PONE-D-20-30363

Exploring providers’ perceived barriers to utilization of antenatal and delivery services in urban and rural communities of Ebonyi state, Nigeria: a qualitative study

PLOS ONE

Dear Dr. EDMUND NDUDI OSSAI,

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.

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We look forward to receiving your revised manuscript.

Kind regards,

Sharon Mary Brownie

Academic Editor

PLOS ONE

Additional Editor Comments 

The review process has identified very significant issues that require attention within your manuscript if it is to be considered for publication. Of concern, your qualitative quotes do not support your findings. For a returned manuscript please ensure that you include a completed 32 step COREQ checklist of the quality reporting of qualitative research https://www.equator-network.org/reporting-guidelines/coreq/ Please also include a table addressing each point raised by the reviewers.

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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: N/A

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: Yes

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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: Introduction

• Much of the literature in the introduction focus on maternal deaths, and access and utilization of ANC as mitigations. Authors worked their way deductively from global perspectives to the Nigerian situation. However, the purpose of the study is to explore providers’ perceived barriers to utilization of antenatal and delivery services in urban and rural Nigerian state. Accordingly, authors should situate the study within theories underlying barriers to utilization of ANC and delivery services.

• What exactly is the problem underlying this study? what does this study seek to achieve? How does this study differ from the vast literatures addressing gaps in maternal and child health within and across LMICs including Nigeria?.

• The conceptualization in its current form is not grounded in new and innovative theoretical perspectives beyond what is known on this subject matter.

Methodology

• Authors stated: “In the second stage, a list of all health facilities in the selected local government areas was made and ranked based on the number of women that utilized the health facilities for antenatal and delivery services in the last six months based on hospital records. Twelve health facilities, six each in urban and rural communities were selected based on this criterion”. It is unclear what the criterion is and how it aided the selection.

• Authors stated: “The key providers of antenatal and delivery services in each of the facilities were purposively selected for interview”. Who were these key providers and why were they sampled purposively?

• Several content overlaps and repetitions appear though out the manuscript and especially the methodology. This phrase “pretested interview guide”, for example is overly repeated throughout the methodology.

Findings

• The lack of systematic conceptualization of perceived barriers from the onset has affected the quality of the findings – which are a bit disjointed. Example, thematic areas of the findings included: Utilization of antenatal and delivery services in health facilities; Reasons for good utilization of health facilities for antenatal and delivery services; Reasons for poor utilization of health services for antenatal and delivery services; Reasons women deliver at home and by traditional birth attendants; Constraints to use of health facilities for antenatal and delivery services; and How to improve utilization of antenatal and delivery services.

• I find it extremely difficult collectively relating the thematic areas to barriers of ANC and delivery service use.

• Moreover, authors earlier argued that quality of maternal of health services in the study areas is extremely weak. This tend to deter women from utilizing ANC and subsequent uptake of delivery services. To the contrary, the first set of findings suggest that providers are doing their utmost best to provide good quality maternal health services. This reflect in these quotes below:

“We offer quality healthcare to our clients, we ensure that they are satisfiedbwith the services they receive from us. We have also ensured that the attitude of health workers is good” (Female participant, urban)

We practice respectful maternity care. The clients are allowed to stay at any position that is comfortable to them during labour unlike before when health workers shunned such practices. Health workers now respect the dignity of the women and this creates a very good impression on them” (Female participant, urban)

• It can be inferred from the quotes above that authors are evading the purpose of this study. Further, to say in one breath that providers are oriented to good quality care and to turn around and accused the same providers of poor attitude appears to turn this study upside down.

Other comments

While authors have done their best in coming out with this manuscript, the conceptualization, findings and conclusions present no significant new information. There are a plethora of quality theories and evidence produced in response to barriers of maternal and delivery service utilization in sub-Saharan Africa. Such findings produced barriers that cut across poverty, income, demographic and geographic factors, cultural and social norms, religion and many more. You can read more about these studies at: https://scholar.google.com/scholar?start=20&q=why+women+deliver+at+home&hl=en&as_sdt=0,5 and particularly the work of Mrisho and colleagues (2007).

Reviewer #2: The authors did a good job presenting the barriers around severe maternal mortality in the southeastern part of Nigeria. While the study falls short of a large sample size, it reveals some of the barriers that can be acted upon as helpful and much-needed steps towards a positive intervention for reducing severe maternal mortality in that part of the country.

I have some minor suggested changes, though.

1. The authors could be silent on the majority Christian mentioned in the method section, except if their study shows that religiosity plays a role in the health outcomes.

2. In the study design section, correct the punctuation typo before (KII).

3. In the study instrument, rephrase the sentence to remove "also" at the end of "use of recorders also.".

4. Combine sections "Study Instrument, Data Collection Methods, Pretesting of instrument" into a single section. There seem to be some repetitions and commonalities.

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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.

PONE-D-20-30363R1

Exploring providers’ perceived barriers to utilization of antenatal and delivery services in urban and rural communities of Ebonyi state, Nigeria: a qualitative study

PLOS ONE

Dear Dr. EDMUND NDUDI OSSAI,

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 25 April. 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,

Sharon Mary Brownie

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments

The manuscript is much improved in the revised version, however, reviewers have identified the need for a number of further improvements. Please consider each carefully and respond to these in full.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

Reviewer #5: 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 #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: N/A

Reviewer #5: N/A

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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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 #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: The authors have addressed all comments. Exploring providers’ perceived barriers to utilization of antenatal and delivery services could help reduce severe maternal mortality in that part of the country.

Reviewer #3: 1. The research question clearly seeks opinion on "barriers" for the utilisation of the Health Facility, whereas the results begin highlighting that the services are well utilised. The paper then goes on to explain how the services rendered can be made more accessible and better but the link to the reader breaks at the first level.

2. What Framework was used for the analysis of the qualitative data?

3. Some recommendations to the barriers can be added in the conclusion for a stronger way forward.

Reviewer #4: The article is very well written and I enjoyed reading the discussion and comments of reviewers have been addressed

Reviewer #5: The authors have sought to explore the reasons for barriers for utilization of antenatal and delivery services from the care-providers' perspective in some rural and urban communities of Ebonyi, Nigeria, through this qualitative study. In reply to previous reviewer comment, they have now amply explained the reasons for choosing the particular centers and the providers for interview. However, they have not been able to adequately answer, what new knowledge has this study added to existing literature because the reasons for not attending for antenatal care and delivery at health-care centers in LMICs are already well-known through previous literature. A few more points on how this could be improved would be beneficial add to knowledge.

There is a lot of repetition in the manuscript (discussion) regarding reasons for poor utilisation of health services. This could be stated more concisely.

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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 #2: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: 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.

Exploring providers’ perceived barriers to utilization of antenatal and delivery services in urban and rural communities of Ebonyi state, Nigeria: a qualitative study

PONE-D-20-30363R2

Dear Dr. EDMUND NDUDI OSSAI,

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,

Sharon Mary Brownie

Academic Editor

PLOS ONE

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 #5: 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 #2: Yes

Reviewer #5: Yes

**********

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

Reviewer #2: Yes

Reviewer #5: N/A

**********

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 #2: Yes

Reviewer #5: 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 #2: Yes

Reviewer #5: 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: The authors have addressed all reviewers' questions. The study is quite important to a region of Africa with high prevalence of maternal mortality.

Reviewer #5: The authors have answered all reviewer queries very well and the article is now good enough to be accepted for publication.

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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 #2: No

Reviewer #5: Yes: Azra Amerjee