PONE-D-20-05281

Changing prevalence and factors associated with Female Genital Mutilation in Ethiopia: data from the 2000, 2005 and 2016 National Demographic Health Surveys.

PLOS ONE

Dear Dr. Azeze,

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PLOS ONE

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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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: The author intended to show how Female Genital Mutilation decrease overtime by using the DHS data of the 2000, 2005 and 2016.

FGM is the harmful traditional practice which was a worldwide problem and a major concern for Africa.

Ethiopia is also one of the country where FGM is highly prevalent. All regions in Ethiopia practiced FGM, and the prevalence ranges from lowest (Tigri) to the highest (Somali). Although the DHS data of 2000, 2005 and 2016 showed a decrease in the prevalence of FGM in Ethiopia, due to its deep-rooted nature, the practice still continued and needs further work.

The study tried to show the decreased prevalence and some factors associated with the practice. I am happy to read this interesting article. However, as a reviewer the author should take into consideration the following comments.

Abstract

Setting: the explanation is definition better to change to Introduction

Female genital mutilation is defined clearly by WHO

The traditional surgical modification might hide the actual definition because modification when it comes to FGM is about reconstructive surgery or any surgery which modified the injured part of the genitalia, so better to use the WHO definition.

Objective

State only the objective (what you intended to study) (30-33)

Introduction

FGM in Ethiopia,

Who classified FGM in to four (avoid incomplete sentence)

Conceder the type of FGM practiced most in Ethiopia (type1&2) (60)

You mentioned the problem in short as worldwide and Africa. Better to state some points how the problem is huge in Africa.

The problem in Ethiopia

Better to mention those who practice FGM such as the regions, ethnicity and religion before mentioning the least and the highest (82,83)

Methodology

Setting

Better to say something about the mortality rate, the literacy status of women and the harmful traditional practice commonly practice including FGM

Although the study showed the declining trend of the practice, girls and women are still victimized, so try to make your conclusion and recommendation strong.

Reviewer #2: The authors used three recent Demographic and Health Surveys (DHS) conducted in Ethiopia to describe trends in female genital cutting (FGC) in the country over time. This is a topic of clear importance to women’s wellbeing in Ethiopia and elsewhere and I am glad to see Ethiopian researchers addressing it. However, there are problems with the statistics presented in this article that must be corrected before it is suitable for publication. Comments specific to each section of the manuscript follow.

Introduction

I would like to see the authors acknowledge that the health consequences of FGC likely vary with the severity of the procedure. The review by Klein et al. (number 3) that is cited is of poor quality. (For example, no recognized methods of bias assessment were used.) I suggest citing a slightly older but more methodologically rigorous review by Berg et al. published in BMJ Open in 2014 instead of the current citation, or at least in addition to it.

Methods

General information on Ethiopia such as its geographic location within Africa, life expectancy, GDP, etc. is unnecessary and does not directly inform the analyses described in this paper. I recommend that the authors remove it.

Analysis and statistics

The use of sampling weights is necessary for nearly all analyses of DHS data and the authors are clearly aware of that need. However, I am not convinced that their use of the weighting variables was correct for two reasons. First, the proportions indicated in the results appear to be unweighted. For example, the precise prevalence of FGC in 2016 that the authors report in Figure 1 can be obtained from dividing the unweighted number of women who underwent FGC by the total number of women interviewed (5101/7248 = 70.4%). This would probably not be the case if weighting was properly done. Second, the prevalence of FGC in 2016 reported by the authors (70.4%) is notably different from that reported in the 2016 Ethiopia DHS final report available on the DHS website, which reports that the weighted prevalence was 65%. Similar problems arise when looking at region-specific estimates. The authors estimate that 28.4% of women in Tigray had undergone FGC in 2016, but the official DHS report from that year indicates that the proportion was 24%.

The citation that the authors provide for their weighting approach (number 20) is for an online forum that discusses weighting for specific sub-samples of the DHS. Since the authors evaluate the entire DHS sample of women (15-49-year-olds), specific weights for subsamples should not have been necessary. More detailed information on how to use the weighting variables is provided directly from the DHS in their report titled Guide to DHS Statistics. If the authors believe that their estimates are correct they must discuss why they deviate from the estimates included in official DHS reports for the country. The issue of weighting must be addressed before the article is ready for publication.

I am also concerned about how the chi squared tests for trend were conducted. The authors do not indicate that they pooled all three datasets together, which leads me to believe that each dataset was analyzed independently. If that is the case, it is difficult to understand how chi squared tests for trend across all three years could have been conducted because this test requires information on the numerator and denominator used to generate the proportion within each sample. More details on the methodology are needed here. If helpful, the BMJ has published a clear text on the chi squared test for trend in its publication ‘Statistics at Square One’ (see Chapter 8).

All of the descriptive statistics presented should be accompanied by confidence intervals, including the proportions.

Results

I am not sure what went wrong during the estimation of odds ratios but some of the estimates presented are nonsensical. For example, the authors report an unadjusted odds ratio of 180.6 for Somali region when compared to Tigray. Using the numbers included in Table 5 we can set up an epidemiologic 2x2 table and calculate the odds of FGC in Tigray (131/462) and the odds of FGC in Somali (225/228) by hand. The unadjusted odds ratio comparing Somali to Tigray is therefore (225/228) / (131/462) = 3.5.

Adjusting the odds ratios is unnecessary in this study. Confounding would be a concern if the authors were interested in estimating the causal effect of each of these traits (i.e. living in a rural area, religion) on FGC status but that is not the case here. I recommend that these analyses be omitted entirely.

Discussion

I was surprised to see the authors state that “it is estimated that one in every 500 circumcisions results in death” (line 294) because I have never come across reliable estimates of mortality associated with FGC, so I followed up the reference. It appears that the reference cited (again from the Klein et al. study) simply took this claim from another commentary (not a scientific investigation) by Marcel Reyners (Reviews in Gynaecological Practice, 2004), who based his estimate on a single source from Egypt in 1989. I was unable to locate the original Egyptian source but even so, it is clear that this estimate is not well supported by evidence and should not be included in a scientific article.

The authors acknowledge and discuss the reliability of self-reports of FGC status and severity. However, they state in lines 328-330 that “All three studies showed that there was no correlation between DHS FGM responses and anatomic extent of cutting.” Only one of the three articles cited (number 35, Bjalkander et al.) actually compares clinically observed FGC severity with DHS responses. Unfortunately, the Bjalkander study is misguided because the authors compared nationally representative DHS statistics from Sierra Leone with the distribution of FGC types observed in a sample taken from one part of the country. (This is concerning because, as the authors highlight in Ethiopia, there are often dramatic differences in FGC prevalence and type between regions.) These references need to be more carefully assessed and the implication that there is no correlation between DHS responses and the actual extent of cutting should be omitted because it is not sufficiently supported by evidence. Moreover, please use caution: the statement noted above from lines 328-330 is nearly a direct quote from the abstract of the Bjalkander article.

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Reviewer #1: No

Reviewer #2: Yes: Alissa Koski

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PONE-D-20-05281R1

Changing prevalence and factors associated with Female Genital Mutilation in Ethiopia: data from the 2000, 2005 and 2016 National Demographic Health Surveys.

PLOS ONE

Dear Dr. Azeze,

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 make the minor corrections requested by the reviewer below. We look forward to receiving the corrections and the opportunity to publish your article once they are made.

==============================

Please submit your revised manuscript by Sep 18 2020 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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• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Amy Michelle DeBaets, PhD

Academic Editor

PLOS ONE

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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 #2: (No Response)

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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 #2: Yes

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

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 #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 #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 #2: The authors responded to all of the concerns I raised in my initial review sufficiently. However, the abstract has not been updated to reflect changes to their methods and results: the prevalence estimate for 2016 does not correspond with what is reported later in the paper (line 195) and the methods still refer to regression adjustment for confounding. This must be corrected.

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Reviewer #2: Yes: Alissa Koski

[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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Changing prevalence and factors associated with Female Genital Mutilation in Ethiopia: data from the 2000, 2005 and 2016 National Demographic Health Surveys.

PONE-D-20-05281R2

Dear Dr. Azeze,

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Amy Michelle DeBaets, PhD

Academic Editor

PLOS ONE

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