Dear Marbán-Castro,

Thank you very much for submitting your manuscript "“One feels anger to know there is no one to help us!”: Perceptions of mothers of children with Zika-associated microcephaly in Caribbean Colombia: A qualitative study" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. In light of the reviews (below this email), we would like to invite the resubmission of a significantly-revised version that takes into account the reviewers' comments.

We cannot make any decision about publication until we have seen the revised manuscript and your response to the reviewers' comments. Your revised manuscript is also likely to be sent to reviewers for further evaluation.

When you are ready to resubmit, please upload the following:

[1] A letter containing a detailed list of your responses to the review comments and a description of the changes you have made in the manuscript. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

[2] Two versions of the revised manuscript: one with either highlights or tracked changes denoting where the text has been changed; the other a clean version (uploaded as the manuscript file).

Important additional instructions are given below your reviewer comments.

Please prepare and submit your revised manuscript within 60 days. If you anticipate any delay, please let us know the expected resubmission date by replying to this email. Please note that revised manuscripts received after the 60-day due date may require evaluation and peer review similar to newly submitted manuscripts.

Thank you again for your submission. We hope that our editorial process has been constructive so far, and we welcome your feedback at any time. Please don't hesitate to contact us if you have any questions or comments.

Sincerely,

Ran Wang, Ph.D., M.D.

Associate Editor

PLOS Neglected Tropical Diseases

Dennis Bente

Deputy Editor

PLOS Neglected Tropical Diseases

***********************

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: The aims and methods were clearly described. I only have one minor suggestion in the "Abstract" to include the number of mothers interviewed in the methodology description. (it was on the author summary);

Reviewer #2: Dear Authors,

I started reading with great interest your article on a topical and important problem that arose after the end of the Zika pandemic, but later I found out that some important corrections need to be made to highlight the value of the article and I present them in detail below.

INTRODUCTION

• In this section is important to describe in more detail the CZS, the comorbid disorders, as well as its serious effects on the neurodevelopment of infants and children.

• Furthermore, if you have access, it would be great to mention the average monthly income in Colombia, the monthly expenses of a family with a child with CZS and how much the state compensates these families could also be included in a short paragraph.

• Also, it should be mentioned the percentage of people who are uninsured or living below the poverty line.

• The insurance system in Colombia

METHODS

• In the CZS, the spectrum of disability varies depending on the severity of microcephaly. Why was your sample not grouped according to their degree of disability?

Reviewer #4: These were described adequately - although there was little description of how participants were selected and recruited. There is also limited discussion of the positionality of the researchers.

--------------------

Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: The manuscript is well-written and deals with a very important topic focused on perceptions of mothers of children with Congenital Zika Syndrome.

The results point to a large spectrum based on knowledge about health care, assistance and rights; and some crucial social, subjective, and economic aspects that were affected in their lives.

I have minor comments:

- I liked how you used the tables and figure to describe and summarize the results;

- Table 2 - include the word "direct" in the description of the table. (Direct and indirect effects...);

Follow few comments and questions, in case you think they are relevant to your argument in results and discussion:

- The fact of participants live in rural and peri-urban areas with low socio-economic status could be an influence of these mothers' views/perceptions? Could you explore it more in the discussion? Are there studies like this in urban areas in Colombia?

- Some studies in Brazil point that groups of mothers with children with microcephaly whether it is online (like WhatsApp groups) or officially organized associations are an interesting way to struggle by rigts, share lived experiences, and have a kind of social support. Have you seen it in your data? I would like to know more about how the mothers share with each other.

- Most of the mothers interviewed had as occupation "caring of her child". Was it a given need by had a child with CZS? To have a child with a CZS has changed their trajectories and project of lives?

Reviewer #2: The results presented clearly and anatically

The tables have sufficient quality

Please explain ''What do you define as “low Socio-economic status?''

Reviewer #4: There are many linguistic errors, some of which I have highlighted. The manuscript should be careful read through and edited to address these.

The results are presented as themes and described in text, tables and a diagram. It is adequate

--------------------

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: (No Response)

Reviewer #2: DISCUSION

• You refer the cesarean section as a routine procedure in cases with microcephaly. Can you tell if you have access, the rates of cesarean sections in Colombia?

• The syndrome has a significant psychosocial impact on families, especially mothers and consequently health care providers. Can you report similar studies from all the affected areas?

CONCLUSIONS

• At this point it is important to emphasize the need to raise awareness of relevant stakeholders, not only locally but also globally. This article highlights not only a significant public health problem and the inequality in access to health services, it presents significant gender inequality issues through presents significant problems of gender inequality through the violation of women's rights and their self-disposition.

Reviewer #4: Overall the conclusions were supported well by the data presented and the limitations given. There was perhaps more that could have been done to explore the positionality of the researchers and how this might have influenced the interviews and the analysis of the data.

A conclusion that the Zika virus has differential affect on men and women is hard to support without having included men in the research.

--------------------

Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: (No Response)

Reviewer #2: Dear Editor

Thank you for the invitatation to review this manuscript. I suggest minor revisions

Kind regards

Reviewer #4: The text includes a great many grammatical and linguistic errors. The text would need to be carefully edited to address these.

--------------------

Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: (No Response)

Reviewer #2: INTRODUCTION

• In this section is important to describe in more detail the CZS, the comorbid disorders, as well as its serious effects on the neurodevelopment of infants and children.

• Furthermore, if you have access, it would be great to mention the average monthly income in Colombia, the monthly expenses of a family with a child with CZS and how much the state compensates these families could also be included in a short paragraph.

• Also, it should be mentioned the percentage of people who are uninsured or living below the poverty line.

• The insurance system in Colombia

METHODS

• In the CZS, the spectrum of disability varies depending on the severity of microcephaly. Why was your sample not grouped according to their degree of disability?

RESULTS

• What do you define as “low Socio-economic status”?

DISCUSION

• You refer the cesarean section as a routine procedure in cases with microcephaly. Can you tell if you have access, the rates of cesarean sections in Colombia?

• The syndrome has a significant psychosocial impact on families, especially mothers and consequently health care providers. Can you report similar studies from all the affected areas?

CONCLUSIONS

• At this point it is important to emphasize the need to raise awareness of relevant stakeholders, not only locally but also globally. This article highlights not only a significant public health problem and the inequality in access to health services, it presents significant gender inequality issues through presents significant problems of gender inequality through the violation of women's rights and their self-disposition.

Reviewer #4: This is an important study exploring the views and experiences of mothers or primary caregivers caring for an infant that has Sika associated microcephaly in Caribbean Colombia. The weakness of the paper that need to be addressed are: improved description of their methods including recruitment, translation in transcription or at report writing and the positionality of the researchers. There are numerous errors, some of which I have highlighted on the pdf of the manuscript which need to be corrected.

Figure Files:

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org.

Data Requirements:

Please note that, as a condition of publication, PLOS' data policy requires that you make available all data used to draw the conclusions outlined in your manuscript. Data must be deposited in an appropriate repository, included within the body of the manuscript, or uploaded as supporting information. This includes all numerical values that were used to generate graphs, histograms etc.. For an example see here: http://www.plosbiology.org/article/info%3Adoi%2F10.1371%2Fjournal.pbio.1001908#s5.

Reproducibility:

To enhance the reproducibility of your results, we recommend that you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. Additionally, PLOS ONE offers an option to publish peer-reviewed clinical study protocols. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols

Attachments

Attachment

Submitted filename: FC PNTD-D-21-00617_reviewer.pdf

Dear Marbán-Castro,

Thank you very much for submitting your manuscript "“One feels anger to know there is no one to help us!”: perceptions of mothers of children with Zika-associated microcephaly in Caribbean Colombia: A qualitative study" for consideration at PLOS Neglected Tropical Diseases. As with all papers reviewed by the journal, your manuscript was reviewed by members of the editorial board and by several independent reviewers. In light of the reviews (below this email), we would like to invite the resubmission of a significantly-revised version that takes into account the reviewers' comments.

We cannot make any decision about publication until we have seen the revised manuscript and your response to the reviewers' comments. Your revised manuscript is also likely to be sent to reviewers for further evaluation.

When you are ready to resubmit, please upload the following:

[1] A letter containing a detailed list of your responses to the review comments and a description of the changes you have made in the manuscript. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

[2] Two versions of the revised manuscript: one with either highlights or tracked changes denoting where the text has been changed; the other a clean version (uploaded as the manuscript file).

Important additional instructions are given below your reviewer comments.

Please prepare and submit your revised manuscript within 60 days. If you anticipate any delay, please let us know the expected resubmission date by replying to this email. Please note that revised manuscripts received after the 60-day due date may require evaluation and peer review similar to newly submitted manuscripts.

Thank you again for your submission. We hope that our editorial process has been constructive so far, and we welcome your feedback at any time. Please don't hesitate to contact us if you have any questions or comments.

Sincerely,

Ran Wang, Ph.D., M.D.

Associate Editor

PLOS Neglected Tropical Diseases

Dennis Bente

Deputy Editor

PLOS Neglected Tropical Diseases

***********************

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #1: The aims and methods were clearly described and more details about participants' recruitment were pointed.

Reviewer #2: • In the CZS, the spectrum of disability varies depending on the severity of microcephaly. Why was your sample not grouped according to their degree of disability?

Reviewer #4: This study has used qualitative methods to explore the experiences of women who have had a child affected by the Zika virus. The design is appropriate and the authors have highlighted important findings. The study authors did not seek to get a sample that represented different socioeconomic groups or ensure that their sample was representative in terms of certain factors. This would have strengthened the work.

There are some important findings, particularly the way the Zika infections exacerbated inequalities, the poor access to family planning services, the lack of access to information, the stigma experienced by women. The findings give valuable information for ways that future outbreaks can be managed and what information needs to be disseminated to vulnerable populations and the nature of the support needed for women in these communities.

--------------------

Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #1: The manuscript is well-written and deals with a very important topic focused on perceptions of mothers of children with Congenital Zika Syndrome.

The results point to a large spectrum based on knowledge about health care, assistance, gender and rights; and some crucial social, subjective, and economic aspects that were affected in their lives.

The tables and figure describe and summarize the results in a good way.

Reviewer #2: The results presented clearly and anatically

The tables have sufficient quality

Please explain ''What do you define as “low Socio-economic status?''

Reviewer #4: The results are clearly presented. the paper has a number of grammatical errors and in two sections the analysis and conclusions do not feel that they are well embedded in the findings. I have made these clear in my accompanying text.

--------------------

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #1: (No Response)

Reviewer #2: CONCLUSIONS

• At this point it is important to emphasize the need to raise awareness of relevant stakeholders, not only locally but also globally. This article highlights not only a significant public health problem and the inequality in access to health services, it presents significant gender inequality issues through presents significant problems of gender inequality through the violation of women's rights and their self-disposition.

Reviewer #4: There are two conclusions where I feel the authors have drawn conclusions that are not supported by the data. The final sentence of the abstract is also vague and could be far more informative given the richness of the findings.

--------------------

Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #1: (No Response)

Reviewer #2: Dear Editor,

Unfortunately, the authors did not revise the manuscript according to our suggestions.

Reviewer #4: These are detailed on an attached word document

--------------------

Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #1: (No Response)

Reviewer #2: INTRODUCTION

• In this section is important to describe in more detail the CZS, the comorbid disorders, as well as its serious effects on the neurodevelopment of infants and children.

• Furthermore, if you have access, it would be great to mention the average monthly income in Colombia, the monthly expenses of a family with a child with CZS and how much the state compensates these families could also be included in a short paragraph.

• Also, it should be mentioned the percentage of people who are uninsured or living below the poverty line.

• The insurance system in Colombia

METHODS

• In the CZS, the spectrum of disability varies depending on the severity of microcephaly. Why was your sample not grouped according to their degree of disability?

The results presented clearly and anatically

The tables have sufficient quality

Please explain ''What do you define as “low Socio-economic status?''

DISCUSION

• You refer the cesarean section as a routine procedure in cases with microcephaly. Can you tell if you have access, the rates of cesarean sections in Colombia?

• The syndrome has a significant psychosocial impact on families, especially mothers and consequently health care providers. Can you report similar studies from all the affected areas?

CONCLUSIONS

• At this point it is important to emphasize the need to raise awareness of relevant stakeholders, not only locally but also globally. This article highlights not only a significant public health problem and the inequality in access to health services, it presents significant gender inequality issues through presents significant problems of gender inequality through the violation of women's rights and their self-disposition.

Dear Editor

Thank you for the invitatation to review this manuscript. I suggest minor revisions

Kind regards

INTRODUCTION

• In this section is important to describe in more detail the CZS, the comorbid disorders, as well as its serious effects on the neurodevelopment of infants and children.

• Furthermore, if you have access, it would be great to mention the average monthly income in Colombia, the monthly expenses of a family with a child with CZS and how much the state compensates these families could also be included in a short paragraph.

• Also, it should be mentioned the percentage of people who are uninsured or living below the poverty line.

• The insurance system in Colombia

METHODS

• In the CZS, the spectrum of disability varies depending on the severity of microcephaly. Why was your sample not grouped according to their degree of disability?

RESULTS

• What do you define as “low Socio-economic status”?

DISCUSION

• You refer the cesarean section as a routine procedure in cases with microcephaly. Can you tell if you have access, the rates of cesarean sections in Colombia?

• The syndrome has a significant psychosocial impact on families, especially mothers and consequently health care providers. Can you report similar studies from all the affected areas?

CONCLUSIONS

• At this point it is important to emphasize the need to raise awareness of relevant stakeholders, not only locally but also globally. This article highlights not only a significant public health problem and the inequality in access to health services, it presents significant gender inequality issues through presents significant problems of gender inequality through the violation of women's rights and their self-disposition.

Reviewer #4: There are some important findings, particularly the way the Zika infections exacerbated inequalities, the poor access to family planning services, the lack of access to information, the stigma experienced by women. The findings give valuable information for ways that future outbreaks can be managed and what information needs to be disseminated to vulnerable populations and the nature of the support needed for ​women in these communities.

The weakness in the paper include some improvements in grammatical errors made

The abstract needs strengthening

The interpretation of the action of health care professionals in relation to abortion, and the comments about the high c section rate stood out as observations that were not substantiated by the data and rather reflected the positionality of the authors.

These are major revisions that need to be addressed before this important paper can be published.

--------------------

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.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #4: No

Figure Files:

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org.

Data Requirements:

Please note that, as a condition of publication, PLOS' data policy requires that you make available all data used to draw the conclusions outlined in your manuscript. Data must be deposited in an appropriate repository, included within the body of the manuscript, or uploaded as supporting information. This includes all numerical values that were used to generate graphs, histograms etc.. For an example see here: http://www.plosbiology.org/article/info%3Adoi%2F10.1371%2Fjournal.pbio.1001908#s5.

Reproducibility:

To enhance the reproducibility of your results, we recommend that you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. Additionally, PLOS ONE offers an option to publish peer-reviewed clinical study protocols. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols

Attachments

Attachment

Submitted filename: Dear authors..docx

Attachment

Submitted filename: Dear Editor.docx

Attachment

Submitted filename: Reviewer Comments.docx

Dear Marbán-Castro,

We are pleased to inform you that your manuscript '“One feels anger to know there is no one to help us!”. Perceptions of mothers of children with Zika virus-associated microcephaly in Caribbean Colombia: A qualitative study' has been provisionally accepted for publication in PLOS Neglected Tropical Diseases.

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.

Should you, your institution's press office or the journal office choose to press release your paper, you will automatically be opted out of early publication. We ask that you notify us now if you or your institution is planning to press release the article. All press must be co-ordinated with PLOS.

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

Best regards,

Ran Wang, Ph.D., M.D.

Associate Editor

PLOS Neglected Tropical Diseases

Dennis Bente

Deputy Editor

PLOS Neglected Tropical Diseases

***********************************************************

Reviewer's Responses to Questions

Key Review Criteria Required for Acceptance?

As you describe the new analyses required for acceptance, please consider the following:

Methods

-Are the objectives of the study clearly articulated with a clear testable hypothesis stated?

-Is the study design appropriate to address the stated objectives?

-Is the population clearly described and appropriate for the hypothesis being tested?

-Is the sample size sufficient to ensure adequate power to address the hypothesis being tested?

-Were correct statistical analysis used to support conclusions?

-Are there concerns about ethical or regulatory requirements being met?

Reviewer #2: The methods presendet clearly and analitically

Reviewer #5: (No Response)

**********

Results

-Does the analysis presented match the analysis plan?

-Are the results clearly and completely presented?

-Are the figures (Tables, Images) of sufficient quality for clarity?

Reviewer #2: The results presendet clearly

Reviewer #5: (No Response)

**********

Conclusions

-Are the conclusions supported by the data presented?

-Are the limitations of analysis clearly described?

-Do the authors discuss how these data can be helpful to advance our understanding of the topic under study?

-Is public health relevance addressed?

Reviewer #2: the conclusions are clearly

Reviewer #5: (No Response)

**********

Editorial and Data Presentation Modifications?

Use this section for editorial suggestions as well as relatively minor modifications of existing data that would enhance clarity. If the only modifications needed are minor and/or editorial, you may wish to recommend “Minor Revision” or “Accept”.

Reviewer #2: (No Response)

Reviewer #5: (No Response)

**********

Summary and General Comments

Use this section to provide overall comments, discuss strengths/weaknesses of the study, novelty, significance, general execution and scholarship. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. If requesting major revision, please articulate the new experiments that are needed.

Reviewer #2: Most issues have been overtaken

Reviewer #5: The epidemic of Zika virus has drawn global attention, largely due to its association with the dramatic increase of neonatal microcephaly. In this study, Elena Marbán-Castro et al. used qualitative methods to investigate the perceptions about ZIKV infection among mothers of children born with microcephaly during the ZIKV epidemic in Caribbean Colombia, and the barriers and facilitators affecting child health follow-up. The design is appropriate and the findings are important. These findings will give valuable information for ways that future outbreaks can be better managed and what information and supports need to be provided to vulnerable populations in these communities.

The authors have satisfactorily answered all the comments raised by previous reviewers, and therefore the manuscript may be accepted for publication with only very minor modifications as listed below.

1. Page 13, Line 283 “Other interviewees learned from itonly once the baby was born...”, should be “...it only...”

**********

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.

If you choose “no”, your identity will remain anonymous but your review may still be made public.