Men’s and women’s knowledge of danger signs relevant to postnatal and neonatal care-seeking: A cross sectional study from Bungoma County, Kenya

Emma Roney; Christopher Morgan; Daniel Gatungu; Peter Mwaura; Humphrey Mwambeo; Alice Natecho; Liz Comrie-Thomson; Jesse N. Gitaka

doi:10.1371/journal.pone.0251543

Peer Review History

Original SubmissionMarch 5, 2020
5 May 2020 Decision Letter - Emma Sacks, Editor PONE-D-20-06532 Men’s and women’s knowledge and practices relating to pregnancy and postnatal care: a cross sectional study from Bungoma County, Kenya PLOS ONE Dear Dr. Gitaka, 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 Jun 19 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, Emma Sacks 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. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants for both the womens and mens samples. Please ensure you have provided sufficient details to replicate the analyses such as: a) the recruitment date range (month and year), b) a description of any inclusion/exclusion criteria that were applied to participant recruitment, c) a table of relevant demographic details, d) a statement as to whether your sample can be considered representative of a larger population, e) a description of how participants were recruited, and f) descriptions of where participants were recruited and where the research took place." 3. Please provide a sample size and power calculation in the Methods, or discuss the reasons for not performing one before study initiation." 4. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. 5. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. 6. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files 7. 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. Editor Comments: Thank you for your revisions. However, there are still many comments from reviewers to address, but we are confident they will make the article stronger. In addition to those from the reviewer: -There is inconsistency is the statement of the objective. The title states knowledge, but the paper suggests knowledge, attitudes and practices, and also at times says "determinants of ANC use and facility based childbirth. Please clarify. -Further, the link between knowledge and male involvement isn't very clear. -The data presented are not very in-depth and it is not clear what this adds to previous literature on this topic, even from Kenya, since there are existing studies. Some of the more nuanced analysis may be in supplemental tables and the authors may want to consider including those info in the main paper. -There is some inconsistency in language about the questionnaire - in some places it is referred to as an interview -I wouldn't say that fathers being influential in maternal and child health is new -"recently" delivered needs to be defined (was it deliveries within a year?); also, how were recently delivered women recruited from ANC?? -the association between knowledge of danger signs and ANC is presented as if knowledge is a factor related to ANC, when it is likely that the association is the other way (those who attend ANC or deliver in a facility learn the danger signs) -low knowledge of danger signs is not only in low income countries, but also among those who are disadvantaged/uneducated in high income settings -if the authors refer to the "first delay" then the 3 delays model has to be explained -how many danger signs were included in the questionnaire? what were they? -For the languages, it if was expected to need other languages besides English and Kiswahili, why not translate ahead of time? it is atypical to use ad hoc translation, as the terminology is then not consistent. -there is redundant demographic info in the descriptions of the male and female samples -there should not be new findings presented in the discussion. The results around how long it took to seek care once identifying an illness should be in the results. -the limitations allude to confidence intervals but these are not presented -why were the women's and men's cohorts not recruited the same way? Needs to be explained in the limitations. [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: Yes Reviewer #3: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 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 Reviewer #3: 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: Yes Reviewer #3: Yes ****** 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: Thank you for the opportunity to review this manuscript, which tackles the important problem of parents knowledge about neonatal danger signs using a cross sectional study from Bungoma County, Kenya. Is the title reflective of the main message: Men’s and women’s knowledge and practices relating to pregnancy and postnatal care—isn’t it really focused on neonatal danger signs? This is a strikingly well written manuscript which has been meticulously copy edited and is easy to read and follow. It makes clear points. I have a few comments which I will hope to strengthen the manuscript further: 1. In the abstract, why are unadjusted models of mothers’ knowledge presented instead of adjusted ones like for the men? 2. Similarly, in the body of the manuscript in the results section please focus only on the adjusted odds ratio’s and remove the unadjusted ones. Flipping back-and-forth between adjusted and unadjusted ones is confusing to the reader 3. Why do the conclusions in the abstract only refer to the mothers’ knowledge? 4. Please clarify in the introduction when ANC is used whether you mean all of antenatal care or antenatal and intrapartum and postpartum care e.g. particularly in lines 81 - 89, but also elsewhere. 5. Another key limitation is that we do not know the response rate 6. In the limitations or strengths could you please mention the degree to which your sample is reflective of the general population in terms of education, age, etc. 7. For your tables, rather than putting the 1.00 in each of the cells indicating the reference, would you consider decluttering the table by putting (Reference) in the first column only? eg Less than 25 years (Reference) 8. Similarly, since you were 95% confidence intervals indicate significance you could delete the P values and just bold the odds ratio’s and 95% confidence intervals instead which would decrease clutter within the table and make it easier for your readers to see the main points 9. Throughout the tables, figures, and manuscript rather than using “father“ please replace with “men” as you do in figure 1 for example. Why? We know from genetics research that 10% of male partners are not actually the father of the child 10. Please comment on missing data for each question 11. Please clarify how missing data was handled e.g. ?complete case analysis Minor points: Please do not start sentences with numbers e.g. line 190 When you print off your figures in black-and-white, are the two colours easily distinguishable? Reviewer #2: I have made separate comments that need to be addressed. These are scattered through the document so can not be displayed here. The attachment will show the areas needing review by the authors. It is a worthwhile papers that shows where health workers need to focuss on Reviewer #3: The methodology used should be justified. For example, why is it that male partners of female participants were not enrolled, instead men we conveniently enrolled from the market place. What was the basis of sample size calculation? Why the difference in sample size? What is the role of the collaborative intervention in this study? The clarity of the methodology will help in the clarity of the results, discussion and conclusions. More comments are in the document. ****** 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: Yes: Sarah McDonald Reviewer #2: No Reviewer #3: 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 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. Attachments Attachment Submitted filename: PONE-D-20-06532_reviewer.pdf Attachment Submitted filename: PONE-D-20-06532_reviewer.doc https://doi.org/10.1371/journal.pone.0251543.r001
Revision 1
1 Nov 2020 Author Response 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. Done 2. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants for both the womens and mens samples. Please ensure you have provided sufficient details to replicate the analyses such as: a) the recruitment date range (month and year), b) a description of any inclusion/exclusion criteria that were applied to participant recruitment, c) a table of relevant demographic details, d) a statement as to whether your sample can be considered representative of a larger population, e) a description of how participants were recruited, and f) descriptions of where participants were recruited and where the research took place." Done. See the methods and results sections as well as the supplementary tables. 3. Please provide a sample size and power calculation in the Methods, or discuss the reasons for not performing one before study initiation." Women and men from the same geographic area were recruited independently, meaning that the responses to each questionnaire are not linked as mother-father dyads. In total, 82 men and 348 women participated in the study. Men whose female partners had recently delivered were recruited through convenience sampling, from those accompanying their female partners to healthcare clinics, and from men in market centres. Women who had recently delivered were recruited at antenatal and postnatal reproductive care units, and in maternal and child health clinics at two health facilities of Webuye level 5 hospital and Bungoma Referral hospital 4. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Copies provided 5. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. We have shared de-identified data at https://doi.org/10.6084/m9.figshare.13048718. Contact information for Mount Kenya University Ethics Review Committee is research@mku.ac.ke. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. We have uploaded the 2 datasets at https://doi.org/10.6084/m9.figshare.13048718. 6. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files Done 7. 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. Done Editor Comments: Thank you for your revisions. However, there are still many comments from reviewers to address, but we are confident they will make the article stronger. In addition to those from the reviewer: -There is inconsistency is the statement of the objective. The title states knowledge, but the paper suggests knowledge, attitudes and practices, and also at times says "determinants of ANC use and facility based childbirth. Please clarify. The new title captures the attitudes as well. -Further, the link between knowledge and male involvement isn't very clear. Indeed this forms part of our research question; what is the best way to address male involvement? What are the knowledge gaps for male involvement? -The data presented are not very in-depth and it is not clear what this adds to previous literature on this topic, even from Kenya, since there are existing studies. Some of the more nuanced analysis may be in supplemental tables and the authors may want to consider including those info in the main paper. We have included more tables to deepen the analyses. Our study is unique in that we address contextual issues in a high burden setting. -There is some inconsistency in language about the questionnaire - in some places it is referred to as an interview. Corrected. -I wouldn't say that fathers being influential in maternal and child health is new. Indeed, this is not new. However we aimed at understanding contextual issues around male involvement in knowledge and practice. In the study context, men have traditionally left child care to women. This perception has been so pervasive that men have been left out in the design of maternal and child health programs and policies. This study hoped to establish a scientific basis for either supporting or refuting these perceptions. -"recently" delivered needs to be defined (was it deliveries within a year?); also, how were recently delivered women recruited from ANC?? Recently delivered means deliveries within a year. Yes, these were recruited from the ANC. -the association between knowledge of danger signs and ANC is presented as if knowledge is a factor related to ANC, when it is likely that the association is the other way (those who attend ANC or deliver in a facility learn the danger signs) This is well understood. However, in our setting, the extended family is also an important source of knowledge on danger signs. -low knowledge of danger signs is not only in low income countries, but also among those who are disadvantaged/uneducated in high income settings This is true, but also outside of the scope of this paper, which focuses on Kenya. -if the authors refer to the "first delay" then the 3 delays model has to be explained We have taken out the word “first” so as to not complicate things with long explanations of a well-known concept. -how many danger signs were included in the questionnaire? what were they? Vaginal bleeding Neo-natal sepsis Jaundice Convulsions Asphyxia High fever Congenital problems Difficulty breathing Severe weakness Accelerated/reduced foetal movement Water breaks without labour Bleeding umbilical cord Poor breastfeeding Other- open ended. -For the languages, it if was expected to need other languages besides English and Kiswahili, why not translate ahead of time? it is atypical to use ad hoc translation, as the terminology is then not consistent. Most of the participants understand Kiswahili, and hence we estimated that there was minimal need to translate to Kibukusu or kisabaoti. -there is redundant demographic info in the descriptions of the male and female samples Corrected. -there should not be new findings presented in the discussion. The results around how long it took to seek care once identifying an illness should be in the results. This information is presented in both the results table S1 and the body of the text (currently line 289) -the limitations allude to confidence intervals but these are not presented. These are in the supplementary tables. -why were the women's and men's cohorts not recruited the same way? Needs to be explained in the limitations. Done. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: Thank you for the opportunity to review this manuscript, which tackles the important problem of parents knowledge about neonatal danger signs using a cross sectional study from Bungoma County, Kenya. Is the title reflective of the main message: Men’s and women’s knowledge and practices relating to pregnancy and postnatal care—isn’t it really focused on neonatal danger signs? Well noted and corrected. This is a strikingly well written manuscript which has been meticulously copy edited and is easy to read and follow. It makes clear points. I have a few comments which I will hope to strengthen the manuscript further: 1. In the abstract, why are unadjusted models of mothers’ knowledge presented instead of adjusted ones like for the men? 2. Similarly, in the body of the manuscript in the results section please focus only on the adjusted odds ratio’s and remove the unadjusted ones. Flipping back-and-forth between adjusted and unadjusted ones is confusing to the reader. We reported on unadjusted odds ratios when the variable was considered to be on the causal pathway, and therefore not included in the multivariate model. This was explained in the methods and is noted in the relevant tables. If we take out the unadjusted ORs, we will lose a big chunk of the data/paper content. 3. Why do the conclusions in the abstract only refer to the mothers’ knowledge? We have states that “knowledge of neonatal danger signs was low”, which was true for both mothers and men. 4. Please clarify in the introduction when ANC is used whether you mean all of antenatal care or antenatal and intrapartum and postpartum care e.g. particularly in lines 81 - 89, but also elsewhere. We have clarified that this is during pregnancy. 5. Another key limitation is that we do not know the response rate The response rate was 88%. 6. In the limitations or strengths could you please mention the degree to which your sample is reflective of the general population in terms of education, age, etc. Done. 7. For your tables, rather than putting the 1.00 in each of the cells indicating the reference, would you consider decluttering the table by putting (Reference) in the first column only? eg Less than 25 years (Reference) Done. 8. Similarly, since you were 95% confidence intervals indicate significance you could delete the P values and just bold the odds ratio’s and 95% confidence intervals instead which would decrease clutter within the table and make it easier for your readers to see the main points We wish to maintain as is, as these complement each other and is the practice generally. 9. Throughout the tables, figures, and manuscript rather than using “father“ please replace with “men” as you do in figure 1 for example. Why? We know from genetics research that 10% of male partners are not actually the father of the child Done. 10. Please comment on missing data for each question. We had very few missing data which were treated automatically under regression analyses in stata. 11. Please clarify how missing data was handled e.g. ?complete case analysis Done. Minor points: Please do not start sentences with numbers e.g. line 190 Well noted and corrected. When you print off your figures in black-and-white, are the two colours easily distinguishable? Yes. Reviewer #2: I have made separate comments that need to be addressed. These are scattered through the document so can not be displayed here. The attachment will show the areas needing review by the authors. It is a worthwhile papers that shows where health workers need to focuss on Reviewer #3: The methodology used should be justified. For example, why is it that male partners of female participants were not enrolled, instead men we conveniently enrolled from the market place. What was the basis of sample size calculation? Why the difference in sample size? What is the role of the collaborative intervention in this study? The clarity of the methodology will help in the clarity of the results, discussion and conclusions. More comments are in the document. Done. See methods section. Reviewer 2 extended comments: Comment: The report is centred on knowledge of newborn danger sign. This should be reflected in the title ie replace “relating to pregnancy and postnatal care”. There are no results on postnatal care Well noted and done. ABSTRACT: The authors studied knowledge rather than costs of care. Further studied should address knowledge Agreed and corrected. Thank you. INTRODUCTION Lines 87-89 & 116-117 “Our research therefore seeks to understand the additional determinants of ANC use and childbirth occurring in a facility, especially those relating to mothers’ and fathers’ perspectives. The cross-sectional study reported here forms part of the ‘Collaborative Newborn Support Project’ and aimed to inform interventions through an assessment of men’s and women’s knowledge and practices relating to pregnancy and postnatal care.” Comment: It’s difficult to correlate ‘additional determinants of ANC use and childbirth’ ‘through an assessment of men’s and women’s knowledge and practices’ Indeed the current study there is little information on actual determinant of use but the authors mostly report on determinants of knowledge. ANC use is a practice, so we are not being contradictory here. We look at determinants of knowledge and then if knowledge is a determinant of use/practice. Also give the readers a brief on the broader ‘Collaborative Newborn Support Project’ how long has been going and at stage was the current done. The Collaborative Newborn Support Project ran from October 2015 to April 2019 and the current study was undertaken July to December 2017. METHODS Study setting does not include the hospitals (for women & men) and the type of markets (for men) where the participants were recruited from. What was their definition of 1. “recently delivered” 2. “delay in seeking health care for the baby? 1. Recently delivered- means had a delivery in the last 1 year. 2. Delay in seeking health care for the baby- Time taken after recognition for need to seek care. We classified this in 3 time bands <1 hour, 1-6 hours and >6 hours. RESULTS Socio-demographic characteristics & Table 1 • To avoid confusion in the column for each characteristic, use men or women instead of husband’s or mother’s. Done • Give median ages for the women & their partners in both columns. Done Do analyses for all the observations to show if there was any significant statistical differences We intentionally did not do this because the data are actually not the same. Men’s sample: In the narrative give the proportion of men who had accompanied their partners in the sample This is already included under the heading ‘women’s and men’s knowledge and practices relating to pregnancy and postnatal care’ (currently line 292-293) Supplementary materials Table S1 Knowledge of at least one postpartum danger sign – which one? ‘’At least one danger sign” refers to respondents listing one or more of the danger signs in their response and does not limit them to a particular one. The authors need to explain why for women data was not reported on the following: 1. Knowledge of at least one postpartum danger sign 2. Accompanied by partner to ANC 3. Accompanied by partner to delivery These weren’t questions in the women’s questionnaire. We do say in the methods that the questionnaires were similar. We have added in slightly more explanation to hopefully make this clearer. DISCUSSION Kenya has a “Mother Child Health Handbook” which is given for each pregnancy and is in taken home by the mother. This handbook has nearly all the information these authors were looking for in the current study, but it is not mentioned at all in the discussion of this paper The Mother Child Handbook captures most of the information we sought, however, in our study we aimed at studying the knowledge, attitudes and practices in our setting in Bungoma County where maternal and newborn indicators are among the worst in Kenya. In revision, we have highlighted the need to enhance utility of the Mother Child Handbook as a source of information on danger signs for families. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0251543.r002
7 Dec 2020 Decision Letter - Emma Sacks, Editor PONE-D-20-06532R1 Men’s and women’s knowledge, attitudes and practices relating to pregnancy and neonatal care: a cross sectional study from Bungoma County, Kenya PLOS ONE Dear Dr. Gitaka, 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 Jan 21 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, Emma Sacks Academic Editor PLOS ONE Additional Editor Comments (if provided): Thank you for these edits - the paper is much clearer. The reviewers have only minor additional comments, which are included as comments in the attached PDF (please let our editorial office know if you have trouble accessing these comments). Additionally: The abstract and title still need some editing to reflect the actual research questions and findings. I suggest you emphasise knowledge of danger signs and care seeking practices, rather than the very general 'knowledge, attitudes, and practices.' The abstract completely leaves out care seeking for newborns, which seems to me that it would be the most likely variable to be impacted by increased knowledge of newborn danger signs. Currently, the focus is on ANC utilisation, which as I have noted before, is more likely to be a driver than an impact of increased knowledge. Please add to the limitations the potential bias of only speaking to married man (and not women's unmarried partners). The difference in recruitment methods between men and women is explained well; however, it is still not clear why they completed different questionnaires and what the potential implications are. [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 #2: All comments have been addressed Reviewer #3: 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 #2: Partly Reviewer #3: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? 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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 Reviewer #3: 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: (No Response) Reviewer #3: The authors have addressed most of the comments raised earlier. I have added a few additional comments in areas where there is still need for justification or more specific details. Otherwise I recommend the article be accepted for publication after the minor corrections. ****** 7. 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Revision 2
22 Jan 2021 Author Response Second response to reviewers PONE-D-20-06532R1 Men’s and women’s knowledge, attitudes and practices relating to pregnancy and neonatal care: a cross sectional study from Bungoma County, Kenya PLOS ONE Editor’s comments and responses The abstract and title still need some editing to reflect the actual research questions and findings. I suggest you emphasise knowledge of danger signs and care seeking practices, rather than the very general 'knowledge, attitudes, and practices.' The abstract completely leaves out care seeking for newborns, which seems to me that it would be the most likely variable to be impacted by increased knowledge of newborn danger signs. Currently, the focus is on ANC utilisation, which as I have noted before, is more likely to be a driver than an impact of increased knowledge. Thank you! The title and abstract have been revised to emphasize the study’s focus on neonatal and postnatal care-seeking, and remove the implication that pregnancy care utilization is an outcome. Please add to the limitations the potential bias of only speaking to married man (and not women's unmarried partners). The difference in recruitment methods between men and women is explained well; however, it is still not clear why they completed different questionnaires and what the potential implications are. Thank you. The Limitations section has been revised to also include the bias of only speaking to married men, and to note the study logistics that determined the use of different questionnaires; also noting that this difference constrains comparability between men’s and women’s answers. Reviewers comments in body of PDF and responses (line numbers refer to PDF) Line 111: Reviewer comment: “what about attitudes?” Response: The title has been altered to no longer refer to attitudes. Line 118: Reviewer comment: “This section should be written to have relevance to the study subject matter. For example, demonstrate how agricultural activities are related to men and women's KAP related to pregnancy and neonatal care. How is the population of the county related to the studied population when this is more of a hospital-based study?” Response: The text has been revised to note the ecological relevance. Line 127: Reviewer: how were these sample sizes determined/ calculated? Response: the convenience sampling has been emphasized in this sentence and below. Line 128: Reviewer: state clearly the one year period- between which actual months that constitute the year. This must be known to inform how screening/recruitment was done. Response: the period has been specified more accurately Line 129: Reviewer: What is the justification for use of this method? this is the poorest method of sampling. it is also inappropriate for sample size and statistical tools are intended for use to determine associations and aimed at generalization. Response: We have added text to note the sampling was determined by the resources available to the project team. With this disclosure to inform readers, we believe the subsequent analysis and interpretation is proportionate and holds value. Line 130: Reviewer: Reviewer: specify the market centres where recruitment was done- how many and which ones? what is their vicinity in relation to the hospitals? Response: Their relationship to the hospitals in the broader study has been specified. Line 130: Reviewer: be consistent in use of terms- 'women' instead of 'mothers', in line with your study title. Response: we have changed ‘mother’ to ‘women’ or equivalent, throughout, except where needed to specify the parental role. Line 130: Reviewer: is it possible that another reason for the selection of these hospitals is because the intervention- the collaborative newborn support project- had taken place at these facilities? Response: we have added this detail. Line 338: Reviewer: the sampling procedure used- convenience this is not only the weakest type of procedure, but it is also inappropriate for a study sample that is calculated using methods aimed at representativeness. Response: we have strengthened our acknowledgement of this limitation Line 353: Reviewer: The findings can only be generalized to the target population attending ANC, stretching it to the County when it is a hospital-based study, and using convenience sampling method is misleading. Response: We have reworded to avoid the over-generalisation Attachments Attachment Submitted filename: Response to reviewers, second letter v2.docx https://doi.org/10.1371/journal.pone.0251543.r004
29 Apr 2021 Decision Letter - Tanya Doherty, Editor Men’s and women’s knowledge of danger signs relevant to postnatal and neonatal care-seeking: a cross sectional study from Bungoma County, Kenya PONE-D-20-06532R2 Dear Dr. Gitaka, 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, Tanya Doherty, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0251543.r005
Formally Accepted
4 May 2021 Acceptance Letter - Tanya Doherty, Editor PONE-D-20-06532R2 Men’s and women’s knowledge of danger signs relevant to postnatal and neonatal care-seeking: a cross sectional study from Bungoma County, Kenya Dear Dr. Gitaka: 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 Professor Tanya Doherty Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0251543.r006

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