Disability, Caste, and Intersectionality: Does Co-Existence of Disability and Caste Compound Marginalization for Women Seeking Maternal Healthcare in Southern Nepal?
Round 1
Reviewer 1 Report
Dear Authors,
I am grateful for the opportunity to comment on your manuscript. Below are my comments and suggestions that I hope clarify and strengthen your article.
About the Researchers: I believe it would be important to provide some background on the researchers' involvement and positionality in the beginning of the article.
Significance of the study: It's important to relate the importance of the study to larger global goals, such as SDG3, for example.
Method: Abstract says "A cross-sectional survey was conducted using a semi-structured questionnaire..." but your Method section (p.4) says "A structured questionnaire with 95 questions...". Please clarify.
Discussion: In terms of educational attainment, two thirds of your sample are illiterate or have primary education. I understand that educational attainment is not among the factors you focused on directly, but there are studies that found the correlation between the educational attainment and maternal care access and outcomes (esp. mortality). You mention some of them. Lower educational attainment is unfortunately "the norm" for disabled people, especially for girls and women. Is it a typical situation for Dalit disabled and nondisabled women as well? What[s the correlation between educational attainment and caste? I believe it's an essential point when you interpret the results, especially in terms of empowerment. You write that "The results show that it is the disability status of pregnant Nepali women, not their caste that determines the utilization of health facility delivery and post-natal care."(p.13) -- Then, what's the "mechanism" that disability determines access to maternal care?
Misc.: Antenatal Care (ANC) is spelled differently in the abstract and in the rest of the text.
Author Response
Please see the attachment
Author Response File: 
Author Response.docx
Reviewer 2 Report
This was a clearly, succinctly written piece that seems to utilise a sound competence in quantitative research methods and analysis to make claims about the significance of caste and disability in Nepali women's access to maternal healthcare services.
I was not entirely convinced, however, that the very broad categorisations of "disability" (defined only by the UNCRPD definition) and of "caste" were sufficiently subtle to justify the conclusions reached. Although the exclusion criteria were clearly set out, for example, no consideration was given to the likely impact of different kinds of impairment: were deaf women more or less likely to access the services provided than women with, say, motor impairments or who were blind? What about distinctions between women who were mildly disabled and those with more profound impairments? The need to dig down more deeply—and more qualitatively—into the data seems all the more urgent given that only 15% of the sample—18 women—were disabled Dalits. The sample seems far too small to support the conclusion that “the results show that it is the disability status of pregnant Nepali women, not their caste, that determines the utilization of health facility delivery and post-natal care.” In any case the claim that either caste or disability status are necessarily “determining” characteristics is problematic and needs rephrasing, but the data is simply not strong enough to make the broader claim either. The comment that it is rather due to “social and household” circumstances, as if these can be separated out from caste and disability status (are these not part of the women’s social circumstances), further compounds the problem. In addition, in drawing a distinction between Dalits, on the one hand, and all other castes on the other, is the author not over simplifying the issue? What about the other caste distinctions described (and, for non-South Asianists, the significance of these distinctions also needs more elaboration—why do we need to know which different groups the women belong to? Elsewhere, although other kinds of socio-economic distinctions are alluded to (and the criteria for classifying the different levels is very clearly set out), more recognition needed to be given to the relationships between each of these categories. Are high castes necessarily of higher economic status, for example? How can we tell when it is caste and when it is economic class that is having an impact on maternal health decisions?
Writing was generally clear, but there were a few minor issues: why “females” (which implies other species beyond the human, as well) rather “women” (1.1, line 5, and possibly elsewhere too).
Overall, I would commend the authors for their clarity of expression and for raising interesting and important questions, but overall I felt that more needed to be done to be justify, or perhaps to nuance, the conclusions drawn.
Author Response
Please see the attachment
Author Response File: Author Response.docx
Round 2
Reviewer 2 Report
I appreciate the thought that has gone in to responding to a previous round of feedback, and am pleased at the way the arguments have been substantiated and given nuance in the latest version. Tempering the conclusions somewhat and being explicit about the limitations of the study on which the article was based also strengthen the piece overall. It also remains well-written and coherently structured.
Author Response
Thank you for your previous comments. We hope, we addressed these to your satisfaction, and we could not see any further comments to address.
