PONE-D-20-26520

Determinants of preterm survival in a tertiary hospital in Ghana: a ten-year review

PLOS ONE

Dear Dr. Agbeno,

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 Dec 20 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Kazumichi Fujioka

Academic Editor

PLOS ONE

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2. In the ethics statement in the manuscript and in the online submission form, please provide additional information about the patient records used in your retrospective study, including: a) whether all data were fully anonymized before you accessed them; and b) the date range (month and year) during which patients' medical records were accessed. If patients provided informed written consent to have data from their medical records used in research, please include this information.

3. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 2 in your text; if accepted, production will need this reference to link the reader to the Table.

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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: Yes

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

Reviewer #1: No

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: No

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: No

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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: This single-center retrospective cohort study over a 10-year period (2010-2019) conducted in the Cape Coast Teaching Hospital showed the mortality/survival rates in the representative NICU in Ghana and some associating factors. This is an important paper, because that might provide an important local epidemiological information for clinical decision making even in resource-constrained countries.

However, to accept the manuscript, there are still concerns about description that the authors should correct or give some comments on.

Major problems

1. Introduction part is too long to be accepted. Authors should focus on what is the background and what the aim of their study is. They should describe them more clearly.

2. Results of Demographic and clinical characteristics

1) Among 2,254 preterm babies, the authors pick up just 1,282 infants for the calculation of the prevalence of live preterm babies, because there was no precise information in 623 from referring facilities and 349 who don’t have any data of birth place. Then they might have excluded so many infants for calculation. I am not sure whether the prevalence of live preterm babies is meaningful data because there might be live preterm babies even among 623 and 349 excluded babies.

2) The number of live preterm babies were 1282, while that of survived were 1523.

I am wondering why the number of survived is larger than that of live preterm babies.

3) To solve those problems, it would be better to make a chart of patient collection.

3. Table 1

1) The authors calculated % in each variable. but it is hard to understand at first looking, because it is not easy to find out how to calculate them. For example, In Male of “Sex of Baby”, they calculated 29.7% in Died, while 70.3% in Discharged alive, and finally sum of % is 100%. On the other hand, total number of Male should be 1115. But sum of 315 in Died and 746 in Discharged alive is not 1115, which makes me confused.

2) Page13: According to APGAR Score at 1 min in Table1, the prevalence of APGAR Score at 1min<4 is higher in “Discharged alive” than “Died” (136/355(38%) vs 205/355 (58%)). Is that true? The title of Table1 is “the Factors influencing the Survival of Preterm Babies”, and so your results mean that lower APGAR Score at 1min is related to higher survival rate.

4. Table3

1) In Table 3, the authors examined factors associated with the Survival of preterm babies and showed the Adjusted OR (95%CI). But I am afraid that their interpretation of results might be wrong.

2) According to Adjusted OR in Weight of Baby with Extremely low as reference (Page 16-17), increased birth weight is correlated with decreased survival rate. Moreover, according to Adjusted OR in APGAR Score at 5min with Score 1 as reference (Page 17-18), increased APGAR Score at 5 min is correlated with decreased survival rate. Those results should not make sense.

3) The results seem to be associated with death of preterm birth, not survival.

Minor problems

1. Page 9: Data collection/handling

The authors performed logistic regression to test for association between survival and its influencing factors. They should clarify with which factors they adjusted analysis.

2. Page10: P=3.06 should be mistyping.

Reviewer #2: General Comments:

This paper reveals the survival rate of preterm infants in Ghana over a 10-year period. Although the prevalence of preterm infants is gradually increasing, survival rates have not changed significantly over the past decade. The lack of mechanical ventilators, non-invasive ventilators, syringe pumps, and blood gas analyzers clearly increases neonatal mortality rates. In the future, the introduction of these devices will improve mortality rates in Ghana. The degree of improvement in neonatal mortality rates may be used to evaluate the cost effectiveness of implemented low-cost health care resources.

Specific recommendations for revision minor:

1. Regarding the following two points:

a) On page 5 “In Ghana, there is a strong association between preterm births and advanced maternal age (>35 years), suboptimal antenatal care, preeclampsia, antepartum haemorrhage, and preterm prelabour rupture of membranes (PPROM).”

b) On page 10 “An increasing trend in prevalence is observed, with 2019 recording 9%, which is the highest for the study period (271/3027). [Figure 1.0].”

The causes of the increased rate of preterm births in Ghana need to be considered. If advanced maternal age pregnancies are the cause, the older the mother is, the higher the child mortality rate should be. However, in this paper, there is no association between child mortality and maternal age.

2. There are small grammatical errors. Examples are listed below:

On page 2:

a) Special Care Baby unit: Special Care Baby Unit

b) Data on 2,254 babies that met the inclusion criteria was extracted: Data on 2,254 babies that met the inclusion criteria were extracted

c) Descriptive statistics were generated and test of association done with chi-square and multivariable logistic regression: Descriptive statistics were generated and tests of association done with chi-square and multivariable logistic regression

d) An increasing trend in prevalence is observed, with 2019 recording the highest of 9% (271/3027).: An increasing trend in prevalence was observed, with 2019 recording the highest at 9% (271/3027).

On page 3:

e) It also highlighted the problem of inadequate data capture: It also highlights the problem of inadequate data capture

On page 7:

f) This study, therefore, will be the first to report on survival of preterm babies: This study, therefore, will be the first to report on the survival of preterm babies

On page 8:

g) which lacks some of the logistics of neonatal intensive care unit (NICU): which lacks some of the logistics of a neonatal intensive care unit (NICU)

On page 9:

h) Data on maternal age, parity, and mode and year of delivery, sex and weight of baby, gestational age, and 1st and 5th minute APGAR scores, length of stay and outcome (whether discharged alive or demised) were collected: Data on maternal age, parity, mode and year of delivery, sex and weight of the baby, gestational age, 1st and 5th minute APGAR scores, length of stay, and outcome (whether discharged alive or demised) were collected

On page 10:

i) whiles data on place of birth of 349 babies were not documented.: while data on the place of birth of 349 babies were not documented.

j) There was no statistically significant relationship between survival and the sex of a neonate (p = 3.06), age of mother (p = 0.598), parity of mother (p = 0.717), year of delivery (p = 0.212) [Table1].: There was no statistically significant relationship between survival and the sex of a neonate (p = 3.06), age of mother (p = 0.598), parity of mother (p = 0.717), or year of delivery (p = 0.212) [Table1].

On page 11:

k) However, the weight of a baby (p = <0.001), referring point (p <0.001),: However, the weight of the baby (p = <0.001), referral point (p <0.001),

On page 21:

l) as well as facilitate antenatal counselling on high-risk infants.: as well as facilitate antenatal counselling in high-risk infants.

On page 22:

m) whiles an overall singleton preterm survival rate of 38.4% has been reported in Nigeria. [26]: while an overall singleton preterm survival rate of 38.4% has been reported in Nigeria. [26]

n) such as provision of warmth,: such as the provision of warmth,

On page 23:

o) Survival of preterm babies is comparatively very high in resource rich countries due to the readily-available technological equipment.: The survival of preterm babies is comparatively very high in resource rich countries due to readily-available technological equipment.

p) Mortality rates is 52%: Mortality rates are 52%

On page 24:

q) consumer-satisfaction: patient-satisfaction

r) We found an increasing prevalence of live preterm birth at CCTH,: We found an increasing prevalence of live preterm births at CCTH,

s) Regarding the characteristics of the population, there was no significant difference between sex of baby and mortality.: Regarding the characteristics of the population, there was no significant difference between the sex of the baby and mortality.

t) Thus, we may have erroneously and inadvertently excluded some preterm babies in this study.: Thus, we may have erroneously and inadvertently excluded some preterm babies from this study.

u) Information gaps in developing countries has been highlighted in a recent review on preterm births, as one of the challenges in assessing accurate epidemiological data.: Information gaps in developing countries have been highlighted in a recent review on preterm births, as one of the challenges in assessing accurate epidemiological data.

On page 25:

v) Our data shows that preterm infants who survive the first six postnatal days have considerable chance of survival until discharge.: Our data shows that preterm infants who survive the first six postnatal days have a considerable chance of survival until discharge.

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Reviewer #1: No

Reviewer #2: Yes: Mitsuhiro Okamoto

[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.]

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PONE-D-20-26520R1

Determinants of preterm survival in a tertiary hospital in Ghana: a ten-year review

PLOS ONE

Dear Dr. Evans Kofi Agbeno

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.

==============================

ACADEMIC EDITOR:

Please correct the minor point suggested by reviewer, the corrected version could be accepted after the check by editorial office.

==============================

Please submit your revised manuscript by Feb 19 2021 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,

Kazumichi Fujioka

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 #1: (No Response)

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 #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: 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 #1: Yes

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: Yes

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 #1: Thank you for your revised manuscript entitled “Determinants of preterm survival in a tertiary hospital in Ghana: a ten-year review”

The revised manuscript shows much improvement by modifying the Tables, and I accept it after they revise two minor problems as below.

Minor problems

1. pp10, % of caesarean section;

In the revised manuscript, you showed the % of caesarean section among the 2254 babies as 45.5%. That is not correct. That should be 44.5%.

2. Table1, Survival pf preterm neonates:

% of death should be 27.6%, not 29.0%. % of discharged/Alive should be 67.6%, not 71.0%.

Reviewer #2: (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 #1: No

Reviewer #2: Yes: Mitsuhiro Okamoto

[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.

Determinants of preterm survival in a tertiary hospital in Ghana: a ten-year review

PONE-D-20-26520R2

Dear Dr. Evans Kofi Agbeno,

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.

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Kind regards,

Kazumichi Fujioka

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Well responded.