboration with stakeholders on screening and managing mental health conditions including suicidal behavior among communities with polygamy marriage.

20 Apr 2021

PONE-D-21-07591

The prevalence of suicidal behavior and its associated factors among wives with polygamy marriage living in Gedeo zone, Southern Ethiopia, 2020.

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Reviewer #1: The study aimed to assess the magnitude and associated factors of suicidal behavior among wives with polygamy marriage living in the Gedeo zone, Southern Ethiopia, 2020”

The point is interested and original, but the manuscript needs major revision

1- General comments

-The manuscript needs an English proofreading.

- results section lack adequate presentation. Insufficient descriptive analysis.

- conclusion isn’t consistent with the results.

- the researchers ignoring some confounding factors such as economic status, Having a pregnancy.

2- Specific comments

2-1 Introduction

- Some studies have measured suicides among women with certain characteristics in Ethiopia. Please mention them in the introduction, such as the study of (Belete and Misgan,2019), their study aimed to determine the prevalence of suicidal behavior in postpartum mothers.

2-2 Methods

- The sampling technique was not mentioned, line 2 mentioned only that systematic random sampling technique was used. It is advisable to mention how was this design achieved and how was the sample size calculated? Also, they should indicate inclusion and exclusion criteria and Response rate. A number of women who “completed the interview”, “refused participation”, “failed to complete the interview” “ number of cases excluded from analysis”.

- It is preferable to the Figure Sampling process of how women were selected systematically from the population. For example see (Belete and Misgan,2019).

2-3 results

- Why was the education variable limited to only two categories (non-formal & primary school) and neglected the other educational categories? Was the sample design limited to educated women with less than elementary education? I want more explanation.

- the researcher mentioned that “Descriptive statistics; frequency, percentage, mean and standard deviation were used to describe the socio-demographic characteristics of respondents” they haven’t continuous variables to calculate mean and SD as they mentioned.

- The researchers did not clearly define the dependent variable in the method section. It must be mentioned that it is a binary variable that takes two outcomes and so on…..

- the researchers should conduct hypothesis tests (chi square test) to examine whether Suicidal behavior differs across variable categories.

- Table (2): There is a fatal mistake, p-values must be mentioned for all variables and not only limited to the significant variables.

- in both Table (1) and (2),The researchers repeated needlessly the frequency distribution of the variables.

- interpretation of significance levels (*,**,***) is missing at table 2.

- Table titles should be rewritten. Title of Table (1) can be “Sociodemographic characteristics of women related to the presence or absence of suicidal behaviour”

- Researchers should have reviewed previous studies and extracted accurately the conceptual framework, the researchers have neglected main confounding variables that affect suicidal behavior and should have been taken into account such as "economic status of women", “Is she pregnant or postpartum mother at the time of the survey?”. The higher the economic status of the woman, the greater her chances of securing her future, enjoying more independence and avoiding suicide. Suicidal behaviour was found high among postpartum mothers and was associated with poor wealth economic status of the (Belete and Misgan,2019).

- When researchers excluded religion variable from the analysis ???

- the researchers didn’t assess the goodness of fit of the multiple logistic regression model. How do I know if their model fits the data? how well the model describes the observed data?. Without such an analysis, the inferences drawn from their model may be misleading or even totally incorrect.

2-4 Discussion:

Line 3 and line 6 repeat the same result ““This study found that 157 (37%) of the respondents had suicidal behavior”

- besides significant association with suicidal behaviour, The researchers should write (adjusted OR (AOR), 95%CI ).

- regarding “Depression is a common psychiatric disorder characterized by loss of interest, negative attitude for self, others, and the future, which all lead to the thoughts and actions of harming self”, they should add reference.

- the researchers didn’t clarify the limitations and strengths of their paper. Researchers should report limitations and potential controversies (if any) raised by the study. The sample design was preferable to contain a control group in order to measure a causal relationship between polygamy and suicidal behavior. also, the researchers have ignored the endogeneity problem that arisen from omitted variables, Wives with polygamy marriage are shaped by many factors such as the wife's health status, the husband's religion, and his educational level, these factors affect the dependent variable at the same time. Therefore, the independent variable “being Wives with polygamy marriage” is correlated with the random error which leads to biased estimates.

2-5 conclusion

- Although the researchers did not measure the effect of the woman's religion or that of her husband on suicide, they mentioned that “Almost all peoples living in this study area are protestant religion followers, and polygamy is against Christianity or the holy bible commandment. So, it would be better if leaders of the religion teach them the right and acceptable types of marriage in Christianity ". Recommendations should stem from the results of the study.

-

2-6 References

• I checked references and found that some references aren’t directly related to the contents of the manuscript, for example, reference#3 aimed to identify the number of synthetic cathinones mentioned in a range of psychonaut, NPS‐related, online sources; and describe the associated acute/long term clinical scenario and the related treatment/management. I need more explanation

Reviewer #2: 1. Summary of the research (summarizing the main research question, claims, and conclusions of the study. Also, providing the context for how this research fits within the existing literature.)

The study titled: “The prevalence of suicidal behavior and its associated factors among wives with polygamy marriage living in Gedeo zone, Southern Ethiopia, 2020” is a topical issue that is addressing a social concern. In the era of globalization and in the fourth industrial revolution epoch. Polygamy and suicidal behaviour is becoming increasingly common, especially in African countries. Accurate data regarding the polygamy scope in Africa is limited and its prevalence varies widely from country to country. Historically, factors such as demographic and socioeconomic transitions have been identified that may appear to perpetuate polygamy, hence suicidal behaviour follows when the marriage is no longer palatable, especially among younger women. Thus, this study has brought out its relevance by carrying out a study using Ethiopia as a case study. Ethiopia is faced with growing prevalence of polygamy marriages as well as suicide behaviour among women in polygamous marriages (I have inserted some Readings in the main work pop up comments).

Manuscript’s strengths: The strength of the manuscript was a study carried out as a cross-sectional survey and also one of the few studies on this topical issue above discussed.

Manuscript’s weaknesses: The manuscript weaknesses was the author had failed to include prevalences of the topical issues and the introduction and methodology is lagging behind (See all my comments on the pop up comment chat on the main body of the paper).

2. Major issues

Major issues were inserted in the body of work (see the yellow pop up comment chat).

Minor issues

Minor issues were inserted in the body of work (see the yellow pop up comment chat).

3. Other points: Get more readings from African countries on polygamy marriage and suicidal behaviour.

4. Overall recommendation: I recommend this study titled: “The prevalence of suicidal behavior and its associated factors among wives with polygamy marriage living in Gedeo zone, Southern Ethiopia, 2020” for publication with major revision (See all comments and suggested readings that will help the work).

Reviewer #3: Thank you for giving the opportunity to review this interesting article. Hope my comments would be helpful to increase the quality of your work.

Abstract: Avoid the repetition in the abstract. Factors such as illiteracy, being a wife of a husband with three and more other wives, current history of depression, intimate partner violence, etc have been mentioned in both results and conclusion sections.

Introduction:

• There is a clear need that this paper needs to be proofread, as there are some grammatical and typography errors throughout the document.

• “Developed countries were launched human and legal rights.” can you mention few countries, this has to be specific.

• Does the literature gather any numerical evidence on the cases on polygamy in Ethiopia? How would you justify that there is a high prevalence of these practises?

Study participants: How many respondents have you selected for the study and how many respondents have you excluded? There should be some information on how you have chosen the respondents. Have you used any sampling frame?

Study Design, Setting and Period:

“wives with polygamy marriage from Nov – Dec 2020” this sentence is not clear; you could add that this study interviewed the women who have been married at the time month of (interview date-November)

Data collection and instruments:

• It would be better to include a table on scores as mentioned in the section, instrument. Results seem rather dramatic.

• Have you been referred to the “questionnaire” ? or a person who asked the questions, as the author used the word “questioner”, this is not clear. This could be seen throughout the paper.

• Variable categories seem restricted that could not see any variations within. If you have collected more information, it would be good to add these. For instance, for age groups, educational status and employment categories. How would you define primary education here? Is it for those who completed up to grade 5 at school? be specific here.

Psychosocial results of respondents

• A summary table may be good to pull the results here, can you mention about respondents who may had depression, intimate partner violence, suicidal behaviour or two of these according to the scores?

• Methods section need to be redesigned, not very clear on what are the outcome variable, independent variable categories and suicide behaviour has been used as a binary variable coded in to two categories.

Factors associated with suicidal behaviour

• Use the standard format when reporting the tables. Check the format of refereed journal articles. There are visible errors in reporting numbers, lack of consistency in gaps and after AOR, add the heading for confidence intervals.

• Prior to the logistic regression have you done a chi-square test to see any association? This is not clear here. Have you found any insignificant variables here?

• Include the significance threshold at the end of the table which are denoted by stars.

Discussion

• This sentence “This study found that 157 (37 %) of the respondents had suicidal behaviour”, has been repeated twice, avoid repetition.

• There is a need of including citation in several places in the discussion, for instance when referring to the cultural difference and contextual definition of having more than one wife.

• Define what is meant by (2.44-6.02), proper way would be AOR 3.83;95% CI 2.44-6.02), repeat it for other places. Mention that 1 has been used as a reference category.

• Why you did not discuss on duration of marriage influence on suicidal behaviour? Have you found any literature in the context of Africa? Can you justify this finding?

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Suzan Abdel-Rahman

Reviewer #2: Yes: Monica Ewomazino Akokuwebe, PhD

Reviewer #3: No

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18 Jun 2021

Point by point response letter

Dear editor and reviewers,

We would like to acknowledge for your detailed and professionally sounded review of our manuscript. We have accessed and found constructive and very important comments to improve the quality of the manuscript. We have taken time to revise the manuscript and all the comments raised are well addressed. We also did a great revision of the manuscript to improve the English language quality.

Please find the revised version of the manuscript with a clean and track change form together with this point by point response letter. In this response letter, our reply is found next to the comments raised for each concern. If addition revision is needed, we are ready to modify it.

Thank you

Regards

Seid Shumye

Corresponding author

Reviewer reports

Reviewer #1: The study aimed to assess the magnitude and associated factors of suicidal behavior among wives with polygamy marriage living in the Gedeo zone, Southern Ethiopia, 2020”

The point is interested and original, but the manuscript needs major revision

1. Reply: Thank you very much. We have accepted the comment and modified accordingly.

General comments

-The manuscript needs English proofreading.

2. Reply: Thank you. We did a great revision of the manuscript to improve the English language quality.

- results section lack adequate presentation. Insufficient descriptive analysis.

3. Reply: we accept the comment and described the findings accordingly.

- conclusion isn’t consistent with the results.

4. Reply: Thank you very much. We accept the comment and revised properly.

- the researchers ignoring some confounding factors such as economic status, Having a pregnancy.

5. Replay: Thank you very much for your suggestion. We accept the comment and stated on the limitation section

2- Specific comments

2-1 Introduction

- Some studies have measured suicides among women with certain characteristics in Ethiopia. Please mention them in the introduction, such as the study of (Belete and Misgan,2019), their study aimed to determine the prevalence of suicidal behavior in postpartum mothers.

6. Reply: Thank you. We accept the comment and incorporated studies which have been done on this issue.

2-2 Methods

- The sampling technique was not mentioned, line 2 mentioned only that systematic random sampling technique was used. It is advisable to mention how was this design achieved and how was the sample size calculated? Also, they should indicate inclusion and exclusion criteria and Response rate. A number of women who “completed the interview”, “refused participation”, “failed to complete the interview” “number of cases excluded from analysis”.

7. Reply: Thank you very much. We accept the comment and tried to clearly mention the flow of the sampling technique as well as the sample size calculation using the standard formula.

- It is preferable to the Figure Sampling process of how women were selected systematically from the population. For example see (Belete and Misgan,2019).

8. Reply: Thank you for your suggestion. We have seen the sampling process of Belete’s study. Since our study was focused only on the community, we clearly stated the process on the revised manuscript.

2-3 results

- Why was the education variable limited to only two categories (non-formal & primary school) and neglected the other educational categories? Was the sample design limited to educated women with less than elementary education? I want more explanation.

9. Reply: Thank you very much. We accept the comment and appreciated your concern. During our data collection, we incorporated different education categories in the questionnaire but in the result section we included the education categories based on our finding from the questionnaire.

- the researcher mentioned that “Descriptive statistics; frequency, percentage, mean and standard deviation were used to describe the socio-demographic characteristics of respondents” they haven’t continuous variables to calculate mean and SD as they mentioned.

10. Reply: Thank you. We accept the comment and incorporate age as a continuous variable to calculate mean and SD.

- The researchers did not clearly define the dependent variable in the method section. It must be mentioned that it is a binary variable that takes two outcomes and so on…..

11. Replay: Thank you very much. We accept the comment and included the outcome variable (presence or absence of suicidal behavior.

- the researchers should conduct hypothesis tests (chi square test) to examine whether Suicidal behavior differs across variable categories.

12. Replay: Thank you very much. We accept the comment. Yes, we conducted the chi square test to see the suicidal behavior across the variables and to identify the candidate variables to multivariate analysis.

- Table (2): There is a fatal mistake, p-values must be mentioned for all variables and not only limited to the significant variables.

13. Reply: Thank you very much. We accept the comment and incorporate the p-values for all variables.

- in both Table (1) and (2),The researchers repeated needlessly the frequency distribution of the variables.

14. Reply: Thank you.

- interpretation of significance levels (*,**,***) is missing at table 2.

15. Reply: Thank you very much. We accept the comment and incorporated accordingly.

- Table titles should be rewritten. Title of Table (1) can be “Sociodemographic characteristics of women related to the presence or absence of suicidal behaviour”

16. Reply: Thank you very much. We accept the comment and modified accordingly.

- Researchers should have reviewed previous studies and extracted accurately the conceptual framework, the researchers have neglected main confounding variables that affect suicidal behavior and should have been taken into account such as "economic status of women", “Is she pregnant or postpartum mother at the time of the survey?”. The higher the economic status of the woman, the greater her chances of securing her future, enjoying more independence and avoiding suicide. Suicidal behaviour was found high among postpartum mothers and was associated with poor wealth economic status of the (Belete and Misgan,2019).

17. Reply: Thank you very much for your suggestion. We accept the comment and stated on the limitation section

- When researchers excluded religion variable from the analysis???

18. Reply: Thank you very much. We accept the comment. Religion variable was excluded during bivariate analysis.

- the researchers didn’t assess the goodness of fit of the multiple logistic regression model. How do I know if their model fits the data? how well the model describes the observed data?. Without such an analysis, the inferences drawn from their model may be misleading or even totally incorrect.

19. Reply: Thank you very much. We accept the comment and incorporated the model fitness accordingly.

2-4 Discussion:

Line 3 and line 6 repeat the same result ““This study found that 157 (37%) of the respondents had suicidal

behavior”

20. Replay: Thank you. We have omitted the unnecessary repetition.

- besides significant association with suicidal behaviour, The researchers should write (adjusted OR (AOR), 95%CI ).

21. Replay: thank you very much. We accept the comment and incorporated accordingly.

- regarding “Depression is a common psychiatric disorder characterized by loss of interest, negative attitude for self, others, and the future, which all lead to the thoughts and actions of harming self”, they should add reference.

22. Replay: Thank you very much. We accept the comment and put the reference.

- the researchers didn’t clarify the limitations and strengths of their paper. Researchers should report limitations and potential controversies (if any) raised by the study. The sample design was preferable to contain a control group in order to measure a causal relationship between polygamy and suicidal behavior. also, the researchers have ignored the endogeneity problem that arisen from omitted variables, Wives with polygamy marriage are shaped by many factors such as the wife's health status, the husband's religion, and his educational level, these factors affect the dependent variable at the same time. Therefore, the independent variable “being Wives with polygamy marriage” is correlated with the random error which leads to biased estimates.

23. Replay: Thank you very much. We accept the comment and incorporated your concerns in the limitation section.

2-5 conclusion

- Although the researchers did not measure the effect of the woman's religion or that of her husband on suicide, they mentioned that “Almost all peoples living in this study area are protestant religion followers, and polygamy is against Christianity or the holy bible commandment. So, it would be better if leaders of the religion teach them the right and acceptable types of marriage in Christianity ". Recommendations should stem from the results of the study.

24. Reply: Thank you very much. We accept the comment and put the recommendation based on our results.

-

2-6 References

• I checked references and found that some references aren’t directly related to the contents of the manuscript, for example, reference#3 aimed to identify the number of synthetic cathinones mentioned in a range of psychonaut, NPS‐related, online sources; and describe the associated acute/long term clinical scenario and the related treatment/management. I need more explanation

25. Replay: Thank you very much. We accept the comment. We have checked all references again and made the corrections properly.

Reviewer #2: 1. Summary of the research (summarizing the main research question, claims, and conclusions of the study. Also, providing the context for how this research fits within the existing literature.)

The study titled: “The prevalence of suicidal behavior and its associated factors among wives with polygamy marriage living in Gedeo zone, Southern Ethiopia, 2020” is a topical issue that is addressing a social concern. In the era of globalization and in the fourth industrial revolution epoch. Polygamy and suicidal behaviour is becoming increasingly common, especially in African countries. Accurate data regarding the polygamy scope in Africa is limited and its prevalence varies widely from country to country. Historically, factors such as demographic and socioeconomic transitions have been identified that may appear to perpetuate polygamy, hence suicidal behaviour follows when the marriage is no longer palatable, especially among younger women. Thus, this study has brought out its relevance by carrying out a study using Ethiopia as a case study. Ethiopia is faced with growing prevalence of polygamy marriages as well as suicide behaviour among women in polygamous marriages (I have inserted some Readings in the main work pop up comments).

Manuscript’s strengths: The strength of the manuscript was a study carried out as a cross-sectional survey and also one of the few studies on this topical issue above discussed.

Manuscript’s weaknesses: The manuscript weaknesses was the author had failed to include prevalences of the topical issues and the introduction and methodology is lagging behind (See all my comments on the pop up comment chat on the main body of the paper).

2. Major issues

Major issues were inserted in the body of work (see the yellow pop up comment chat).

1. Reply: Thank you very much for your constructive comments and suggestions. We accept the comments and suggestions and revised the manuscript accordingly.

Minor issues

Minor issues were inserted in the body of work (see the yellow pop up comment chat).

2. Reply: Thank you very much. We accept the comments and modified accordingly.

Other points: Get more readings from African countries on polygamy marriage and suicidal behaviour.

3. Reply: Thank you very much. We have incorporated studies which have done in Africa in the revised manuscript

Overall recommendation: I recommend this study titled: “The prevalence of suicidal behavior and its associated factors among wives with polygamy marriage living in Gedeo zone, Southern Ethiopia, 2020” for publication with major revision (See all comments and suggested readings that will help the work).

Reviewer #3: Thank you for giving the opportunity to review this interesting article. Hope my comments would be helpful to increase the quality of your work.

Abstract: Avoid the repetition in the abstract. Factors such as illiteracy, being a wife of a husband with three and more other wives, current history of depression, intimate partner violence, etc have been mentioned in both results and conclusion sections.

1. Reply: Thank you very much. We accept the comment and avoided the unnecessary repetition.

Introduction:

• There is a clear need that this paper needs to be proofread, as there are some grammatical and typography errors throughout the document.

2. Reply: Thank you very much. We have revised the grammatical/ language editing by English language experts in all components of the manuscript.

• “Developed countries were launched human and legal rights.” can you mention few countries, this has to be specific.

3. Reply: yes, we can mention few developed countries which launched human and legal rights to condemned polygamous marriage. Such as Canada, USA, and Australia..

• Does the literature gather any numerical evidence on the cases on polygamy in Ethiopia? How would you justify that there is a high prevalence of these practises?

4. Reply: Thank you very much. We have found study which has done in Ethiopia. In Ethiopia, polygamy cultural practices accounts 14 %.

Study participants: How many respondents have you selected for the study and how many respondents have you excluded? There should be some information on how you have chosen the respondents. Have you used any sampling frame?

5. Reply: Thank you very much. We accept the comment and incorporated the total samples for the current study. We have clearly stated how we chose the respondents in the revised manuscript.

We used the respondent’s household as a sampling frame by assigned marks on their doors.

Study Design, Setting and Period:

“wives with polygamy marriage from Nov – Dec 2020” this sentence is not clear; you could add that this study interviewed the women who have been married at the time month of (interview date-November)

6. Reply: Thank you very much. We accept the comment and modified accordingly.

Data collection and instruments:

• It would be better to include a table on scores as mentioned in the section, instrument. Results seem rather dramatic.

7. Reply: Thank you for your suggestion to include item scores. We did it for the outcome variable (suicidal behavior) accordingly.

• Have you been referred to the “questionnaire” ? or a person who asked the questions, as the author used the word “questioner”, this is not clear. This could be seen throughout the paper.

8. Reply: Thank you for your concern. We modified (replaced) the term “questioner “by “questionnaire” throughout the document.

• Variable categories seem restricted that could not see any variations within. If you have collected more information, it would be good to add these. For instance, for age groups, educational status and employment categories. How would you define primary education here? Is it for those who completed up to grade 5 at school? be specific here.

9. Reply: Thank you very much. We would like you acknowledge your concern. Of, course we have included extended categories in the questionnaire but after we collected the data we categorized based on our findings and used different literatures.

Psychosocial results of respondents

• A summary table may be good to pull the results here, can you mention about respondents who may had depression, intimate partner violence, suicidal behaviour or two of these according to the scores?

10. Reply: Thank you. It is very nice comment and we summarized depression and intimate partner violence results using the bar graph (figure). For the first objective; prevalence of suicidal behavior among wives with polygamous marriage; the results were shown using table according to the scores.

• Methods section need to be redesigned, not very clear on what are the outcome variable, independent variable categories and suicide behaviour has been used as a binary variable coded in to two categories.

11. Reply: Thank you very much. We accept the comment and made a clear statement in the revised manuscript. We put the study variable as sub section like the outcome variable (presence or absence of suicide) and independent variable categories in the revised manuscript.

Factors associated with suicidal behaviour

• Use the standard format when reporting the tables. Check the format of refereed journal articles. There are visible errors in reporting numbers, lack of consistency in gaps and after AOR, add the heading for confidence intervals.

12. Reply: Thank you. We accept the comment and modified the table using the standard format

• Prior to the logistic regression have you done a chi-square test to see any association? This is not clear here. Have you found any insignificant variables here?

13. Reply: we appreciate your comment. Yes, we did a chi-square test to see the association between the independent and dependent variables and to the select the candidate variables for the logistic regression analysis. We put a chi-square test results in the revised manuscript.

• Include the significance threshold at the end of the table which are denoted by stars.

14. Reply: Thank you. We accept the comment and incorporated the significant threshold denoted by stars at the bottom of the table.

Discussion

• This sentence “This study found that 157 (37 %) of the respondents had suicidal behaviour”, has been repeated twice, avoid repetition.

15. Reply: Thank you. We accept the comment and modified accordingly.

• There is a need of including citation in several places in the discussion, for instance when referring to the cultural difference and contextual definition of having more than one wife.

16. Reply: Thank you very much. We accept the comment and put the references accordingly.

• Define what is meant by (2.44-6.02), proper way would be AOR 3.83;95% CI 2.44-6.02), repeat it for other places. Mention that 1 has been used as a reference category.

17. Reply: it is very nice comment. We accept the comment and modified accordingly.

• Why you did not discuss on duration of marriage influence on suicidal behaviour? Have you found any literature in the context of Africa? Can you justify this finding?

18. Reply: Thank you very much. We acknowledge your concern. The reason why we didn’t discuss duration of marriage; it wasn’t the significant variable during the logistic regression analysis output.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

11 Jul 2021

PONE-D-21-07591R1

The prevalence of suicidal behavior and its associated factors among wives with polygamy marriage living in Gedeo zone, southern Ethiopia, 2020.

PLOS ONE

Dear Dr. Seid Shumye,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 25 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Shah Md Atiqul Haq

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear Authors,

Based on the advice I suggest to revise the paper by following the reviewers' comments and suggestions.

Please resubmit the revised version.

Best regards,

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I am not satisfied with the responses.Statistical analysis is unreliable.

he paper lacks sufficient quality for publication, I evaluated it as a whole, but I was not convinced of it,I am not satisfied with the responses the researchers did not make the modifications with the required quality.

Reviewer #3: There is a problem with keeping spaces consistent throughout.

The fertility rate is high in this area as compared to other parts of the country. This needs to be cited.

Add few sentences on systematic random sampling technique. It seems quite arbitrary.

Results

My confusion still remains as to why your age, husband's work, and educational level sections are so limited. Adding more categories would be helpful.

It would be beneficial to add a brief paragraph to describe the outcome variables and other covariates (see the standard journal article format). Additionally, you were unable to refer to 1 since it is used as a reference category.

Despite your acknowledgment in your comments, I have not been able to understand when you used the Chi-square test. It is of major concern that some variables, such as religion, were left out of the AOR model and that some variables, such as depression, and domestic violence, were absent from the first table. This needs to be clearly specified. Additionally, you could replace the first table with chi-square results and 95%CI intervals, since it makes no sense to repeat percentages in both tables.

Discussion

Why haven't you compared your results with previous studies in Africa in the Discussion?

Is that due to the lack of studies? As well, I suggest reviewing a standard discussion of a journal article that explains the results critically rather than simply reporting them.

The study should also be mentioned with its strengths and limitations -which is a glaring omission.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: suzan Abdel-Rahman mohamed

Reviewer #3: Yes: Gayathri Abeywickrama

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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4 Aug 2021

Additional Editor Comments (if provided):

Dear Authors,

Based on the advice I suggest to revise the paper by following the reviewers' comments and suggestions.

Please resubmit the revised version.

Best regards,

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #3: (No Response)

________________________________________

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #3: Yes

________________________________________

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #3: Yes

________________________________________

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #3: Yes

________________________________________

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

________________________________________

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

1. Reviewer #1: I am not satisfied with the responses. Statistical analysis is unreliable.

The paper lacks sufficient quality for publication, I evaluated it as a whole, but I was not convinced of it, I am not satisfied with the responses the researchers did not make the modifications with the required quality.

Author’s response: Dear reviewer, we authors want to ask excuse for your feeling of being not satisfied with our response.

We tried to revise again your comments and incorporate responses.

Note: We authors are ready to correct each specific question you want to raise for clarification and elaboration again. We authors are also ready to submit the data if you have such significant concern.

2. Reviewer #3: There is a problem with keeping spaces consistent throughout.

Author’s response: Thank you dear reviewer. We accept the comment and corrected accordingly.

The fertility rate is high in this area as compared to other parts of the country. This needs to be cited.

Author’s response: Thank you dear reviewer.

The reference you asked was cited properly and written as follows

The zone has a population of 850, 534 and 500,000 of them were females. The fertility rate is higher in this area as compared to other parts of the country (22).

3. Add few sentences on systematic random sampling technique. It seems quite arbitrary.

Author’s response: Dear reviewer, we included few sentences and re- written as follows

Sampling Technique

This study used a systematic random sampling technique. To get the sampling frame of the sample, we gave coding for each number households practicing polygamy marriage. There were 1692 households who practiced polygamy and living in the Gedeo zone. To calculate Kth interval, we used the formula (N/n), where N= Total number of population and n= required sample. Kth interval= (1692/423=4th) and include all samples by counting every 4th interval.

Results

4. My confusion still remains as to why your age, husband's work, and educational level sections are so limited. Adding more categories would be helpful.

Author’s response: Dear reviewer, our participant’s data was in to two for Age, Husband work and educational classification.

This is based on the finding of our data.

5. It would be beneficial to add a brief paragraph to describe the outcome variables and other covariates (see the standard journal article format).

Author’s response: Dear reviewer, it was corrected as follows

Study variables

Dependent/out-come variable

Suicidal behaviour (Yes/No)

Independent variables

Socio-demographic variables: Age, educational status, employment, residence, husband work, wife’s house

Marriage and psycho-social variables: religion, and duration of marriage, number of wives at a time, distance of the two wife’s house, family size, social support, and duration of marriage.

6. Additionally, you were unable to refer to 1 since it is used as a reference category.

Author’s response: we were rewritten on the bottom of the table as follows

7. Despite your acknowledgment in your comments, I have not been able to understand when you used the Chi-square test.

Authors response: Dear reviewer one of the reviewers suggested to include chi-square

8. It is of major concern that some variables, such as religion, were left out of the AOR model.

Authors response: Dear reviewer, we included and corrected as follow

Religion Protestant 329(77.7% 172 157 1

Orthodox 64(15.1%) 29 35 1.32(0.77- 2.26)

Muslim 30(7.09) 14 16 1.252(0.59- 2.64)

9. And that some variables, such as depression, and domestic violence, were absent from the first table.

Author’s response: Thank you, Dear reviewer; it was there in table 2

Depression Yes 237(56.0%) 132 105 17.6 .000027

No 186(43.9%) 65 120

Intimate partner violence Yes 144(43.0%) 90 54 30.4 0.00001

No 279(65.9%) 96 183

10. This needs to be clearly specified. Additionally, you could replace the first table with chi-square results and 95%CI intervals, since it makes no sense to repeat percentages in both tables.

Author’s response: Dear reviewer, we merged both table 1 and table 2 by including the Chi-square result

Variables Category variables Suicidal behavior

X2 Adjusted odds ratio (AOR), 95% CI P-value

Yes No

Age Below 30 135 94 41 3.1205 1.48(0.96, 2.29) 0.43

Above 30 288 175 113 1

Educational status Non formal(illiterate) 309 211 98 34.7904 3.83 (2.44-6.02) 0.001*

Primary school

(grade 1-8) 114 41 73 1

Residence Urban 42 19 23 3.22 0.53(0.28,1.01) 0.13

Rural 381 232 149 1

Religion Protestant 329(77.7% 172 157 1.6788 1

Orthodox 64(15.1%) 29 35 1.32(0.77- 2.26)

Muslim 30(7.09) 14 16 1.252(0.59- 2.64)

Husbands work Farmer 313 140 173 0.83 1

Merchant 110 43 67 0.79(0.51,1.24) 0.24

Wives work House wife 250 134 116 5.71 1

Farmer 89 39 50 0.68(0.41,1.10) 0.10

Merchant 84 52 32 1.41(0.85, 2.33) 0.37

Number of wives at a time Two 300 132 168 13.4 1

Three 123 79 44 2.29(1.48,3.53) 0.01*

Distance of the two wives house < 20 km 148 94 54 0.67 1.21(0.80,1.83) 0.15

>20 km 275 162 113 1

Family size <3 157 95 62 0.56 1.17(0.78,1.74) 0.17

>3 266 151 115 1

Depression Yes 237 132 105 17.6 2.37(1.60-3.52) 0.001**

No 186 65 120 1

Intimate partner violence Yes 144 90 54 30.4 3.18(2.09,4.83) 0.02*

No 279 96 183 1

Social support Poor 182 106 76 24.7 3.02(1.92, 4.75) 0.01*

Moderate 89 36 53 1.47 (0.85,2.54) 0.29

Strong 152 48 104 1

Duration of marriage < 3 year 63 38 25 1.27 0.94(0.53, 1.67) 0.11

3-6 year 148 99 49 1.25(0.80, 1.94) 0.14

>6year 212 131 81 3.1205 1

Discussion

11. Why haven't you compared your results with previous studies in Africa in the Discussion?

Is that due to the lack of studies? As well, I suggest reviewing a standard discussion of a journal article that explains the results critically rather than simply reporting them.

Author’s response: Thank you very much for great suggestions.

We included African studies such as South Africa, Uganda and Ghana

The study should also be mentioned with its strengths and limitations -which is a glaring omission.

Author’s response: Thank you very much. We accept the comment and added the strength and limitation of our study in the revised manuscript.

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Reviewer #1: Yes: suzan Abdel-Rahman mohamed

Reviewer #3: Yes: Gayathri Abeywickrama

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12 Oct 2021

The prevalence of suicidal behavior and its associated factors among wives with polygamy marriage living in Gedeo zone, southern Ethiopia, 2020.

PONE-D-21-07591R2

Dear Dr. Seid Shumye,

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Academic Editor

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Additional Editor Comments (optional):

Dear authors,

Thank you for addressing the reviewers' comments and suggestions.

Before final acceptance of the paper, I would ask you check English of the paper by a native.

Best wishes

Reviewers' comments:

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Reviewer #3: All comments have been addressed

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Reviewer #3: No

15 Oct 2021

PONE-D-21-07591R2

The prevalence of suicidal behavior and its associated factors among wives with polygamy marriage living in Gedeo zone, southern Ethiopia, 2020.

Dear Dr. Shumye:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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