PGPH-D-23-01804

Southern Ethiopian skilled birth attendant variations and maternal mortality: a multilevel study of a population-based cross-sectional household survey

PLOS Global Public Health

Dear Kea,

Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’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 15th November, 2023. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the 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'.

Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Collins Otieno Asweto, PhD

Academic Editor

PLOS Global Public Health

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1. Please include a complete copy of PLOS’ questionnaire on inclusivity in global research in your revised manuscript. Our policy for research in this area aims to improve transparency in the reporting of research performed outside of researchers’ own country or community. The policy applies to researchers who have travelled to a different country to conduct research, research with Indigenous populations or their lands, and research on cultural artefacts. The questionnaire can also be requested at the journal’s discretion for any other submissions, even if these conditions are not met.  Please find more information on the policy and a link to download a blank copy of the questionnaire here: https://journals.plos.org/globalpublichealth/s/best-practices-in-research-reporting. Please upload a completed version of your questionnaire as Supporting Information when you resubmit your manuscript.

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.

Additional Editor Comments (if provided):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does this manuscript meet PLOS Global Public Health’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: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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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: No

Reviewer #2: No

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

PLOS Global Public Health 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

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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: First of all, this is a very important study addressing the importance and consequences of using skilled birth attendants (SBAs) in safeguarding safe motherhood principles. The findings of the study have potentials to impact public health policy and programme development. I have made a number of observations with regards to the manuscript.

1. The objectives of the study are many and important but need to presented more clearly.

2. The methodology comprising the study population, the sampling design, data analysis, and ethical consideration are comprehensively presented in the manuscript.

3. The section in the methods that I think the authors need to address is the sample size presented. In the abstract, 3191 women were said to have been interviewed but in the sample determination, figures such as 768 and 8880 are also talked about. There appears to be contradiction here and so, please, reconcile and be consistent.

4. In the introduction, the authors seem to be reporting results of their study in lines 84-91. Please, check and reserve your findings to the results section.

5. The policy recommendations appear to sound like authorizing or commanding instead of advocacy. Please, check.

Despite the above, the study is very comprehensive and well conducted on a very critical maternal, child, and reproductive health issue. Please, check my comments in the PDF attached.

Reviewer #2: Overall, Aschenaki et al. discuss the coverage of SBA in Sidama national regional state and its correlation with maternal mortality. This topic is very relevant and of great public health importance in Sub-Saharan Africa. Overall, the article is well written and the information is clearly presented. The conclusion are in line with the research findings.

Abstract

The abstract is well written. It summarises the important aspects of the study well. However, to comply with the journal guidelines, subheadings may be eliminated.

Introduction.

The introduction gives a good preamble to the research topic. It sets a good background for the reader to understand this research topic. However, it would be nice to describe the setting of Sidama national region including the physical, social, economic structures as this helps the reader to understand the research context better.

Methods

The methods are described sufficiently for the research to be reproduced.

Results

The results are well presented. The effect of larger sampling units on the results was accounted for, which is good. However, the number of women interviewed is a lot higher than the proposed sample size, is there an explanation for this?

The data in support of these has not been provided yet and therefore, the results cannot be proven.

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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.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Maternal mortality in Southern Ethiopia.pdf

Southern Ethiopian skilled birth attendant variations and maternal mortality: a multilevel study of a population-based cross-sectional household survey

PGPH-D-23-01804R1

Dear Kea,

We are pleased to inform you that your manuscript 'Southern Ethiopian skilled birth attendant variations and maternal mortality: a multilevel study of a population-based cross-sectional household survey' has been provisionally accepted for publication in PLOS Global Public Health.

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

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

IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript.

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 globalpubhealth@plos.org.

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

Best regards,

Collins Otieno Asweto, PhD

Academic Editor

PLOS Global Public Health

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Reviewer Comments

Take note on minor changes as recommended by Reviewer 3:

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

Reviewer #3: (No Response)

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2. Does this manuscript meet PLOS Global Public Health’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: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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4. 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

Reviewer #3: Yes

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

PLOS Global Public Health 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

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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: I have reviewed the entire manuscript a number of times and have observed that all my concerns and recommendations have been adequately addressed. The manuscript has, therefore, become much clearer and meaningful to the reader.

Reviewer #2: All previous comments addressed. no additional comments.

Reviewer #3: I am reviewing a revised version of this manuscript, specifically the Revised Manuscript with Track Changes and am using the line numbering from that version. The authors have responded appropriately to the previous reviewers' comments and have made the necessary revisions in the manuscript.

This paper presents an analysis of the impact of skilled birth attendants on maternal mortality. The findings are important for decision making and resource allocation by the Ethiopian government and are relevant to many other LMICs. I feel that the paper is ready for publication, but would benefit from a small number of minor revisions to improve clarity and readability. Again, I am using the Line Numbering fro the "Revised Manuscript with Track Changes."

Line 67: Change "mother-in-law" to "mothers-in-law"

Line 75: change "...like.." to "...such as the level of husband education.."

Line 83: Replace the "and" with just a comma

Line 147: Again replace "mother-in-law" with "mothers-in-law"

Line 158: Change sentence to read, "...household characteristics such as the level of education of the husband,...."

Line 284: In this table change the heading of "Number of ANC visit" to Number of ANC visits"

Line 426, I would recommend that you change the sentence to read, "The probable reason for lower MMR is that the district has better roads."

Line 463: I would suggest that you change the sentence to read, "...women live far from the nearest hospital had fewer women assisted by SBA for their deliveries."

Line 469: I would suggest retaining the word, "should" rather than deleting it. This does represent an important recommendation that derives from the research described in this paper.

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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.

Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public.

For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Paul R DeLay MD, DTM&H (Lond)

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