PONE-D-19-26327

Community perspectives towards men’s involvement in maternity care: an exploration of potential barriers to men’s involvement in maternity care in a central Tanzanian community

PLOS ONE

Dear Dr., Gibore,

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.

We would appreciate receiving your revised manuscript by Feb 04 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.

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Please include the following items when submitting your revised manuscript:

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• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

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We look forward to receiving your revised manuscript.

Kind regards,

Calistus Wilunda, DrPH

Academic Editor

PLOS ONE

Additional Editor Comments:

The objective as stated in the abstract is slightly different from the one in the manuscript body. In the abstract, you mention “...to explore community perspectives on potential barriers toward men’s involvement…”, but in the main manuscript the objective is “…to provide opportunity for both men and women to share their experiences of male involvement…”.

Please explain more about data collection procedures in the manuscript. For instance, data collection tools are mentioned in the abstract but not in the main text. Include some of the information you have provided in the checklist you attached.

The checklist you provided is inadequate. Please include a 32-item COREQ checklist specifying the Item, Guide question, and the Page/section in your manuscript where this is reported. Refer to Table 1 of this paper: https://academic.oup.com/intqhc/article/19/6/349/1791966

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When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

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2. Please include a copy of the interview guide used in the study, in both the original language and English, as Supporting Information, or include a citation if it has been published previously.

3. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information

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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: Partly

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?

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: Recommendation: Major revision

Overarching comments

The authors work from a rich dataset and have reviewed a broad cross-section of relevant literature. However, in my opinion the study findings are not presented in a way that displays the analytical depth or precision that is expected from an academic article. While some substantial edits may be required to draw out the authors’ rich and nuanced findings, I believe that the authors’ methodology and conceptual focus have generated important findings that should be disseminated following revision.

Major revisions

The authors’ analysis and insights could be expressed more clearly in the manuscript. For example: “The effect of men’s involvement on health outcomes for women and children is directly linked to men’s knowledge, education, attitudes and behaviours” (Introduction, lines 49-51). What, specifically, do the authors mean here? The phrase “directly linked to” is not clear to me. Another example: the phrase “demonstrations of maleness” (Introduction, lines 56-57) is unclear. The authors engage with complex and nuanced concepts in the manuscript, and the language they use does not adequately express their points.

More broadly, in my opinion the manuscript does not engage in sufficient depth with the key issue of gender norms and gender power relations. The authors mention this issue, and to an extent situate their findings in the context of a patriarchal system. However, I believe that a deeper analysis is not clearly expressed in the current manuscript. For example, participants’ quotes illustrate a range of personal perspectives and community perspectives on male involvement, from an act of love to an act and practical/emotional support, to an act of jealousy, to a responsibility as head of the household, etc. However the authors do not address this diversity of rationales for male involvement, or the range of gender norms and gender power dynamics that inform these diverse perspectives. In a single paper it may not be feasible to engage deeply with the broad range of issues raised by the authors’ findings. I suggest that the authors clarify and narrow the aims and scope of the manuscript, in order to more deeply engage with their material.

Minor essential revisions

In my opinion the authors are inaccurate when they state that studies investigating barriers to men’s involvement in maternity care are limited (Introduction, line 74). There is a substantial and rapidly growing body of work in this area. Could the authors provide more detail on the specific gap in the literature that they have identified? The authors should also provide citations for some of the studies they mention that are focused on male involvement in PMTCT (Introduction, lines 72-73).

The study does not include the perspectives of single, unmarried, and first-time parents. The implications of this on study findings should be discussed as a limitation.

What are the “distinctive characteristics” of the study sites (Study area, line 112)? Additionally, qualitative sampling is typically designed to explore diversity, rather than to be representative, so the rationale for sampling diverse sites could be rephrased.

The themes ‘Women’s desire to have their partners in the antenatal clinic’, ‘Health care system barriers’, and ‘Location of the health care facilities’ would benefit from the addition of more illustrative quotes, to flesh out key findings and fully articulate the theme. For example, the single illustrative quote included in ‘Location of the health care facilities’ does not explain why this barrier impacts women’s male partners, but not women.

Discretionary, but recommended, revisions

The authors may wish to include a visual summary of their themes, to replace or complement the text summary in the first paragraph of the Results section.

The attributions for illustrative quotes (e.g. “FGD(2)-male participant Msalato_Dodoma municipal”) are distracting and could be formatted differently.

Reviewer #2: GENERAL COMMENTS

Thank you for giving me an opportunity to review this manuscript. The manuscript is relevant and focuses on an important public health issue. Overall, this manuscript suggests that the authors have undertaken a tremendous amount of work in the collection of data. The amount of interviews, and focus group discussions clearly demonstrate the amount of efforts the authors have invested on the collection of this data. However, there are some important issues which the authors need to address before the manuscript is accepted for publications.

Furthermore, the manuscript needs serious editing by a professional language editor. There are many editorial errors, unclear and or sensitive and inconsistently used words.

Title: The authors need to recast the title to make it short and clear. Delete unnecessary repetition of words in the title.

Abstract:

� Line 26- need to be clear if they used content or thematic approach in data analysis. In the paper, they talk about thematic rather than content analysis.

� Line 44 – chores instead of chore

INTRODUCTION

Major Comments

� The concept male involvement should be comprehensively defined not just focusing on clinic attendance. Similarly, the discussion on male involvement should include psychological, medical, socio-cultural etc. The authors need to include empirical evidence on the benefits and potential harms of male involvement in maternal health care.

� There is need to clearly indicate the knowledge gap and how the study advances existing knowledge.

Minor Comments

� Line 49-51, recast this sentence. Similarly, line 56 -58.

� Line 61, add word use or uptake after contraceptive.

� Line 62, delete word maternal after increase

� Line 66 – there is need also to highlight potential harms of male involvement in maternal health care.

� Line 69-73 – recast this sentence.

� Line 72 – the concept maternity care needs to be clearly defined.

MATERIALS AND METHODS

Major Comments

� More information is needed on methods and data collection. For example, how were participants for the FGDs selected? What were the inclusion and exclusion criteria? Who conducted interviews and FGDs? Where were interviews and FGDs conducted? How were the number of interviews and FGDs determined - how saturation point was reached? How FGDs were organized? How quality was maintained during data collection? How was the Nvivo 9 software used in the data analysis.

� More clarity is needed on the data analysis. The qualitative analysis part is rather simplistic and unclear. For example, who coded the data? How codes were determined? How was the coding done? Which themes emerged and how these themes were generated?

Minor Comments

� Line 111 – 112 not clear what the authors mean.

� Line 114 – 120 recast the paragraph, similarly, line 122 – 136.

RESULTS

Major Comments

� This section is unnecessarily too long. There is need to reduce the number of quotes and only use them when necessary.

� There is no table that show the themes and codes identified under each theme and makes it difficult to comment on how the codes are interpreted and how similar codes are categorized in to the same theme. However, some of the themes need to be merged to avoid repetition. For example, there are many repetition of what is discussed in the workload support and cultural barriers to male involvement.

� While the authors indicate that they conducted 32 FGDs, throughout the results section all quotes only refer to FGD 1 and FGD 2. There is also confusion in many quotes. Sometimes FGD 1 indicate female participants and in other places male participants. Similarly, FGD 2 in some places they refer female participants while in other places male participants.

Minor Comments

� Line 166 – 175 – need to summarize this paragraph

� Line 315 – 317 – this theme needs to be expanded. It would also be good to get perceptions of men on this issue.

� Line 370 – 380 – the quote is extremely long

� Line 441 – 461- this is different from pregnancy outside marriage.

� Line 493 – 513 – The description of this theme is not focused. Many issues are mixed together and thus difficult for the reader to understand.

� Line 515 – this theme could better be named as lack of knowledge.

� Line 528 – replace word nevertheless with an appropriate word.

� Line 550 – make the theme short, it reads like a sentence rather than theme.

� Line 582 – 586 – this theme needs to be expanded. Why women are able to attend health facilities despite the long distance? why not men? Are women in these communities physically stronger than men?

� Line 607 –619- small consultation room is not discussed in the text. Only privacy in the labour room is discussed.

� Line 621 – 640 – This theme is not clear. In Tanzania, maternal and child health services are nor charged. How then do shortage of medical supplies hinder men’s participation in maternal and child health services?

DISCUSSION

Overall, the discussion is weak and unnecessarily long. The discussion part is not different from the Finding. No new arguments that lead to conclusion. There is no critical analysis and reflection of the findings. Repeatedly, findings are compared with studies conducted in other countries. The authors need to discuss implications of the findings in Tanzania context.

Minor comments

� Line 653 – 658 – These concepts should have been introduced in the results section. Don’t introduce new concepts in the discussion.

� Pg 21- how are the two paragraphs different? Both seem to refer to cultural gender roles in the community.

� Line 682 – 683 – Which study area are you referring to?

� Line 683 – 686 – no need of repeating methods

� Line 704 – 708 – This was not discussed in the results section. Don’t introduce new findings in the discussion.

� Line 709 – 711 – The authors need to explain why women were able to attend despite long distance?

� Line 711 – 715 – This strategy already ended in 2017 (2007 -2017). How can implementation then be accelerated?

� Line 770 – 771 – No findings on the consultation rooms was reported in the results section.

� Line 779 – 786 Need to refer to the correct name of the Ministry. This Ministry has changed since 4 years ago.

� Line 788 – 791 This was not discussed in the results section. Don’t introduce new findings in the discussion.

STRENGTHS AND WEAKNESSES

� How can findings of a qualitative study conducted in 16 villages be generalized for the entire country? The authors need to understand the purpose of conducting qualitative studies and why they differ from quantitative studies.

CONCLUSIONS AND RECOMMENDATIONS

� There is no conclusion; the current conclusion is rather a summary of findings. The authors need to provide conclusions of the paper. Recommendations are generally weak. The authors should provide recommendations which are aligned to the findings of the study.

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Reviewer #1: No

Reviewer #2: Yes: Stephen Maluka

[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.]

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PONE-D-19-26327R1

Community perspectives: an exploration of potential barriers to men’s involvement in maternity care in a central Tanzanian community

PLOS ONE

Dear Dr., Gibore,

Thank you for submitting your manuscript to PLOS ONE. Peer review for this manuscript is now complete but I notice that you sometimes use the present tense in the results section (for example line 423) . Can you please revise this section accordingly. You can also use this opportunity to proofread the  entire manuscript  and correct any grammatical errors. For instance, you talk of "Men's attendance to maternity health services". I think it is correct to say "Men's attendance of maternity healthcare services..."

We would appreciate receiving your revised manuscript by May 21 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,

Calistus Wilunda, DrPH

Academic Editor

PLOS ONE

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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 #2: 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 #2: Yes

**********

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

Reviewer #2: N/A

**********

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 #2: 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 #2: 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 #2: The manuscript has improved significantly. I am happy that the authors have addressed all important comments I raised. I have not additional comments.

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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 #2: Yes: Stephen Maluka

[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.

Community perspectives: an exploration of potential barriers to men’s involvement in maternity care in a central Tanzanian community

PONE-D-19-26327R2

Dear Dr. Gibore,

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.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

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With kind regards,

Calistus Wilunda, DrPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: