Author's response to reviews Title:Empowerment and Adequate Use of Antenatal Care among Women in Ghana: A Cross-Sectional Study Authors: Heather Sipsma ( sipsmah@uic.edu) Angela Ofori-Atta ( angela.oforiatta@yahoo.com) Maureen Canavan ( maureen.canavan@yale.edu) Christopher Udry ( christopher.udry@yale.edu) Elizabeth Bradley ( elizabeth.bradley@yale.edu) Version:4Date:20 August 2014 Author's response to reviews: Referee 1 Comment 1 The outcome indicator was based on the number of antenatal care visits. It is very likely that the course of pregnancy, physiological or pathological, is associated with both, the number of antenatal visits and also with the empowerment indicators. In fact, these indicators could be an expression of socio-economic deprivation which is usually associated with worst health status. To the extent these associations do exist, a bias could occur. Women with pathological pregnancies should be excluded from the analysis, also considering that maternal mortality in Ghana is so high. Response We understand the reviewer’s concern and have added the following sentences to the limitations, as the data needed to differentiate high-risk/pathological pregnancies from low-risk/normal pregnancies were not available (P. 11): …we could not exclude women with pathological or high-risk pregnancies; the existence of such could be associated with both her number of antenatal care visits and empowerment, thus potentially confounding our results. We believe, however, that this confounding would potentially bias our results towards the null as pathological pregnancies are likely associated with higher numbers of antenatal care visits and lower levels of empowerment. Comment 2 Particularly relevant is considered by the AA the interaction found between women education and empowerment; this result is emphasized in the abstract and in the conclusions. A significant association between physical abuse and adequate antenatal care among not educated women was found (OR=0.01, 95%CI=<0.01, 0.11). The confidence limits need to be clearly defined (what does