PONE-D-20-09737

Health System and Quality of Care Factors Contributing to 522 Maternal Deaths in East Java, Indonesia

PLOS ONE

Dear Dr. Mahmood,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: Yes

Reviewer #2: Partly

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

Reviewer #1: Yes

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: 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 paper presents an extraordinary overview of the systemic processes that have resulted in an unacceptable level of maternal mortality in East Java. All too often we are lured into a false sense of security by the ongoing introduction of advancing technologies that serve to improve clinical outcomes, not recognizing that the salutary impact of that process is the proper implementation of those technologies and, perhaps most importantly, the development of a clinical system that accurately evaluates an individual and provides for the proper clinical setting and staff that can best utilize technology and expertise to assure optimal outcomes. This paper clearly describes a situation where, despite the availability of appropriate clinical technology, a broken system serves to maintain an inappropriate rate of maternal mortality. The paper is easy to follow but suffers slightly from occasional poor style and syntax, as well as an occasional spelling error, scattered throughout the manuscript. Nonetheless, this paper presents critically important information to our readers and to obstetrical providers and administrators worldwide.

Reviewer #2: Overall , the paper is very long. I do not think there is substantial additional value from the details of the 522 deaths, or the 70 deaths. The information in these sections has been widely demonstrated in previous published literature.

I suggest removing these sections, and concentrating on telling a much more concise story about the deaths that were analysed in detail. The introduction and the discussion should also be substantially reduced.

Minor points:

The manuscript would benefit from review by a native English speaker to correct minor errors eg in abstract and introduction “now receiving antenatal care for an adequate number of times”

Line 68 “In East Java in 2016, 97% and 78% of women had at least one and four ANC visits (respectively) to skilled attendants”. Please describe the proportion of women who have a skilled attendant at delivery

Line 70 : “Recently, the East Java MMR has stagnated with little reduction.” Please reference this data

Line 72 Please reconsider this statement. The paper by Hogan shows a steadily decreasing MMR everywhere except sub Saharan Africa, specifically demonstrated in Webfigure 6c. Maternal mortality ratio (MMR) per 100, 000 live births, high MMR regions

Line 82 “Better performing health systems and good quality care are needed to reduce these deaths, the majority of which now occur at the time of labour and delivery and in the postpartum period (Renfrew 2014). “ This sentence appears to simply repeat the previous sentence and could be removed.

Line 123 – line 142. I am unclear if this section refers to the current paper, or the previous paper by the same author. If it refers to the previous paper, I do not think it needs to be included with this degree of detail.

Table 1 – this is a very detailed table that doesn’t provide much additional information. An attempt should be made to describe the uncertainty, or variability around these numbers from year to year.

Comparisons regrading rates of death by age or parity, as has been done throughout the manuscript are not very useful without knowing the age/parity of the entire population of women giving birth.

269: concomitant illness. This list varies from very mild disease to very severe disease which was very likely to contribute to maternal death ( left to right shunt and Eisenmengers disease). It

276: this cesarean section rate seems consistent with the very high cesarean rate for the hospital, as described in line 156 , and so does not support the argument that the women were in critical condition.

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Reviewer #1: Yes: Prof. Lee P. Shulman, Feinberg School of Medicine of Northwestern University, Chicago, Illinois, USA.

Reviewer #2: No

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Health System and Quality of Care Factors Contributing to Maternal Deaths in East Java, Indonesia

PONE-D-20-09737R1

Dear Dr. Mahmood,

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.

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Kind regards,

Emily A Hurley, M.P.H., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: 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: (No Response)

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

Reviewer #1: (No Response)

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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: (No Response)

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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: (No Response)

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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: (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