PONE-D-19-26928

Qualitative assessment of the healthcare use experience of women with a recent perinatal mortality in Sindh, Pakistan

PLOS ONE

Dear Jamil Ahmed

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

While the manuscript is presented to a high standard, the reviewers raise a number of minor points that, collectively, would improve reader understanding of methods and findings. Please also consider the suggested change in the title.  

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Vicki Flenady

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately 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: N/A

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). 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: Yes

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

PLOS ONE 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: 1. I think there is a need to change the title of the study. Currently, it is little confusing.

Topic could be: Exploring women’s experience of healthcare use during pregnancy and childbirth to understand factors contributing to perinatal deaths

2. Talk a little bit more about your results in abstract section. You can reduce some text from background and methods if you like.

3.I think you can further strengthen the rationale by explicitly stating the current gaps in the community-based maternal and child care services. Line no 100

4. Specify what factors, in particular, you would like to explore through this study? sociocultural? socioeconomic? religious? individual? biological? Line no 107

5. Line no 109. Within qualitative research, what design you employed to conduct this study? exploratory? descriptive? case study? etc.

6. Under the settings heading, you have not mentioned why this Tando Muhammad Khan District has been selected?

7. Can you add the interview guides as appendix?

8. I couldn't see ethical considerations of this research in the methods section. Did you took consent with study participants?

9. Regarding analysis, the FGDs and IDIs were analysed as one data set?

10. I think it would be great if you could provide a table for study participants for FGDs and IDIs. Also, how many participants in one FGD?

11. Also, the age and other demographic characteristics of participants that you have presented in results section could also be well presented in a table.

12. I think you should rephrase your themes like unavailability of the healthcare services, poor access to care and poor quality of care. The themes should give a quick understanding about the study results.

13. I think you can also make sub-themes within themes like high cost of care within poor access to care theme and so on.

14. Discussion section can be further strengthened by some good policy recommendation as in background section you stated that .. the purpose is to reorient policies and services

Reviewer #2: Reviewer’s Comments

Qualitative assessment of the healthcare use experience of women with a recent perinatal mortality in Sindh, Pakistan

First of all congratulations on a huge undertaking. To do this type of research in a developing country is extremely challenging. Obtaining Ethics committee approval, involving translation, and accessing 25 mothers in a rural community are wonderful accomplishments.

The description of your research process was clear and accurate. The participant’s comments were powerful and supported your conclusions and recommendations. The inclusion of health care providers was also important for validating what the mothers were saying. Excellent references!

A few areas might be better worded or clarified.

I am unclear as to who lady health workers are. I googled it and found out, but I wonder if a brief description of these women, with education and training details might be good.

Line 104 is unclear to me. “we found that women with a high perinatal loss in Pakistan also have low empowerment” What is women with a high perinatal loss? Do you mean women who experience perinatal loss also experience lack of power? Maybe clarify.

Line 235 Should the last word be “highly” rather than high?

Line 401 is unclear to me. “Most women in Pakistan (82% using public care and 96% using private care) pay out of pocket for comprehensive emergency obstetric care service costs (16).” Might be clearer to say 82% of those using public care…

Line 412 I am unsure of what you are saying here. “This study also showed that the effects on neonatal (and maternal) survival were much better in least developed countries” Could you clarify or explain further?

Thank you for this work. It is applicable to my work in a different developing country and I understand the great need. Your manuscript will help us continue to take steps that will impact the stillbirth rate worldwide!

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Reviewer #1: Yes: Anam Feroz

Reviewer #2: Yes: Sue Steen

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

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. Registration is free. 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. Please note that Supporting Information files do not need this step.

PONE-D-19-26928R1

Exploring women’s experience of healthcare use during pregnancy and childbirth to understand factors contributing to perinatal deaths in Pakistan: a qualitative study

PLOS ONE

Dear Dr. Ahmed,

Thank you for submitting the revised version of your manuscript to PLOS ONE. After a second round of review, we feel that it does not fully meet PLOS ONE’s publication criteria yet. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the second review process.

We would appreciate receiving your revised manuscript by April 20th 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable 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. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled '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.

We look forward to receiving your revised manuscript.

Kind regards,

Sara Ornaghi, M.D., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

The topic of this manuscript is of utmost importance. However, manuscript's intelligibility is limited by the presence of grammar mistakes throughout the document. For instance, meaning of sentences in Line 126-128 and 132-136 is difficult to understand as they are currently written. I'd suggest to have the manuscript revised by an English-proficient individual. Additional minor comments:

- Line 114: ‘other high perinatal burden countries’. I suppose the authors mean ‘other high perinatal mortality-burden countries’ as specified in line 119. Please correct.

- Line 123: ‘..management of server infections’. I suppose the authors mean severe. Please correct.

- Line 193: please specify the occupation of the local Sindhi speaking interviewer at the time of the study and the type of training she received.

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Reviewers' comments:

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 #3: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Partly

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

Reviewer #3: No

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). 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 #3: No

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

PLOS ONE 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 #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 #3: The authors performed a qualitative research on the causative factors of perinatal deaths in a rural area in Pakistan, interviewing women and families involved, as well as health care officers and lady health workers.

I agree with the second reviewer on emphasizing the novelty and the effort of giving voice to women of this area, underlining social and economical problems of that society.

However, as stated by Reviewer1, the manuscript needs to be reviewed in order to sound more scientific, although maintaining its qualitative nature.

To do this, my suggestions are the followings (mainly in agreement with Reviewer 1):

• I suggest to add the interview guides as appendix: it would be useful for the scientific community in order to reproduce the same methodology for other qualitative studies on perinatal death.

• I think it would be useful to provide a table for study participants for FGDs and IDIs, although the numbers are small.

• Demographic data of participants are mandatory, presented in a table (age, BMI, parity, ...).

Other minor changes:

• Introduction line 105: I would abbreviate in "Perinatal mortality is a challenge in developing countries..."

• Introduction line 108: I would add "compared to 4 per 1000 births in high-income countries".

• Results line 256: I would use "delivered" rather than "birthed".

• Concerning grammar, pay attention to the use of articles: sometimes you can substitute "the women" with just "women". Please correct it in the manuscript.

• Try to be more concise in the Discussion.

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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.

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Reviewer #3: Yes: Annalisa Inversetti

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

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. Registration is free. 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. Please note that Supporting Information files do not need this step.

Exploring women’s experience of healthcare use during pregnancy and childbirth to understand factors contributing to perinatal deaths in Pakistan: a qualitative study

PONE-D-19-26928R2

Dear Dr. Ahmed,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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With kind regards,

Sara Ornaghi, M.D., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

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 #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

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

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). 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 #3: Yes

**********

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

PLOS ONE 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 #3: Yes

**********

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 #3: (No Response)

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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.

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 #3: Yes: Annalisa Inversetti