PCLM-D-25-00488

‘Water is a good thing, but when it destroys it is not good’: The influence of changing weather patterns on access to antenatal care services in Western Kenya - a qualitative study

PLOS Climate

Dear Dr. Matanda,

Thank you for submitting your manuscript to PLOS Climate. After careful consideration, we feel that it has merit but does not fully meet PLOS Climate’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.

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We look forward to receiving your revised manuscript.

Kind regards,

Stefan Wheat, MD

Academic Editor

PLOS Climate

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Additional Editor Comments (if provided):

Dear Authors,

Thank you for submitting your manuscript and for the opportunity to review your work. Overall, the manuscript was well received and addresses a topic of clear relevance and interest to the field. Reviewers appreciated the importance of the subject matter and the potential contribution of your analysis.

However, they also identified several substantive issues that will need to be addressed before the manuscript can be considered for acceptance. As outlined in the reviewers’ comments, major revisions are required to strengthen the clarity, rigor, and organization of the paper.

We invite you to revise and resubmit the manuscript, providing a detailed response to each reviewer comment. We look forward to reviewing a revised version should you choose to proceed.

Sincerely,

Stefan Wheat

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Climate’s publication criteria ? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented.-->?>

Reviewer #1: Yes

Reviewer #2: Partly

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

Reviewer #1: N/A

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)??>

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. 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: No

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: This article highlights the significant challenge that pregnant women and mothers face from natural hazards due to the climate change effect. I appreciate the author’s effort to put the evidence on how the Kenyan government seriously anticipates the impact of climate change on women’s health in their national adaptation plan. Furthermore, this article also successfully presented the distinct outcome due to different geographic area characteristics. The quotation in this paper is really engaging. However, the discussion section is quite lacking in insight; it seems to be the repetition of the introduction. Furthermore, there must be alignment of conclusion and recommendation, which refers to the objective of the study that aims to include malaria prevention as a part of maternal health in Kenya.

Feedback from review

1. Please ensure the length of the abstract meets the journal guideline. The conclusion part is quite long, and the recommendation is too broad.

2. There should not be abbreviations in the abstract, i.e., ANC. Just write it as it should be.

3. If you intend to write ANC as antenatal care in the abstract, please make sure you type 'antenatal care' first, then put the abbreviation at line 61.

4. See lines 100-101. Could you please explain briefly to whom health managers refer? What is the role of health managers? Why is it important to be involved in your study?

5. Please list the question or at least the topics to be questioned in each type of data collection (key interview, FGD, in-depth interview).

6. In FGD, please explain your method to ensure that everyone has equal participation.

7. See line 135; please refer directly to the person who works on this paper as the data analyst.

8. Please put a quotation to support lines 222-227.

9. Please put a quotation to support lines 250-254.

10. Unfortunately, the discussion cannot explain how participants tend to have strong perspectives on climate change. In the discussion, the author should explain whether the perspectives of participants regarding the effect of climate change on women’s health are good enough. Regardless of whether it is good or not, the author should explain where the participants can access the information to make them knowledgeable about the topic.

11. Please include the implication of malaria prevention in the conclusion and recommendation of the manuscript.

Reviewer #2: Introduction:

• Double check grammar throughout more generally

• Line 25 – can you provide the breakdown of how many young vs. older pregnant people were interviewed. I know it is mentioned later, but I think it would benefit to have it here as well.

• Line 55 – Can you provide the year where there was increased malaria prevalence?

• I recommend swapping paragraph 2 and 3 of the introductions, I think it would help with the flow and getting more specific towards your research question.

• I think what you are saying about the paragraph on malaria is important and provides context, but it makes me think that the study is about malaria specifically, when it is a subtopic. Maybe being a bit broader on the consequences in previous literature regarding maternal health and climate change would be helpful, to provide a lead in.

• Line 75 – this is the first time you are talking about frontline healthcare workers and their impacts. Provide some context of this in the introduction prior to getting into your research objectives.

• I would recommend providing some context for why stakeholders were also decided to be apart of this discussion and how their perspectives are necessary for change, etc.

Methods:

• Do you have any previous papers to cite to show how this is a part of a larger study (Line 83)

• The methods give more of a sense that the study is about malaria than it is about climate change. Can you make that more obvious? Or can you adjust your research questions to show malaria is a wider focus?

• Study Site – I would recommend providing slight background context for the weather patterns in these two sites over the last year or so to introduce it

• I think it jumps into ANC contacts without really defining what it is, (are these contacts they have as part of their medical care? Introduce it, and maybe it needs to be a subsection of your study site. Does not flow the best (line 94-98)

• The stats you are providing, is this generally within the counties the data? Is this within your data set of interviewees? Make it a bit clearer.

• I am interested to learn about your recruitment strategy for these interviews with all groups. How did you go about it?

• Where did the interviews take place for each group?

• This kind of study I believe would need some form of positionality/reflexivity statement, if that could be added.

Results:

• Some form of framework or theory to organize your results would be beneficial to have it grounded. I could see intersectionality, or the socio ecological model making sense.

• I think the quotes you have are extremely rich! But each subtopic is talking about a lot of content. I think it could be separated even more to keep the ideas somewhat aligned and organized.

• I find the connection of bringing in the vaccine seems very sporadic throughout, can you try and blend it, or bring it into your research questions as it does seem to be a central theme.

• I like table 1 and how it showcases/summarizes the main ideas. However, I feel like it feels a bit awkward having it at the end of the results. I think it could be at the beginning to provide a high level overview and then using this structure to organize the results. It just feels a bit unstructured right now.

• You have such a rich data set of interviews from so many different perspectives. Right now, everything is combined, but I think it could be stronger with a bit more differentiation between the different “groups” that were interviewed.

Discussion:

• You bring up really strong points, but I think the discussion would be stronger if you grounded it in more literature. Providing some insights on what other papers in similar regions, or similar conditions in other countries have found? Doing some comparison and contrasting. Is this aligned with previous literature, or is it novel findings?

• I think ending your discussion on more of a “policy/action” standpoint would be stronger. Right now, ending it on a statistic feels a bit unfinished. A paragraph around implications, next steps, recommendations would go over well.

Thank you for the opportunity to review this manuscript! Important findings that will have big impacts; however, I think it could be presented in a stronger manner. I appreciate you considering these comments and wish you the best of luck.

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Reviewer #1: No

Reviewer #2: No

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‘Water is a good thing, but when it destroys it is not good’: The influence of changing weather patterns on access to antenatal care services in Western Kenya - a qualitative study

PCLM-D-25-00488R1

Dear Dr. Matanda,

We are pleased to inform you that your manuscript '‘Water is a good thing, but when it destroys it is not good’: The influence of changing weather patterns on access to antenatal care services in Western Kenya - a qualitative study' has been provisionally accepted for publication in PLOS Climate.

Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow-up email from a member of our team.

Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated.

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Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Climate.

Best regards,

Stefan Wheat, MD

Academic Editor

PLOS Climate

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Additional Editor Comments (if provided):

Reviewer Comments (if any, and for reference):