Perinatal outcome of meconium stained amniotic fluid among labouring mothers at teaching referral hospital in urban Ethiopia

Lemi Belay Tolu; Malede Birara; Tesfalem Teshome; Garumma Tolu Feyissa

doi:10.1371/journal.pone.0242025

Peer Review History

Original SubmissionMay 9, 2020
9 Jul 2020 Decision Letter - Abhishek Makkar, Editor PONE-D-20-13739 Perinatal Outcome of Meconium Stained Amniotic Fluid among labouring mothers at teaching referral hospital in urban Ethiopia. PLOS ONE Dear Dr. Tolu, 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 Aug 23 2020 11:59PM. 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. 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). 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'. 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. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Abhishek Makkar, M.D. Academic Editor PLOS ONE Journal Requirements: 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 https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2.We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed: https://www.jcdr.net/ReadXMLFile.aspx?id=3781 In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed. Additional Editor Comments (if provided): Dear Dr. Tolu, Thanks for your submission. Please address both reviewer's comments and resubmit revised version by 8/21/2020. Looking forward to revision. [Note: HTML markup is below. Please do not edit.] 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: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: I Don't Know ****** 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 ****** 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: No ****** 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: Comments and Suggestions for Authors A well thought study looking at the perinatal outcome of meconium stained amniotic fluid(MSAF) among laboring mothers at teaching hospital in Ethiopia. This study brings out important information regarding the outcomes of MSAF in Ethiopia. Corrections: Line 42 –Can be corrected as: Meconium stained amniotic fluid is usually seen in 12 to 16% of deliveries. Line 47- Can be corrected as: Though its controversial to differentiate physiologic or pathologic meconium staining of amniotic fluid, there are few shreds of evidence that indicates its association (instead of associated) with increased meconium aspiration syndrome, respiratory distress, neonatal sepsis and perinatal mortality. Line 77: Gestational age was (instead of is) calculated from reliable last normal menstrual period or early ultrasound done before 24 weeks and those with an unknown date or without early ultrasound were (where) excluded. Line 168: All thin (grade one) stained fluid gave birth vaginally, while 80(86%) of thick (grade two and three) group underwent (instead of undergone) operative delivery. Line 190 : Our study also highlighted that 86% of (thich )thick stained 190 amniotic fluid group (grade two and three) undergoes operative delivery which indicates the risk of fetal heart rate abnormality with meconium staining Line 202 : Several investigators Line 209 : In the current research, MAS was (has) diagnosed in 6.3 % a baby of the stained fluid group, which is 2.3 times compared to a non-stained fluid group Table :2 P value is not in line for prim gravida and Induced labor. Suggestions 1.It is unclear what the primary objective of this study was in the introduction. To determine the outcomes for physiologic v pathologic meconium staining or to compare MSAF outcomes with clear amniotic fluid. My recommendation is to have a clear objective in your introduction. 2.My suggestion is to compare Meconium aspiration syndrome between different types of MSAF and not with clear amniotic fluid and also to analyze the outcome differences between different types of MSAF 3. Were there any other conflicting variables like scheduled repeat C- section? Were those mothers excluded 4. My suggestion is also to compare the outcomes based on different Gestational age (Early term, term and post term). Reviewer #2: Dear Editor, Thank you for the opportunity to review this paper. The author present epidemiology of MAS in Ethiopia. There is paucity of any epidemiological data for Africa and this paper is worth publishing. General notes: The text should be proofread for spelling, spacing and grammatical mistakes. The overall readability is borderline, but in several spots it is very difficult to understand what the authors mean. Please have the text proofread and edited. I appreciate the authors efforts to have the text proofread by a professional service, but it seems the editing service used by authors was substandard. Specific comments: Line 68 and 69 do not belong to methods since you report the results. Please move it to the result section. Line 158. You define prolonged rupture of membranes as longer than 12h. It seems to be different from 18 hours used in the US. Can you explain somewhere the choice of this particular interval? Lines 172-174. By definition, MSAF is one of the requirements to establish MAS diagnosis (your lines 105-106). How the patients with no MSAF were diagnosed with MAS? In the description of demography (Table 1), the religion part might be misunderstood by some readers. Please specify if the Orthodox religion means Orthodox Judaism or Orthodox Christianity. I would spell out religions as Christian with subgroups of Eastern Orthodox and Protestant. Alternatively, I would spell out Orthodox Judaism and Christian (Protestant). Table 2. Please specify if the diabetes was type one or pregnancy-induced. It is interesting, that the follow-up was performed via a cell phone connection. Please, comment if the population of the woman included in the study or admitted to the hospital truly represent the population of Addis-Ababa. I would expect that only small proportion of the population could afford cell phones. Please clarify if I am wrong. Good luck. ****** 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. 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 [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.] 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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0242025.r001
Revision 1
9 Jul 2020 Author Response July 10, 2020 To: PLOS ONE Editor in chief. Dear Editor in chief. We would like to thank the editor and reviewers for their thoughtful review of the manuscript. They raise important issues and their inputs are very helpful for improving the manuscript. We agree with almost all their comments and we have revised our manuscript accordingly. We respond below in detail to each of the editor comments. We hope that you find our responses satisfactory and that the manuscript is now acceptable for publication Looking forward hearing from you soon Sincerely, Lemi B Tolu (MD, Assistant prof of obstetrics and gynecology). Saint Paul’s Millennium Medical College (SPHMMC) Department of Obstetrics and Gynecology Addis Ababa, Ethiopia. Email: lemi.belay@gmail.com Dear editor Thanks for thoughtful review of the manuscript. Below is point by point response to raised concerns and how we changed the manuscript according to the comments. #Editor 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. Response: Dear editor thank you very much manuscript revised according to the journal requirement. 2. We noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed: Response: Thank you a lot, concern addressed (line 42-62) Reviewer #1: A well thought study looking at the perinatal outcome of meconium stained amniotic fluid (MSAF) among laboring mothers at teaching hospital in Ethiopia. This study brings out important information regarding the outcomes of MSAF in Ethiopia. Response: Thank you very much for energizing comment, below is the line by line response to concerns. #Corrections: 1. Line 42 –Can be corrected as: Meconium stained amniotic fluid is usually seen in 12 to 16% of deliveries. Response: Corrected (Line 42) 2. Line 47- Can be corrected as: Though its controversial to differentiate physiologic or pathologic meconium staining of amniotic fluid, there are few shreds of evidence that indicates its association (instead of associated) with increased meconium aspiration syndrome, respiratory distress, neonatal sepsis and perinatal mortality. Response: Corrected (line47) 3. Line 77: Gestational age was (instead of is) calculated from reliable last normal menstrual period or early ultrasound done before 24 weeks and those with an unknown date or without early ultrasound were (where) excluded. Response: Corrected (line 85) 4. Line 168: All thin (grade one) stained fluid gave birth vaginally, while 80(86%) of thick (grade two and three) group underwent (instead of undergone) operative delivery. Response: Corrected (Line 178) 5. Line 190: Our study also highlighted that 86% of (thich) thick stained 190 amniotic fluid group (grade two and three) undergoes operative delivery which indicates the risk of fetal heart rate abnormality with meconium staining Response: Corrected (Line 199) 6. Line 202: Several investigators Response: Corrected (Line 212) 7. Line 209: In the current research, MAS was (has) diagnosed in 6.3 % a baby of the stained fluid group, which is 2.3 times compared to a non-stained fluid group 8. Table :2 P value is not in line for prim gravida and Induced labor. Response: corrected (table 2) #Suggestions 1.It is unclear what the primary objective of this study was in the introduction. To determine the outcomes for physiologic v pathologic meconium staining or to compare MSAF outcomes with clear amniotic fluid. My recommendation is to have a clear objective in your introduction. Response: Thank you, suggestion addressed (68-69) 2.My suggestion is to compare Meconium aspiration syndrome between different types of MSAF and not with clear amniotic fluid and to analyze the outcome differences between different types of MSAF Response: Dear reviewer thank you very much, the wrong comparison with clear amniotic fluid is corrected as Meconium aspiration syndrome was seen in 9(6.3%) stained fluid group (line 183-184). Unfortunately, among those 9 (6.3%) who developed MAS we didn’t collected the subgroups on thickness of amniotic fluid. 3. Were there any other conflicting variables like scheduled repeat C- section? Were those mothers excluded Response: Dear reviewer our population are those in labour, admitted to labour ward. 4. My suggestion is also to compare the outcomes based on different Gestational age (Early term, term and post term). Response: Dear reviewer we did gestational age matched data collection to control possibility of gestational age confounding the outcomes. Reviewer #2: #General notes: The text should be proofread for spelling, spacing and grammatical mistakes. The overall readability is borderline, but in several spots, it is very difficult to understand what the authors mean. Please have the text proofread and edited. I appreciate the authors efforts to have the text proofread by a professional service, but it seems the editing service used by authors was substandard. Response: Dear reviewer, thank you very much. We reviewed the whole manuscript to address the spelling, spacing and grammatical mistakes concern. #Specific comments: 1. Line 68 and 69 do not belong to methods since you report the results. Please move it to the result section. Response: Concern addressed (line 76-77 and line 144-145) 2. Line 158. You define prolonged rupture of membranes as longer than 12h. It seems to be different from 18 hours used in the US. Can you explain somewhere the choice of this interval? Response: Dear reviewer yes, it is true different definitions is used for prolonged rupture of membrane. Pediatrics commonly use 18 hrs. in our hospital to consider for risky of neonatal sepsis. In Obstetrics 12 hrs. is commonly used 3. Lines 172-174. MSAF is one of the requirements to establish MAS diagnosis (your lines 105-106). How the patients with no MSAF were diagnosed with MAS? Response: Thank you the wrong comparison corrected as Meconium aspiration syndrome was seen in 9(6.3%) stained fluid group (line 183-184) 4. In the description of demography (Table 1), the religion part might be misunderstood by some readers. Please specify if the Orthodox religion means Orthodox Judaism or Orthodox Christianity. I would spell out religions as Christian with subgroups of Eastern Orthodox and Protestant. Alternatively, I would spell out Orthodox Judaism and Christian (Protestant). Response: Thanks, concern addressed as Orthodox Christian (Table 1) 5. Table 2. Please specify if the diabetes was type one or pregnancy-induced. Response: Thanks, concern addressed as pregestational DM (Table 2) It is interesting, that the follow-up was performed via a cell phone connection. Please, comment if the population of the woman included in the study or admitted to the hospital truly represent the population of Addis-Ababa. I would expect that only small proportion of the population could afford cell phones. Please clarify if I am wrong. Response: Dear reviewer currently most Ethiopians, even rural one had cell phone. The fact that our study is in Addis Ababa, capital city makes the follow up easy as our study population were from Addis Ababa or surrounding city. Attachments Attachment Submitted filename: Reviewer.docx https://doi.org/10.1371/journal.pone.0242025.r002
26 Aug 2020 Decision Letter - Abhishek Makkar, Editor PONE-D-20-13739R1 Perinatal Outcome of Meconium Stained Amniotic Fluid among labouring mothers at teaching referral hospital in urban Ethiopia. PLOS ONE Dear Dr. Tolu, 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. Manuscript does need minor revision. Please address all concerns raised by Reviewer 2. We will look forward to your submission. Please submit your revised manuscript by Oct 10 2020 11:59PM. 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. 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). 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'. 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. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Abhishek Makkar, M.D. Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] 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 #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 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: (No Response) Reviewer #2: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: (No Response) Reviewer #2: I Don't Know ****** 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: (No Response) 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 #1: (No Response) Reviewer #2: No ****** 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: (No Response) Reviewer #2: Dear Authors, Sorry for delay with my review – it is crazy around here (in my part of the planet). I would like to stress it again, I like the idea of your paper and this data should be published in the best possible form. I am still not satisfied with the English part. I see the other reviewer helped you with some of that, but the text still needs a major proofreading. For example, your home city is misspelled on the first page. It is spelled as “Addis ababa” �. The title has words started with capital letters in random order. Chose one style. Capitalize them all or none. Obviously, the first word in the sentence and the name of the country should be capitalized, should you chose not capitalizing all the words. And so on and so on for the entire paper including papers. Your result part of the summary is too descriptive. The readers will be looking for specific numbers of incidence of MAS in MSAF, Apgar scores, NICU admission rates and so on. Your description what was higher or lower is not enough. Please, provide the data of the incidence of MSAF and MAS in the summary. Please add the proportion of primigravida mothers in your population to the summary, if the space allows. Actually, you could cut out a big proportion of the statistics part form the summary to include more data. It is interesting, that most of your patient population were primigravida. Perhaps you may explain this in discussion, why your group is so different from the rest of the country with average fertility rate over 4. Also, your group is very different form the rest of the country in regard of the literacy. You report that 6-8% of your mothers were illiterate, while in general illiteracy rate in Ethiopia is reported to be more than 50%. Perhaps you would like to mention this and explain why your group is different. Could it be explained by better education in Addis Ababa or just the population your hospital serves? My primary concern is that you group is not true representative of population of the country in terms of education, wealth and accessibility to health care. This in turn could result in different accessibility and desire to use the health care services. With all value of your data it is important to mention the limitations. Perhaps I have missed it, but I was not able to see the reason for Cesarean section delivery in your patients. It is important to indicate whether it was scheduled or the obstetricians had to do it emergently for any reason. Perhaps you also could discuss if the Cesarean section delivery places a baby at risk of MAS or the Cesarean section serves as a rescue for infants who are about to develop MAS. Table 4 – I do not see a reason for removal of the MAS incidence from this table. Isn’t it the main outcome? Good luck. ****** 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 #1: No Reviewer #2: No [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.] 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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0242025.r003
Revision 2
27 Aug 2020 Author Response August 27, 2020 To: PLOS ONE Editor in chief. Dear Editor in chief. We would like to thank the editor and reviewers for their thoughtful review of the manuscript. They raise important issues and their inputs are very helpful for improving the manuscript. We agree with almost all their comments and we have revised our manuscript accordingly. We respond below in detail to each of the editor comments. We hope that you find our responses satisfactory and that the manuscript is now acceptable for publication Looking forward hearing from you soon Sincerely, Lemi B Tolu (MD, Assistant prof of obstetrics and gynecology). Saint Paul’s Millennium Medical College (SPHMMC) Department of Obstetrics and Gynecology Addis Ababa, Ethiopia. Email: lemi.belay@gmail.com Dear editor Thanks for thoughtful review of the manuscript. Below is point by point response to raised concerns by reviewer#2. Reviewer #2: Dear Authors, 1. I would like to stress it again, I like the idea of your paper and this data should be published in the best possible form. Response: dear reviewer thanks a lot. We will also do our best to extent of our potential and consult people in our network. 2. I am still not satisfied with the English part. I see the other reviewer helped you with some of that, but the text still needs a major proofreading. For example, your home city is misspelled on the first page. It is spelled as “Addis ababa” �. The title has words started with capital letters in random order. Choose one style. Capitalize them all or none. Obviously, the first word in the sentence and the name of the country should be capitalized, should you chose not capitalizing all the words. And so on and so on for the entire paper including papers. Response: Dear Reviewer thanks for the comment. Title edited accordingly and the whole text proofreading done by two authors (me and Garumma Tolu Feyissa). However, “Addis Ababa” is normally spelled like that though we might find “Addis Abeba” in some texts. 3. Your result part of the summary is too descriptive. The readers will be looking for specific numbers of incidence of MAS in MSAF, Apgar scores, NICU admission rates and so on. Your description what was higher or lower is not enough. Please, provide the data of the incidence of MSAF and MAS in the summary. Please add the proportion of primigravida mothers in your population to the summary, if the space allows. You could cut out a big proportion of the statistics part form the summary to include more data. Response: Dear reviewer the abstract section was edited accordingly (lines 31-40) 4. It is interesting, that most of your patient population were primigravida. Perhaps you may explain this in discussion, why your group is so different from the rest of the country with average fertility rate over 4. Also, your group is very different form the rest of the country in regard of the literacy. You report that 6-8% of your mothers were illiterate, while in general illiteracy rate in Ethiopia is reported to be more than 50%. Perhaps you would like to mention this and explain why your group is different. Could it be explained by better education in Addis Ababa or just the population your hospital serves? My primary concern is that you group is not true representative of population of the country in terms of education, wealth and accessibility to health care. This in turn could result in different accessibility and desire to use the health care services. With all value of your data it is important to mention the limitations. Response: Dear reviewer thank you very much for the input, the concerns where addressed (lines 192-193 and lines 225-232). 5. Perhaps I have missed it, but I was not able to see the reason for Cesarean section delivery in your patients. It is important to indicate whether it was scheduled, or the obstetricians had to do it emergently for any reason. Perhaps you also could discuss if the Cesarean section delivery places a baby at risk of MAS or the Cesarean section serves as a rescue for infants who are about to develop MAS. Response: Included with indications for both groups (lines 171-175 and lines 198-199) 6. Table 4 – I do not see a reason for removal of the MAS incidence from this table. Isn’t it the main outcome? Response: Dear reviewer MAS was removed from table because of the contradiction of MAS among clear amniotic fluid group and expressed in sentences (lines 178-179) as “Meconium aspiration syndrome was seen in 9(6.3%), stained fluid Attachments Attachment Submitted filename: Response to reviewers .docx https://doi.org/10.1371/journal.pone.0242025.r004
4 Sep 2020 Decision Letter - Abhishek Makkar, Editor PONE-D-20-13739R2 Perinatal outcome of meconium-stained amniotic fluid among labouring mothers at teaching referral hospital in urban Ethiopia. PLOS ONE Dear Dr. Tolu, 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. Concerns raised by reviewers still need to be addressed to present manuscript that is clear and easy to read. Your submission still requires substantial editing for English grammar and usage We would recommend that you have your manuscript copy-edited by either a native-English speaking colleague or a professional copy-editing service. While you may approach any qualified individual or any professional scientific editing service of your choice, PLOS has partnered with American Journal Experts (AJE) to provide discounted services to PLOS authors. AJE has extensive experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. If there are still language issues in text that AJE has edited, AJE will re-edit the text for free. To take advantage of this special partnership, visit the AJE website and enter referral code PLOS15 on the registration page for a 15% discount off AJE services (http://www.aje.com/c/plos15). If you are already registered with AJE, please log in and enter PLOS15 at the bottom of your researcher dashboard under ‘Join a Group.’ Please note that PLOS ONE does not receive any compensation in relation to services completed by AJE and that having the manuscript copyedited by AJE or any other editing services does not guarantee selection for peer review" Please submit your revised manuscript by Oct 19 2020 11:59PM. 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. 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). 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'. 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. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Abhishek Makkar, M.D. Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] [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.] 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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0242025.r005
Revision 3
15 Sep 2020 Author Response September 2020, 2020 To: PLOS ONE Editor in chief. Dear Editor in chief. We would like to thank the editor and reviewers for their thoughtful review of the manuscript. They raise important issues and their inputs are very helpful for improving the manuscript. We agree that the manuscript requires editing for English grammar and usage. Hence, the manuscript was copy edited by two authors (one research fellow at Drexel university/USA) and Pre-Publication Support Service (PRESS). PRESS is Michigan University/USA based publication support organization providing manuscript preparation and copy editing. We hope that you find our revision satisfactory and that the manuscript is now acceptable for publication Looking forward hearing from you soon Sincerely, Lemi B Tolu (MD, Assistant prof of obstetrics and gynecology). Saint Paul’s Millennium Medical College (SPHMMC) Department of Obstetrics and Gynecology Addis Ababa, Ethiopia. Email: lemi.belay@gmail.com Attachments Attachment Submitted filename: Editor respons.docx https://doi.org/10.1371/journal.pone.0242025.r006
25 Sep 2020 Decision Letter - Abhishek Makkar, Editor PONE-D-20-13739R3 Perinatal outcome of meconium-stained amniotic fluid among labouring mothers at teaching referral hospital in urban Ethiopia. PLOS ONE Dear Dr. Tolu, 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. I want to compliment authors for making significant improvement to last version. There are some minor issues that need addressed. Please address the following: In Results section: Line 156: Either add women or patients after pregnant. Line 156: Add Patients after postpartum Line 157: add and after interview. Discussion: 236:you have typo, I think you mean to say non-stained 238: take out similar, its redundant. 239: Please rephrase the line, its not clear. Do you mean to state " 6.3% of babies in stained fluid group" Conclusion: 260: I would advise making line more generalized than giving specific timeline, the way its worded is a strong statement to make. I am assuming you are concluding it based on limited data you mentioned in line 234 and 235 in discussion. Please consider changing it to " Knowing the high risk of early neonatal death we advise early postnatal follow up should be considered for infants born to mothers with thick MSAF." Please submit your revised manuscript by September 30th. 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. 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). 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'. 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. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Abhishek Makkar, M.D. Academic Editor PLOS ONE [Note: HTML markup is below. Please do not edit.] [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.] 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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0242025.r007
Revision 4
25 Sep 2020 Author Response September 25, 2020 To: PLOS ONE Editor in chief. Dear Editor in chief. We would like to thank the editor for the thoughtful review of the manuscript. They raise important issues and their inputs are very helpful for improving the manuscript. We agree with all points raised and modified the manuscript accordingly. We hope that you find our revision satisfactory and that the manuscript is now acceptable for publication Looking forward hearing from you soon Sincerely, Lemi B Tolu (MD, Assistant prof of obstetrics and gynecology). Saint Paul’s Millennium Medical College (SPHMMC) Department of Obstetrics and Gynecology Addis Ababa, Ethiopia. Email: lemi.belay@gmail.com Dear Editor Thank you very much. Please see the point by point response to raised concerns 1. In Results section: Line 156: Either add women or patients after pregnant. Response: Done line 136 Line 156: Add Patients after postpartum Response: Done line 137 2. Line 157: add and after interview. Response: Done line 137 3. Discussion:236: you have typo, I think you mean to say non-stained Response: thank you very much, yes, it is to mean non-stained, corrected line 212 4. 238: take out similar, its redundant. Response: Done, line 214 5. 239: Please rephrase the line, it’s not clear. Do you mean to state " 6.3% of babies in stained fluid group" Response: Done, line 215 to 216 6. Conclusion: 260: I would advise making line more generalized than giving specific timeline, the way its worded is a strong statement to make. I am assuming you are concluding it based on limited data you mentioned in line 234 and 235 in discussion. Please consider changing it to " Knowing the high risk of early neonatal death we advise early postnatal follow up should be considered for infants born to mothers with thick MSAF." Response: Dear editor thank you very much for such beautiful thought and input, it means a lot. Corrected as “knowing the high risk of early neonatal death we advise early postnatal follow up should be considered for infants born to mothers with thick MSAF”, line 236-237 Attachments Attachment Submitted filename: Editor respons.docx https://doi.org/10.1371/journal.pone.0242025.r008
26 Oct 2020 Decision Letter - Abhishek Makkar, Editor Perinatal outcome of meconium-stained amniotic fluid among labouring mothers at teaching referral hospital in urban Ethiopia. PONE-D-20-13739R4 Dear Dr. Tolu, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. 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 onepress@plos.org. Kind regards, Abhishek Makkar, M.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0242025.r009
Formally Accepted
5 Nov 2020 Acceptance Letter - Abhishek Makkar, Editor PONE-D-20-13739R4 Perinatal outcome of meconium stained amniotic fluid among labouring mothers at teaching referral hospital in urban Ethiopia. Dear Dr. Tolu: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Abhishek Makkar Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0242025.r010

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