Association between intimate partner violence and male alcohol use and the receipt of perinatal care: Evidence from Nepal demographic and health survey 2011-2016.

The utilization of perinatal care services among women experiencing intimate partner violence (IPV) and male alcohol use is a major problem. Adequate and regular perinatal care is essential through the continuum of pregnancy to mitigate pregnancy and birth complications. The aim of this study is to determine the association between IPV and male alcohol use and the receipt of perinatal care in Nepal. This study used pooled data from 2011 and 2016 Nepal Demographic and Health Surveys (NDHS). A total of 3067 women who interviewed for domestic violence module and had most recent live birth 5 years prior surveys were included in the analysis. Multivariable logistic regression analysis was performed to determine the association between IPV and male alcohol use and the receipt of perinatal care. Of the total women interviewed, 22% reported physical violence, 14% emotional violence, and 11% sexual violence. Women who were exposed to physical violence were significantly more likely to report non-usage of institutional delivery [adjusted Odds Ratio (aOR) = 1.30 (95% Cl: 1.01, 1.68)] and skilled delivery assistants [aOR = 1.43 (95% Cl: 1.10, 1.88)]. Non-attendance of 4 or more skilled antenatal care visits was associated with a combination of alcohol use by male partner and exposure to emotional [aOR = 1.42 (95% Cl: 1.01, 2.00)] and physical violence [aOR = 1.39 (95% Cl: 1.03, 1.88)]. The negative association between IPV and perinatal care suggests it is essential to develop comprehensive community-based interventions which integrates IPV support services with other health services to increase the uptake of perinatal care through the continuum of pregnancy.

Introduction

Maternal mortality refers to deaths due to complications from pregnancy or childbirth. Between year 2000 and 2017, there has been a 38% decline in global maternal mortality ratio—from 342 deaths per 100,000 live births to 211 deaths indicating an average annual reduction rate (ARR) of 2.9% [1]. Despite this significant progress, the reported global ARR in maternal mortality is less than half the 6.4% annual rate needed to meet the Sustainable Development global target of 70 maternal deaths per 100,000 live births by 2030. South Asia specifically achieved the greatest overall percentage reduction in maternal mortality rate (MMR), with a reduction of 59%—from 395 deaths per 100,000 live births to 163 deaths between 2000 and 2017 with Nepal also achieving a decline from 550 deaths per 100,000 live births to 186 deaths [1].

Most pregnancy-related complications leading to maternal mortality are preventable by quality healthcare during pregnancy and childbirth. Within the continuum of care, perinatal care is the care given to women from pregnancy through to one year after childbirth with antenatal care (ANC) and postnatal care (PNC) being care given before and after childbirth respectively. Perinatal care provides a platform for critical healthcare functions including health promotion, prevention, screening, and diagnosis of diseases. Adequate and regular perinatal care could mitigate pregnancy and birth complications, foetus and infant risk of complications as well as inform women about important steps to be taken to protect their infant and ensure a healthy pregnancy. Yet in many countries’ women continue to receive inadequate perinatal care. The importance of adequate perinatal care cannot be over-emphasized as this is essential health care delivered to women with the goal of early and timely prevention, identification, and treatment of health risks that may contribute to adverse health outcomes [2]. WHO recommends a minimum of eight antenatal contacts with the first contact occurring in the first 12 weeks of gestation, and subsequently at 20, 26, 30, 34, 36, 38 and 40 weeks of gestation [2]. In Nepal, standard ANC services include at least four ANC visits (first at the fourth month, second at the sixth month, third at the eighth month, and fourth at the ninth month of pregnancy). However, the coverage of the four ANC visits within the country is not high at 69% [9], of which less than 25% of women receive good-quality ANC care [10]. Furthermore, the 2015 National Health Facility Survey reported that during the provision of perinatal care, important dimensions of ANC services such as effectiveness, efficiency, and safety were poor [12]. Research has shown that there are several factors associated with the lack of adequate and timely perinatal care [3, 4]. Experiencing Intimate Partner Violence (IPV) has been reported as one such factor associated with inadequate uptake of perinatal care [5]. IPV exposes reproductive age women to a wide range of health problems that can either directly or indirectly lead to maternal mortality and morbidity [6]. IPV affects one in three ever-partnered women worldwide in their lifetime [7]. A substantial body of evidence attests to the negative association between IPV and the uptake of adequate perinatal care, and skilled delivery care [8-11]. The World Health Organization (WHO) has identified pathways by which IPV may contribute to sexual and reproductive health outcomes. WHO notes that coercion by the perpetrator of IPV negatively affects women’s autonomy, thereby limiting their ability to make decisions about when and if to seek health care during pregnancy and after childbirth. IPV also results in mental health problems such as depression and anxiety [12]. Such mental health problems reduce a woman’s desire to obtain health care services and their ability to make decisions regarding their own health [12]. Though previous studies have reported an association between IPV and inadequate antenatal care [8, 9], and low utilization of skilled delivery care [10, 11], other studies have reported no evidence of an association [13, 14]. This disparity in findings may be as a result of methodological differences around definitions of IPV assessment tools and outcome measures [15, 16]. Given this inconsistency in the findings, it is important to conduct a population-based country-specific analysis to ascertain the impact of IPV on perinatal care.

In addition, research has shown that a major contributor to the occurrence of IPV is male alcohol consumption, especially at harmful and hazardous levels [17]. Alcohol impacts cognitive and physical functioning resulting in increased aggression, reduced self-control, and a propensity to resort to violence for conflict resolution [18, 19]. While there is robust data on the association between alcohol use and IPV, it must be noted that the influence of alcohol consumption as a direct cause of IPV has been a topic of debate [16] due to the presence of additional factors such as low socio-economic status and impulsive personality [17]. These factors also could be exacerbated by frequent heavy drinking which could lead to stressful relationships which in turn increases the risk of conflict and violence. However, the role of male alcohol consumption in shaping the extent of IPV as well as its influence on the receipt of perinatal care is still largely uncertain.

In Nepal, a substantial number of reproductive age women experience IPV, which affects their health in many ways, including during and after pregnancy. A recent research reported that IPV is widespread in Nepal with about a quarter of ever-married women experiencing IPV most commonly in the form of beating, neglect, and verbal abuse [20, 21]. They identify low education, childhood exposure to parental partner violence, and alcohol misuse by husband as contributors to IPV. Patriarchal systems that perpetuate male dominance of women in Nepal makes partner violence acceptable and this acts as a barrier for women experiencing IPV to seek help [20-23].

Alcohol use in Nepal is culturally and socially acceptable and embedded as part of the religious and cultural life within some communities [24]. Alcohol is regarded as “pure offerings to God” and therefore having religious importance [24]. Although a significant proportion of the Nepalese population abstain from alcohol consumption, the prevalence of alcohol misuse have been increasing with rates of binge drinking as high as 70% [24]. Previous studies conducted in Nepal has shown that spousal violence and male alcohol use was associated with the receipt of low levels of skilled maternity care either across the pregnancy continuum or at recommended points during or after pregnancy [10]. Therefore, it is crucial to understand the association between IPV, male alcohol use and perinatal care, not only because it may increase health professionals’ ability to identify women experiencing IPV, but also because of the health implications such as maternal complications and poor pregnancy outcomes in which victims of IPV face across the pregnancy continuum.

Hence, the main aim of this study is to utilise pooled data from 2011 and 2016 Nepal Demographic and Health Survey (NDHS) to determine the association between IPV and male alcohol use and the receipt of perinatal care in Nepal after controlling for potential confounding factors. Findings from this study would be useful to policy makers and public health researchers in formulating effective interventions aimed at improving the receipt of perinatal care service by reducing IPV among women of reproductive age.

Materials and methods

This study used pooled data obtained from 2011 and 2016 NDHS [25, 26]. The surveys were implemented by New ERA under the aegis of the Ministry of Health of Nepal in conjunction with the United States Agency for International Development (USAID) and ICF Macro, Calverton, MD, USA [17]. The NDHS is a nationally representative survey which collect data on fertility, family planning and maternal and child health using standardized questionnaires, manuals, and field procedures that are comparable across countries. The 2011 and 2016 NDHS used a multistage cluster sampling design which was stratified by geographical regions and urban-rural areas. The 2011 and 2016 NDHS were approved by the ethics committee of Nepal Health Research Council (NHRC) and human research ethics committee (HREC) in ICF Macro International. The Independent Review Boards of New Era and ICF Macro International reviewed and approved all the data collection tools and procedures for NDHS. This study was based on an analysis of existing dataset in the DHS repository that are freely available online with all identifier information removed (http://dhsprogram.com). The first author communicated with MEASURE DHS/ ICF International, and permission was granted for the use of 2011 and 2016 NDHS.

A total of 25,536 women aged 15–49 years were interviewed in the two surveys (12,674 women in 2011 NDHS and 12,862 in 2016 NDHS) with an average response rate of over 97%. Survey data was collected from women with most recent live births 5 years prior each NDHS and women who were interviewed for the domestic violence module. As shown in S1 Fig, a total of 4079 and 3985 women had recent live births 5 years prior to 2011 and 2016 NDHS, respectively. Of which 1538 women were selected for the domestic violence module in 2011 NDHS and 1529 in 2016 NDHS. Combining both 2011 NDHS and 2016 NDHS, 3067 women who interviewed for domestic violence module had most recent live birth 5 years prior surveys. Women questionnaires designed for violence module were used to construct exposure variables. Details of the survey methodology, sampling procedures, and questionnaires are provided in the respective NDHS reports [17, 18].

Dependent variable: Perinatal care

The dependent variable was perinatal care which is defined as care provided at 22 completed weeks of gestation till seven completed days after birth. Perinatal care takes into account antenatal and early postnatal care. WHO recommends a minimum of eight antenatal care contacts to reduce perinatal mortality and improve women’s experience of care [2]. However, in this study 4 or more ANC visits was used because this was WHO recommendation at the time the 2011 and 2016 NDHS were conducted. For a positive pregnancy experience, 49 WHO recommendations on ANC were developed related to five types of interventions: (i) Nutritional interventions; (ii) Maternal and foetal assessment; (iii) Preventive measures; (iv) Interventions for common physiological symptoms; and (v) Health system interventions to improve utilization and quality of ANC [2]. In high mortality settings and where access to facility-based postnatal care is limited, WHO and UNICEF recommend at least two home postnatal visits for all home births: the first visit should occur within 24 hours from birth and the second visit on day 3 [20]. WHO guidelines for postnatal care addresses the timing, number, and place of postnatal contacts as well as the content of postnatal care for all mothers and babies during the six-week period after birth. For this study, we examined receipt of perinatal care using three indicators: (i) Non-use of 4 or more skilled ANC visits; (ii) Non-use of institutional delivery; and (iii) Non-use of skilled delivery assistants.

Descriptive study variables

The potential confounding variables were type of residence (urban and rural), ecological region (Terai, hill or mountain), household wealth index (poor, middle, rich), maternal education (secondary and higher primary, no education), maternal current working status (currently not working and currently working), husband education (secondary and higher, primary, no education), ethnicity (Brahmin/Chettri, Janajati including newar, Dalit, others including Muslim), maternal age, parity, maternal smoking status, exposure to mass media and year of survey (NDHS 2011 and NDHS 2016). The household wealth index is a composite index based on a household’s ownership of selected assets, such as televisions and bicycles, materials used for housing construction and types of water access and sanitation facilities [27]. The exposure variables were husband/partner alcohol drinking and IPV which was represented in three forms: physical violence, emotional violence, and sexual violence.

Statistical analysis

This study pooled data from NDHS 2011 and 2016 to increase sample size. Analyses were performed using Stata version 15.0 (StataCorp, College Station, TX, USA). The dependent variables were based on the uptake of the three perinatal care services and coded as ‘0’ [if respondents reported 4 or more ANC visits, if the deliveries took place in a health facility, or if the deliveries were assisted by doctors, nurses, or midwives]; and ‘1’ [if respondents did not report 4 or more ANC visits, if the deliveries did not take place in a health facility, or if the deliveries were not assisted by doctors, nurses, or midwives]. Frequency tabulation was performed to describe the characteristics of study population. The Taylor series linearization method was used in the surveys to estimate the confidence intervals (Cls) around prevalence estimates of IPV. Generalized linear latent and mixed models (gllamm) with the logit link and binomial family [28] that adjusted for cluster and violence specific sampling weights were used to examine the impact of each of the exposure variables on the uptake of perinatal care while taking confounding variables into account. After fitting multivariate logistic regression models, Hosmer-Lemeshow goodness-of-fit test was performed by using ‘svylogitgof’ command in stata which showed non-significant results (p>0.05) suggesting adequate fit. In addition, time dependent confounder (year of survey) was included in the regression analysis to ensure the results are similar over a 5-year interval.

Results

Characteristics of the sample

Table 1 shows the characteristics of the weighted study sample with live births who were interviewed for domestic violence module in Nepal (2011–2016). A total weighted sample of 2,727 women were interviewed for the domestic violence module in both surveys with 1374 (50.4%) in 2011 NDHS and 1353 (49.6%) in 2016 NDHS. Of these, 37.3% lived in urban areas while 62.7% lived in rural areas. The Terai, Hill and Mountain regions had 44.9%, 45.8% and 9.3% inhabitants, respectively. Approximately 45% were poor and 34.8% rich. While 38% reported no maternal education and 42.6% reported secondary and higher maternal education, 16.9% reported no husband education and 60.2% reported secondary and higher husband education. About 43.2% mothers were not currently working while 56.8% were currently working. The sample also reported higher exposure to mass media (83.5%) and maternal smoking status of 7%. Husband/partner who drank alcohol was 47.6%, women who reported physical, emotional, and sexual violence were 22.3%, 14.1% and 11.4% respectively.

Table 1

Characteristics of study sample (weighted) with live births who were interviewed for domestic violence module in Nepal (2011–2016).

Characteristics	N	%
Year of survey
2011	1374	50.4
2016	1353	49.6
Type of Residence
Urban	1018	37.3
Rural	1710	62.7
Ecological region
Terai	1225	44.9
Hill	1248	45.8
Mountain	255	9.3
Household wealth index
Poor	1228	45.0
Middle	550	20.2
Rich	950	34.8
Maternal education
Secondary and higher	1162	42.6
Primary	530	19.4
No education	1036	38.0
Maternal current working status
Currently not working	1178	43.2
Currently working	1550	56.8
Husband education(N = 2715)
Secondary and higher	1641	60.2
Primary	613	22.5
No education	461	16.9
Ethnicity
Brahmin/Chettri	871	31.9
Janajati including newar	902	33.1
Dalit	469	17.2
Others including Muslim	487	17.9
Maternal age
14–24	1150	42.2
25–34	1288	47.2
35–49	290	10.6
Parity
1	949	34.8
2	795	29.1
3+	985	36.1
Maternal smoking status
No	2536	93.0
Yes	191	7.0
Exposure to mass media
No	450	16.5
Yes	2278	83.5
Husband/partner drinking alcohol
No	1429	52.4
Yes	1299	47.6
Physical violence
No	2118	77.2
Yes	609	22.3
Emotional violence
No	2343	85.9
Yes	385	14.1
Sexual violence
No	2416	88.6
Yes	312	11.4
Total	2728	100.0

Impact of violence

In the univariate analysis, women who were exposed to all three forms of violence: emotional, physical, and sexual violence were less likely to attend 4 or more skilled ANC visits, and utilize institutional delivery and skilled delivery assistants. While in the multivariable analysis, women who were exposed to physical violence were significantly less likely to utilize institutional delivery and skilled delivery assistants as shown in Table 2.

Table 2

Impact of alcohol use and different forms IPV on receipt of perinatal care in Nepal (20011–2016).

Exposure variables	Non-use of 4 or more skilled ANC visits		Non-use of institutional delivery		Non-use of skilled delivery assistants
	Unadjusted OR (95% CI)	Adjusted OR (95% CI)	Unadjusted OR (95% CI)	Adjusted OR (95% CI)	Unadjusted OR (95% CI)	Adjusted OR (95% CI)
Emotional violence
No	1.00	1.00	1.00	1.00	1.00	1.00
Yes	1.73(1.32, 2.26) **	1.17(0.89, 1.55)	1.53(1.16, 2.01) *	1.07(0.80, 1.44)	1.62(1.22, 2.16) *	1.14(0.84, 1.54)
Physical violence
No	1.00	1.00	1.00	1.00	1.00	1.00
Yes	1.87(1.48, 2.35) **	1.22(0.95, 1.55)	1.94(1.52, 2.46) **	1.30(1.01, 1.68) *	2.12(1.65, 2.74) **	1.43(1.10, 1.88) *
Sexual violence
No	1.00	1.00	1.00	1.00	1.00	1.00
Yes	1.56(1.16, 2.10) *	1.05(0.77, 1.44)	1.45(1.06, 1.97) *	0.98(0.71(1.36)	1.55(1.13, 2.14) *	1.00(0.71, 1.41)
Alcohol use by male partner
No	1.00	1.00	1.00	1.00	1.00	1.00
Yes	1.74(1.44, 2.10) **	1.22(1.99, 1.50)	1.53(1.26, 1.84) **	1.01(0.82, 1.25)	1.50(1.23, 1.84) **	0.96(0.77, 1.19)
Combination of alcohol use and emotional violence
No alcohol no violence	1.00	1.00	1.00	1.00	1.00	1.00
Alcohol but no violence	1.63(1.33, 1.99) **	1.17(0.95, 1.46)	1.60(1.29, 1.98) **	1.10(0.88, 1.38)	1.50(1.20, 1.87) **	0.99(0.79, 1.25)
No alcohol but violence	1.41(0.89, 2.24)	0.97(0.60, 1.57)	2.14(1.33, 3.48) *	1.67(0.98, 2.73)	1.94(1.19, 3.14) **	1.48(0.90, 2.46)
Alcohol and violence	2.60(1.87, 3.61) **	1.42(1.01, 2.00) *	1.75(1.25, 2.45) **	0.91(0.63, 1.31)	1.94(1.35, 2.76) **	0.99(0.68, 1.45)
Combination of alcohol use and physical violence
No alcohol no violence	1.00	1.00	1.00	1.00	1.00	1.00
Alcohol but no violence	1.65(1.33, 2.04) **	1.20(0.96, 1.51)	1.54(1.23, 1.92) **	1.06(0.83, 1.35)	2.05(1.50, 2.80) **	0.97(0.76, 1.24)
No alcohol but violence	1.83(1.24, 2.68) *	1.19(0.81, 1.75)	2.45(1.68, 3.58) **	1.67(1.13, 2.48) *	1.42(0.68, 2.49)	1.73(1.15, 2.61) *
Alcohol and violence	2.60(1.95, 3.47) **	1.39(1.03, 1.88) *	2.27(1.68, 3.07) **	1.17(0.85, 1.62)	2.90(1.77, 4.75) **	1.26(0.90, 1.77)
Combination of alcohol use and sexual violence
No alcohol no violence	1.00	1.00	1.00	1.00	1.00	1.00
Alcohol but no violence	1.73(1.41, 2.11) **	1.23(0.99, 1.52)	1.47(1.19, 1.81) **	0.98(0.79, 1.23)	1.39(1.12, 1.73) *	0.91(0.72, 1.14)
No alcohol but violence	1.59(0.98, 2.58)	1.05(0.64, 1.74)	1.20(0.73, 1.97)	0.83(0.50, 1.40)	1.08(0.64, 1.81)	0.71(0.42, 1.22)
Alcohol and violence	2.31(1.59, 3.36) **	1.23(0.83, 1.81)	2.11(1.43, 3.12) **	1.07(0.70, 1.63)	2.40(1.59, 3.62) **	1.15(0.74, 1.79)

*P Value<0.05;

**P Value<0.001;

Model adjusted for Year of survey, type of residence, ecological region, household wealth index, maternal education, maternal current working status, husband/partner education, ethnicity, maternal age, parity, maternal working status, and exposure to mass media.

Impact of male alcohol use

In the univariate analysis, women with partners who drank alcohol were less likely to attend 4 or more skilled ANC visits, and utilize institutional delivery and skilled delivery assistants than their counterparts with partners who do not drink alcohol as shown in Table 2.

Impact of violence and male alcohol use (combined)

In the univariate analysis, women who reported alcohol use with or without exposure to emotional violence were less likely to attend 4 or more skilled ANC visits, and utilize institutional delivery and skilled delivery assistants than their counterparts. While women who reported no alcohol use but exposure to emotional violence were less likely to utilize institutional delivery and skilled delivery assistants. Likewise, women who reported alcohol use with or without physical violence as well as women who reported no alcohol use, but exposure to physical violence were less likely to attend 4 or more skilled ANC visits, and utilize institutional delivery than their counterparts. Furthermore, women who reported alcohol use with or without exposure to sexual violence were less likely to attend 4 or more skilled ANC visits, and utilize institutional delivery and skilled delivery assistants than their counterparts.

In the multivariable analysis, women who reported a combination of alcohol use by partner and exposure to emotional violence as well as women who reported a combination of alcohol use by partner and exposure to physical violence were less likely to attend 4 or more skilled ANC visits than their counterpart with no partner who drinks alcohol and no exposure to emotional or physical violence respectively. Women who reported no alcohol use by partner, but exposure to physical violence were less likely to utilize institutional delivery and skilled delivery assistants.

Discussion

This study examined the association between IPV and male alcohol use and the receipt of perinatal care in Nepal. IPV and male alcohol use are known to expose women to a wide range of health problems due to complications from not accessing and utilising maternity health-care services [5, 17]. Over the study period (2011–2016), IPV and male alcohol use were reported to have a significant impact on the usage of maternity health-care services in Nepal.

In this study, women exposed to physical violence were less likely to access and utilise skilled delivery assistants. Research has shown that delivery attended by skilled professionals contribute to better pregnancy and childbirth outcomes, early detection, and management of complications in the ANC period, as well as during delivery and in the postnatal period [2, 29, 30]. The lack of utilisation of skilled birth attendants by women experiencing IPV could be due to sociocultural factors which prevent engagement with maternity health-care services. In line with our finding, a previous study found that there was a decrease in the use of maternity health-care services by women experiencing IPV due to poor education and health-seeking behaviour, coupled with a lack of adequate information [31]. In addition, a similar study conducted in Kenya also reported that women’s experience of IPV may influence and subsequently reduce their usage of skilled birth attendance [32].

This study also found that women who are exposed to physical violence were less likely to utilise institutional delivery. This could be attributed to the need to maintain privacy and confidentiality. One of the factors that mitigate against women who experience IPV is the idea that family problems should be kept private [33]. These norms and values may act to undermine the impact of IPV and deter women from seeking help and support. Furthermore, women experiencing physical violence tend to avoid circumstances that would result in involuntary reporting of their spouses for fear of continued abuse. These women also avoid situations where they are forced to interact with institutions that are mandatory reporters, including hospitals. Universal screenings administered by health or social work professionals are being carried out in antenatal and other health care settings to detect domestic and family violence and mandatory reports are made [34].

In this study, women who reported experiencing emotional or physical violence with a partner who consume alcohol were less likely to attend the recommended antenatal visits. Alcohol abuse by men has been found to be a significant determinant of IPV against women [35-37] and increase the display of controlling behaviours by the man such as demanding the woman ask for permission before seeking healthcare [38]. This increased display of controlling behaviours and violence might be due to an impaired cognitive function, which reduces self-control and leaves the individual less capable of negotiating a non-domineering and non-violent resolution to conflicts. A report by the WHO also identifies alcohol consumption at harmful levels as a major contributor to the occurrence of IPV [17]. The impact of such behaviour may lead to partner interference with recommended ANC visits attendance. A similar study carried out in Mozambique [39] found that emotional violence was the most reported form of partner violence which impacts on a woman’s utilisation of ANC service. The study also reported that women experiencing emotional and physical abuse women were more likely to initiate and access ANC late during pregnancy resulting in possible high mortality [40].

This study had some limitations. First, the analyses were based on cross-sectional data, hence, causality cannot be established between study outcome and confounding factors. Second, despite the use of a comprehensive set of variables in our analysis, the effect of residual confounding as a result of unmeasured co-variates which might influence the receipt of perinatal care, such as pregnancy complications, pre-existing maternal health conditions, quality of maternal care available as well as personal or sociocultural perceptions may have been ruled out. However, this study also had several strengths. First, the 2011 and 2016 NDHS were nationally representative survey which used standardized methods that achieved an average response rate of 97%; therefore, the findings from this study could be generalized to the entire Nepalese population and is unlikely to be affected by selection bias. Second, this study used pooled data from 2011 and 2016 NDHS with large sample size and increased statistical power. Third, the use of random effect multilevel modelling which accounts for the hierarchical structure of the data and the variability within the exploratory variables better estimates the level of association between the potential confounding factors with the study outcome [41]. Finally, standardized uniform questionnaires, were used to collect information across both surveys which increase accuracy and promote coherence of the data used for analysis.

This study is useful in public health planning to reinforce the need to support women experiencing IPV through the pregnancy continuum in accessing perinatal care. It will also assist the Nepalese government in developing and implementing appropriate programs aimed at improving receipt of perinatal care amongst vulnerable women.

Conclusions

This research aimed to fill a gap in the literature and explored the association between IPV and male alcohol use and perinatal care seeking in Nepal. The statistical analysis have shown that women who experienced IPV either in the form of physical or emotional abuse and reported alcohol use by partner were less likely to receive the WHO recommended level of perinatal care, which is attend 4 or more antenatal clinics run by trained health care providers. This reduction in antenatal care prevents women from receiving the care and treatment required for preventing maternal deaths and promoting mother and child wellbeing. Moreover, the negative association between IPV and perinatal care, suggests there are social, cultural and structural barriers that prevent these women from accessing crucially needed care not just for their pregnancy but also for addressing their mental health needs arising from their IPV experience. Thus, it is essential to develop comprehensive interventions addressing not just the interpersonal level factors between the couple, and mothers-in-law, but also the social cultural norms that perpetuate IPV and alcohol misuse and prevent women from seeking perinatal care. This calls for community-based interventions including screening for IPV designed in a way that makes it easier for women to get the help they need. Integrating perinatal, mental health and IPV support services with other health services and providing a home visiting service may contribute to increasing the uptake of perinatal care and reducing the incidence of IPV.

Composition of study sample (unweighted numbers).

(DOCX)

Click here for additional data file.

18 Aug 2021

PONE-D-21-11367

Association between intimate partner violence and male alcohol use and the receipt of perinatal care Evidence from Nepal demographic and health survey 2001–2016

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- PLOS ONE has a publication critiera that says 'studies involving humans categorized by race/ethnicity, age, disease/disabilities, religion, sex/gender, sexual orientation, or other socially constructed groupings, authors should explicitly describe their methods of categorizing human populations'. Given this, please can you explain why you use the following groupings for ethnicity? Brahmin/Chettri, Janajati including newar, Dalit, others including Muslim. Is this a standard way to categorise ethnicities in Nepal?

- Please describe the contributions of all authors - see https://journals.plos.org/plosone/s/authorship for guidance

- Please use the apropriate reporting guidelines to report your work - see here: https://journals.plos.org/plosone/s/submission-guidelines The STROBE cross sectional checklist might be the most appropriate for you

- Please rephrase the following sentence 'However, the role of male alcohol consumption in shaping the extent of IPV as well as its influence on the receipt of perinatal care cannot be over-emphasized' - this sentence does not make sense in the current place in the manuscript as you have not yet shown what the role of alcohol is.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. 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: Partly

Reviewer #2: Yes

Reviewer #3: No

**********

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

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

**********

3. 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: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. 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 #2: Yes

Reviewer #3: Yes

**********

5. 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

This is a manuscript on secondary data analysis, exploring the association of intimate partner violence (IPV) and male alcohol use on the receipt of perinatal care. The study objective is timely, and on target. I have some comments mostly on the statistical analysis side:

(a) The dependent variable "perinatal care" has been explained in a separate section, however, it was not made clear the exact nature of the response, i.e., is it a binary response (which I think it is), or something else. If binary, clearly mention how the cutoff was determined. It is not clear.

(b) Taylor series linearization method was employed to calculate the variance estimates; some more details needed for the reader. Is it automatic inside Stata?

(c) Please explain why both logit and binomial family was used under the Generalized linear latent and mixed modeling. Where is the mixed modeling coming from (like, what is the cluster)? Be clear. What is the context of binomial modeling?

(d) No goodness-of-fit measures were provided; see below (STATA may have such a command)

https://www.stata-journal.com/article.html?article=st0099

(e) A small sample size/power description may allow readers to understand what effect size the authors wanted to achieve before conducting the analysis, and the appropriateness of the sample size. You may ignore the survey weighting while calculating the power, if such a program, or method doesn't exist.

Reviewer #2:

This paper used the 2011 and 2016 Nepal Demographic and Health Surveys to look at the association between IPV, male alcohol use and perinatal care. The introduction should be reorganized to flow better and focus on the context of Nepal. The paper can be strengthened by expanding upon why the analysis methods were chosen.

Reviewer #3:

The 2011 and 2016 NDHS data is used together and analysed. But it was not clear that both instruments and methods were the same. It should be explained in methods.

Analysis

The 2011 and 2016 NDHS data were combined and analysed. No effort was taken to show that both samples and findings are similar. It is difficult to assume that the factors are unchanged over a 5-year interval and here it looks like the two different data sets are combined and analysed to get results. the combination of two data sets seems to be purely for the increase in sample size without considering any other factors.

An option is to compare and contrast the data set before combining both. In this combination, authors can compare the similarities of key factors such as IPV, alcohol consumption and ANC care. If both data sets are similar, they can be combined and analysed. if not it's good to analyze it separately and compare.

**********

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.

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: No

Reviewer #2: No

Reviewer #3: Yes: Muzrif Munas

[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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: PONE-D-21-11367.docx

Click here for additional data file.

29 Sep 2021

Editor comments

Comment: PLOS ONE has a publication criterion that says 'studies involving humans categorized by race/ethnicity, age, disease/disabilities, religion, sex/gender, sexual orientation, or other socially constructed groupings, authors should explicitly describe their methods of categorizing human populations'. Given this, please can you explain why you use the following groupings for ethnicity? Brahmin/Chettri, Janajati including newar, Dalit, others including Muslim. Is this a standard way to categorise ethnicities in Nepal?

Response: Thank you for your comment. The listed groupings for ethnicity in the study are the recognised ethnic groups in Nepal and are reported as such in all Nepalese Demography and Health Surveys (2006, 2011 and 2016).

In Nepal, Brahmin/Chettri is considered as advantaged ethnic group and belongs to the top of ethnic hierarchy whereas Janajati including Newar, and Dalit are relatively disadvantaged and socioeconomically marginalized groups. Others including Muslim are different group of people who are neither Brahmin/Chettri nor Dalit or Janajati and has been categorised as others including Muslim. Some of these have been discussed in the final report of NDHS (2011-2016). Please see https://dhsprogram.com/pubs/pdf/FR336/FR336.pdf

Comment: Please describe the contributions of all authors – see https://journals.plos.org/plosone/s/authorship for guidance

Response: Thank you for your advice. However, the document you shared provides information on PLOS ONE’s authorship policies and does not state that the information should be included in the manuscript. Furthermore, following PLOS ONE’s submission guidelines (https://journals.plos.org/plosone/s/submission-guidelines#loc-style-and-format), there is no section within the manuscript where authors’ contribution is solicited. However, we have clearly indicated each authors’ contribution in the submission system as advised in PLOS ONE’s authorship policy.

Comment: Please use the appropriate reporting guidelines to report your work - see here: https://journals.plos.org/plosone/s/submission-guidelines The STROBE cross sectional checklist might be the most appropriate for you

Response: Thank you for your advice. We adhered strictly to PLOS ONE’s submission guidelines as outlined in https://journals.plos.org/plosone/s/submission-guidelines. We also adhered to STROBE cross sectional study checklist to the extent suitable for our study given that our study is based on secondary data analysis.

Comment: Please rephrase the following sentence 'However, the role of male alcohol consumption in shaping the extent of IPV as well as its influence on the receipt of perinatal care cannot be over-emphasized' - this sentence does not make sense in the current place in the manuscript as you have not yet shown what the role of alcohol is.

Response: Thank you for your insightful comment. We have considered your comment and revised the manuscript accordingly. The manuscript now reads

“However, the role of male alcohol consumption in shaping the extent of IPV as well as its influence on the receipt of perinatal care is still largely uncertain”. Please see lines 127 - 129.

Reviewer #1 comment

This is a manuscript on secondary data analysis, exploring the association of intimate partner violence (IPV) and male alcohol use on the receipt of perinatal care. The study objective is timely, and on target. I have some comments mostly on the statistical analysis side:

Comment: (a) The dependent variable "perinatal care" has been explained in a separate section, however, it was not made clear the exact nature of the response, i.e., is it a binary response (which I think it is), or something else. If binary, clearly mention how the cutoff was determined. It is not clear.

Response: Thank you for your comment. We have revised the manuscript to make clear the nature of the response as follows:

“The dependent variables of this study were based on the uptake of the three perinatal care services and coded as ‘0’ [if respondents reported 4 or more ANC visits, if the deliveries took place in a health facility, or if the deliveries were assisted by doctors, nurses, or midwives]; and ‘1’ [if respondents did not report 4 or more ANC visits, if the deliveries did not take place in a health facility, or if the deliveries were not assisted by doctors, nurses, or midwives]”. Please see lines 215 – 220.

Comment: (b) Taylor series linearization method was employed to calculate the variance estimates; some more details needed for the reader. Is it automatic inside Stata?

Response: Thank you for your comment. However, we believe that the information provided on the Taylor series linearization method is sufficient to provide the reader with the necessary details to validate our analysis.

Comment: (c) Please explain why both logit and binomial family was used under the Generalized linear latent and mixed modeling. Where is the mixed modeling coming from (like, what is the cluster)? Be clear. What is the context of binomial modeling?

Response: First of all, we would like to highlight that when the link function is the logit function, the binomial regression becomes the well-known logistic regression. Both the logit and binomial family was used because Generalized linear latent and Mixed Models (GLLAMM) is a stata program to fit multilevel latent variable models for (multivariate) responses of mixed type including counts, duration, ordered and unordered categorical responses [Please see: Rabe-Hesketh S, Skrondal A. Multilevel and longitudinal modeling using Stata. STATA press; 2008]. To use GLLAMM program in stata, it is mandatory to first identify the link and corresponding family; and therefore, both the logit and corresponding family (binomial) were used. In the past, we have extensively used this program to fit multivariate regression models that also adjust for multi-stage clustering and sampling weights for complex survey design like DHS [Please see: https://link.springer.com/article/10.1186/s12884-019-2234-6; https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202603

Comment: (d) No goodness-of-fit measures were provided; see below (STATA may have such a command)

https://www.stata-journal.com/article.html?article=st0099

Response: Thank you for the important comment, and we have performed Hosmer-Lemeshow goodness-of-fit test [Please see https://journals.sagepub.com/doi/10.1177/1536867X0600600106], and the text below has been added into the revised manuscript.

“After fitting multivariate logistic regression models, Hosmer-Lemeshow goodness-of-fit test was performed by using ‘svylogitgof’ command in stata which showed non-significant results (p>0.05) suggesting adequate fit”. Please see lines 226 – 228.

Comment: (e) A small sample size/power description may allow readers to understand what effect size the authors wanted to achieve before conducting the analysis, and the appropriateness of the sample size. You may ignore the survey weighting while calculating the power, if such a program, or method doesn't exist.

Response: This study was based on secondary data analysis of 2011 and 2016 NDHS which were nationally representative surveys with an average response rate of 97%. The sample size has already been calculated for each DHS (Please see individual DHS report for NDHS 2011 and 2016). However, we adjusted for difference in cluster and survey weight.

Reviewer #2 comment

This paper used the 2011 and 2016 Nepal Demographic and Health Surveys to look at the association between IPV, male alcohol use and perinatal care. The introduction should be reorganized to flow better and focus on the context of Nepal. The paper can be strengthened by expanding upon why the analysis methods were chosen.

Comment: 1. Further description on factors that affect maternal mortality for women in Nepal specifically will be helpful.

Response: Thank you for your comment. Our study is focused primarily on perinatal care in Nepal and as such our narrative is in-line with the direction of our study. We recognize the impact perinatal care has on maternal mortality and has briefly acknowledged that. However, further discussion on the factors that affect maternal mortality for women in Nepal is out of the scope of our study.

Comment: 2. It would be useful to outline other pathways by which IPV reduces uptake of perinatal care services outside from decision making and poor mental health.

Response: Thank you for your comment. To the extent of our literature review and based on WHO report, we have identified and hence acknowledge these pathways through which IPV reduces uptake of perinatal care services. As we identify more pathways, we will be including them in our upcoming studies.

Comment: 3. Make sure there is consistency in using the term perinatal care and antenatal care.

Response: Thank you for your comment. We have included a definition of perinatal care and antenatal care through which we believe will address any ambiguity in the use of the terms in our manuscript.

The manuscript now reads:

“Within the continuum of care, perinatal care is the care given to women from pregnancy through to one year after childbirth with antenatal care and postnatal care being care given before and after childbirth respectively”. Please see lines 80-82.

Comment: 4. The statement about mothers-in-law and their role seems misplaced. Either expand upon their role and how this relates to IPV or take it out.

Response: Thank you for your comment. We agree that the statement seems misplaced and have taken it out.

Comment: 5. Why are only 4 or more ANC visits considered use of ANC when the recommendation is 8?

Response: Thank you for your comment. Though WHO recommends 8 ANC visits, Nepal still uphold 4 ANC visits as the national standard, and this is what is reported in Nepal Demography and Health Surveys (DHS). The manuscript has been revised to reflect this information. The manuscript now reads:

In Nepal, standard ANC services include at least four ANC visits (first at the fourth month, second at the sixth month, third at the eighth month, and fourth at the ninth month of pregnancy). Please see lines 92 – 94.

Comment: 6. Clarification and a reason as to why this analysis plan was chosen would strengthen the statistical methods.

Response: We do not quite understand this comment. We believe that the analysis is self-explanatory. First, we estimated prevalence, and their 95% CI to understand the characteristics of study sample, followed by fitting multivariate logistic regression model while taking into account cluster and sampling weights (specific to violence module) to understand the impact of male alcohol use and IPV on the uptake of perinatal care services in Nepal.

Comment: 1. Line 104-105 in the introduction needs a citation.

Response: Thank you for your comment. A citation has now been added. Please line 112.

Comment: 2. Line 124-127 needs a citation.

Response: Thank you for your comment. Unfortunately, we could not find a suitable citation for the suggested statement. Therefore, we have removed the statement from the manuscript.

Comment: 3. Line 139 needs a citation.

Response: Thank you for your comment. A citation has now been added. Please see line 139.

Reviewer #3 comment

Comment: The 2011 and 2016 NDHS data is used together and analysed. But it was not clear that both instruments and methods were the same. It should be explained in methods.

Response: Thank you for your comment. In the method section we clearly stated that DHS including Nepal DHS use standardized questionnaires, manuals, field procedures and sampling techniques that are comparable across countries and time. Please see lines 162 – 166.

Comment: The 2011 and 2016 NDHS data were combined and analysed. No effort was taken to show that both samples and findings are similar. It is difficult to assume that the factors are unchanged over a 5-year interval and here it looks like the two different data sets are combined and analysed to get results. the combination of two data sets seems to be purely for the increase in sample size without considering any other factors.

An option is to compare and contrast the data set before combining both. In this combination, authors can compare the similarities of key factors such as IPV, alcohol consumption and ANC care. If both data sets are similar, they can be combined and analysed. if not it's good to analyze it separately and compare.

Response: This is a valid point indeed. However, the aim of this study was not to compare and contrast key factors between the two NDHS (NDHS 2011 and NDHS 2016), rather was to provide a stronger evidence based on a pooled dataset that also takes time dependent confounder (year of survey) into account. The inclusion of time dependent confounder (year of survey) in the regression analysis is to ensure our results are similar over a 5-year interval. We have clarified the inclusion of time dependent confounder (year of survey) in our method section of the revised manuscript.

Submitted filename: Response to Reviewers.docx

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22 Oct 2021

PONE-D-21-11367R1Association between intimate partner violence and male alcohol use and the receipt of perinatal care Evidence from Nepal demographic and health survey 2011–2016PLOS ONE

Dear Dr. Akombi-Inyang,

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 Dec 06 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.

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Sandi Dheensa

Academic Editor

PLOS ONE

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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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: All comments have been addressed

Reviewer #2: (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: (No Response)

Reviewer #2: Yes

**********

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

Reviewer #1: (No Response)

Reviewer #2: 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 Response)

Reviewer #2: 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: (No Response)

Reviewer #2: 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: (No Response)

Reviewer #2: 1. Though it’s helpful to have the code in the statistical analysis section, it might be better be better placed in a table or annex rather than in the text.

2. What assumptions, if any, were made about the data in order to perform the statistical analysis?

3. Can you further explain how husband alcohol use was quantified (ie, if binary is it that the husband could range from drinking one drink to many in a day)? In the discussion the focus is on alcohol abuse by men, might me good to add in studies that focus on recreational alcohol use as well if the variable of husband alcohol use ranges from recreational use to abuse.

4. Might be important to talk about stigma about reporting IPV and how that could effect your results.

**********

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: No

Reviewer #2: No

[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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Review2.docx

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25 Oct 2021

Response to Reviewer 2

Comment 1: Though it’s helpful to have the code in the statistical analysis section, it might be better be better placed in a table or annex rather than in the text.

Response: Thank you for your suggestion. However, after reviewing several similar publications we are of the opinion that the preferred way to ensure our study is well understood by the reader is to briefly include the coding in the statistical analysis section. We have also published numerous studies in PLOS ONE as well as in other journals giving the coding information in the statistical analysis section. Please see some similar publications below:

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236435

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202603

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0223385

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0203278

https://www.hindawi.com/journals/bmri/2020/5487164/

Comment 2: What assumptions, if any, were made about the data in order to perform the statistical analysis?

Response: Thank you for your comment. However, we do not fully understand your comment. Our study was based on secondary data analysis, and we have provided all necessary information in the statistical analysis section. All limitations to the study have also been stated in the limitation section.

Comment 3: Can you further explain how husband alcohol use was quantified (ie, if binary is it that the husband could range from drinking one drink to many in a day)? In the discussion the focus is on alcohol abuse by men, might me good to add in studies that focus on recreational alcohol use as well if the variable of husband alcohol use ranges from recreational use to abuse.

Response: In NDHS (2011-2016), women completing the violence module were asked - Does (did) your (last) (husband/partner) drink alcohol? and the results were recorded as binary (YES/NO). Data on quantity of alcohol consumption were not collected in NDHS. Therefore, this study is not able to distinguish if alcohol use by husband was recreational or abuse.

Comment 4: Might be important to talk about stigma about reporting IPV and how that could effect your results.

Response: Thank you for your comment. In the limitation section, we include "personal or sociocultural perceptions" as an unmeasured co-variate which might have been ruled out in the analysis. Stigma, we believe falls under that category. In addition, further discussion on stigma and how it impact on IPV is beyond the scope of our study.

Submitted filename: RESPONSE TO REVIEWER 2.docx

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2 Nov 2021

Association between intimate partner violence and male alcohol use and the receipt of perinatal care Evidence from Nepal demographic and health survey 2011–2016

PONE-D-21-11367R2

Dear Dr. Akombi-Inyang,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Sandi Dheensa

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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: (No Response)

Reviewer #2: Yes

**********

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

Reviewer #1: (No Response)

Reviewer #2: 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 Response)

Reviewer #2: 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: (No Response)

Reviewer #2: 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: (No Response)

Reviewer #2: (No Response)

**********

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: No

Reviewer #2: No

18 Nov 2021

PONE-D-21-11367R2

Association between intimate partner violence and male alcohol use and the receipt of perinatal care: Evidence from Nepal demographic and health survey 2011–2016

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