PONE-D-20-03726

Indigenous women’s perspectives on accessing maternal health care services in the Chittagong Hill Tracts (CHT), Bangladesh: a qualitative descriptive study

PLOS ONE

Dear Shahinoor Aktor,

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Reviewer #1: Comments on Manuscript: Indigenous women’s perspectives on accessing maternal health care services in the Chittagong Hill Tracts (CHT), Bangladesh: a qualitative descriptive study

Thank you for requesting me to review this manuscript. This paper is an important contribution to the use of MCH services and disrespect and abuse of women in MCH services by health workers. A lot of this work has been done in low (e.g. Malawi) and middle income countries. However, this paper is important because it focuses on marginalized communities.

Introduction

Perhaps it would be proper to indicate how many ANC visits WHO expects women to have.

Analysis

1. Was the analysis theory or data driven?

2. The analysis could benefit from further categorization or classification of the barriers according to various themes (e.g. health care barriers, individual barriers, community barriers etc.). The Bradley paper below could perhaps give some insights on how to arrange the themes.

A) System barriers - could look at those barriers related to the health care systems

B) Health provider barriers e.g. unethical practices that are done without informed consent of the participants who have a loop inserted without their knowledge, midwives and cleaners who request for payment from patients

C) Individual barriers - These would pertain to the barriers pertinent to the participants like lack of money, lack of knowledge etc.

Some categories were not necessarily barriers, but merits of the home care delivery, so maybe they could fall under perceptions of participants, like, the comparison they make between health care and home delivery.

I would add to line 655 - unethical and unfair demands

References

Bradley, S., McCourt, C., Rayment, J., & Parmar, D. (2016). Disrespectful intrapartum care during facility-based delivery in sub-Saharan Africa: a qualitative systematic review and thematic synthesis of women's perceptions and experiences. Social Science & Medicine, 169, 157-170.

Reviewer #2: Identification of barriers to access of maternity care is important. It is disappointing that the researchers did not look at enablers as well, as often the voice of indigenous women about what has worked/is working well identifies what can be strengthened. The barriers identified are generalised to other indigenous women not only to other areas in Bangladesh but worldwide. I would like to suggest that the authors revisit these assumptions, in particular as purposive sampling was used with a small group of women from CHT region. It is unclear if the participants all spoke the same language or whether Bangla was their first language. Having information or service provision in one's own language was not identified as a barrier in the abstract and received only a small menton in the article. Numerous health literature research has shown that this is one of the biggest barrier. Some sentence structures are long and lose clarity. There is inconsistency with some terminology, e.g. Bangladesh is a low to middle income country but sometimes referred to as low income country. It appears the author assumes being indigenous means diverse socio-cultural backgrounds. Clarity around this would enhance the understanding for the reader. It would be useful to include a short paragraph explaining the difference between minority groups and indigenous groups and describe the general indigenous people group of Bangladesh. It appears the term minority groups and indigenous groups are used interchangeable in this study. The corresponding article with this study published by BMJ: Akter S, Rich JL, Davies K, Inder KJ. Access to maternal health care services among Indigenous women in the Chittagong Hill Tracts, Bangladesh: A cross-sectional study. BMJ Open. 2019. doi: http://dx.doi.org/10.1136/bmjopen-2019-033224 is well written and it may be useful to enlist the support of the co-authors of that study to address the long sentences and repeat expressions in the current article.

Other studies who adress barrier identifications have also asked the participants how to overcome these. If the current authors plan further studies in this area, it is suggested to consider this as an inclusion.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Comments on Bangladesh PLOS manuscript March 2020.docx

Attachment

Submitted filename: PONE-D-20-03726_reviewer Bangladeash qual access 2020 RM.docx

PONE-D-20-03726R1

Barriers and enablers to accessing maternal health care services in the Chittagong Hill Tracts, Bangladesh: A qualitative descriptive study of Indigenous women’s experiences

PLOS ONE

Dear Dr.Shahinoor Akter,

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.

Please submit your revised manuscript by 5th August 2020. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're 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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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Sharon Mary Brownie

Academic Editor

PLOS ONE

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Reviewers have recommended some further areas for improvement within your manuscript. Please respond to each and every recommendation and return your revised manuscript along with a table of author responses.

Reviewers' comments:

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Comments to the Author

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Reviewer #1: (No Response)

Reviewer #2: (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 #1: Yes

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: N/A

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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 #1: Yes

Reviewer #2: 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 #1: Yes

Reviewer #2: 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: Most of the comments have been adrressed. The last sentence can be shortened to read: Although there were two questions meant to elicit enablers of health service use, the data were limited as women focused more on barriers to access.

On page 4 line 97 there is an APA reference which should be corrected to align with the journal referencing.

There is a minor editorial on page 27 line 561, delete a.

Otherwise with these minor changes, the paper can be accepted.

Reviewer #2: It is commendable that the author has addressed most of the review feedback provided. Here are further recommendations to strengthen the article:

- although it was recommended that the title changes to barrier and enablers..., there however are no enablers identified in the re-submitted article as suggested, hence I recommend now to remove the word 'enabler' from the title

- line 148 remove the word facilitators, as they are not identified in the article

- line 168 'upazilas' needs a capital U

- line 242 please add women after 'Most (n=11)'

The abstract conclusion and the article conclusion do not really reflect the findings. 'What is meant with 'systemic reform' ?- Revisit the following article and https://bmjopen.bmj.com/content/9/10/e033224 and read the conclusions and abstract. It is informative to see that the language concern is being mentioned in the abstract and this additions is welcomed and importunate, however, it features only marginally in the study, hence other significant findings need to be mentioned e.g. fear, distance, costs, lack of trust, maltreatment from staff, lack of knowledge all are important barriers

- Please also note on the reference list: reference 38 and reference 39 are missing their doi's. Either add them or delete doi

- Table 1 - #3 and #4 while km has now been added there needs to be gap between the number and km as it has been presented with all others, consistency is required. Thank you.

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Reviewer #1: No

Reviewer #2: No

Barriers to accessing maternal health care services in the Chittagong Hill Tracts, Bangladesh: A qualitative descriptive study of Indigenous women’s experiences

PONE-D-20-03726R2

Dear Dr. Shahinoor Akter,

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Additional Editor Comments

Reviewer recommendations have been satisfactorily addressed.