PONE-D-20-38899

Community’s experience and perceptions of maternal health services across the continuum of care in Ethiopia: a qualitative study

PLOS ONE

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Reviewers' comments:

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Comments to the Author

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

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Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Partly

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

Reviewer #1: N/A

Reviewer #2: N/A

Reviewer #3: N/A

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

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Reviewer #1: General comments

Maternal and child health is still a priority of concern in Ethiopia. I read this manuscript with pleasure and I found it an interesting topic. In general, the study is presented logically and scientifically, well-edited, and it is in a standard English language. I have only a few comments mostly on clarification.

Q1. Under the methods(L120 – 124): The sentence starting with “ where I am providing technical assistance…) is confusing and not important to indicate who you are working for. In this study, there is more than one author and it is unknown who I refer to. This could also raise an issue of conflict of interests if the project owner is also the principal investigator of this study. I suggest either modifying this paragraph or avoiding using first-person singular pronouns.

Q2: Data collection: When were the themes developed? Was it before or after data collection? It is mentioned that you have used both deductive and inductive coding, but it is not clear if themes were developed after the interview based on the findings or you come up with pre-identified themes. Please also justify the reason to choose either one or both methods.

Q3. Results:

You have mentioned that the study used participants from high and low-performing districts(L137-139). However, in your results, when you quote the participants' thoughts, you didn't indicate whether the participant is from(high performing or low-performing district). In my opinion, it would be more informative if you could add where the participant is from( high or low performing district). E.g. ……………(Community leader, High performing district, IDI).

Q4. Although this study is not comparative, I think it is possible to narrate if there is any difference between the high performing and low performing districts with respect to your study themes. Are there any best practices or lessons learned from the high-performing districts? This can be included in your result or discussion part unless I have missed it.

Q5. The phrase(L314) “fear of the growth of the baby” is not clear. What does fear of the growth of the baby mean and how it could be a reason for discontinuation of PNC services?

Reviewer #2: 1. Title: In this study, authors mainly shared the community’s experience rather than perceptions; so I will suggest to remove the word “perception” from the title, and also to make the necessary changes throughout the document including the research questions and keywords.

2. Keywords: Suggesting to remove “postnatal care” as it is the part of continuum of care. Community has negative experience not only related to the postnatal care but also to the two other aspects (ANC and intrapartum) of continuum of care.

3. Financial disclosure: Without having any specific fund, how the data collection and data analysis chapters were managed? Is this study part of the L10K project? Is there any incentive or token of appreciation for the FGD and IDI participants? If not, what’s motivate them to participate in this study?

4. In Abstract: Number of FGD and IDI needs to mention clearly.

5. In the background, the definition of continuum of care needs to explain clearly. To justify the problem statement properly, the overall maternal health situation needs to describe including the trends of MMR, and how it differs between urban and rural areas. This study’s main focus is at the primary level health care which is not reflected in the background.

6. Method section: This is a qualitative study where purposive sampling is acceptable; even then, please mention “what are the efforts the investigators made to avoid biasness”, as at line 120-121, it was mentioned “how the principal investigator is involved with the study areas”, whether this working relationship affects the study findings or not. It was mentioned that the data analysis (line 189) is guided by the conceptual framework but I did not find the framework. I am suggesting to add the brief description of the framework in the method section

7. Results: Please add the age range for all kinds of participants in addition to their mean age. Line 219-220, please explain with references- what are the evidences of utilizing ANC, facility delivery, infant vaccination and postpartum family planning services by most of the women? Is it the study findings or overall Ethiopian’ maternal health situation? Throughout the document, I did not find any positive experience, almost all are the negative experiences mentioned by study participants. If the study participants have any positive experience which authors did not add to this manuscript or if there is any evidence, better to present with reference to justify this statement.

Mothers and the community are not aware of PNC service. As there is a national guideline [Ref 42], authors should discuss about this guideline early instead of mentioning at the last line of the conclusion; also “what are the barriers to implement this guideline”- need to discuss.

Why health promotion activity did not focus on PNC services? Who is the implementer of the health promotion activity, whether government or non- government/private agency? -- need to discuss.

Line 241- What is the reason of “unknown LMP” as it leads to delayed booking?

Line 324-“did not realize she is pregnant until the 4th or 5th month”; why these women did not notice their missed menstrual period? whether these women were having irregular menstrual period or not. All these issues need to be find out by the researchers?

Line 369 -370- as this study area is located in rural area; how the respondents are comparing their experience with that of urban patients; this is not clear to me

Line-379- “women give birth without disclosing their pregnancy”- can authors explain how women hide their 9-month pregnancy period? How the community or family members help them to hide it?

Line 523_ “unduly exposure of women’s reproductive organs and lack of privacy”- what does this mean? Whether the vaginal examination is done in open space in presence of other people who are not service providers. Because, at the line 362- the community leaders said that “he was waiting outside far from the delivery room” i.e. even husband was not allowed to stay with wife.

8. Discussion: This section is relatively weak and needs to be strengthening by explaining the study findings with proper justification and evidences. In this section, authors re-emphasised the study findings with some justification which is not sufficient. The study findings need to be explained by the authors. Example:

Line 535 – “lack of trust” – what is the suggestion of authors to improve the trust?

Line 558- why community people does not know about PNC service if it is available? What are the main barriers?

Line 563- “maternal health services are weak” whether authors can make this conclusion based on this qualitative study? To justify this statement, authors need to mention other evidences if available?

Line 565—566- this is confusing; if it is the responsibility of health workers to provide PNC at home; then why we are expecting that health care providers of the health center will suggest the mothers to come at the facility for PNC?

Line 571-574: If the authors suggested for “mixed-method of PNC service”, what will be the effective implementation strategy to avoid the duplication of services between health workers and health care providers, and how to ensure the proper implementation of PNC services. This needs to be explained clearly by authors.

9. Minor issues:

a. In-text citation should be within square bracket

b. Before using any abbreviation, it needs to spell out the full term first e.g. line 63 (COC), line 84 (EDHS), line 108 (HEP), line 120 (L10K); please check all abbreviation and make necessary changes following the rules of abbreviations. The list of abbreviation is also missing

c. Birr is the unit of currency in Ethiopia; it needs to be presented at the international currency unit like USD; otherwise it will be difficult for the international readers to understand it clearly

d. In the same way, authors should explain “kebeles”;

e. Line 198- please check the sentence to complete it

f. Community leader vs community elders (line 414, 426, 585) – needs to be consistent as the operational definition of leaders and elders are different.

g. At the end of each quotation whether the anonymous identifier can be part of the sentence e.g. “……………………………………….” (recently delivered mother, FGD).

h. What is the gender of community leaders? Are they all males or mixed i.e. some are males and rest are females, please mention it?

i. Line 133- community volunteers – do they receive any incentive for their work?

Reviewer #3: Good article and informative. Minimal errors need to be addressed:

1) Some abbreviations ie. CoC and HEW were not put in a full meaning - take note for the abbreviation in the article and the rest will follow the abbreviation. Please look at the introduction section.

2) How does author ensure the adequacy of the sample size in this study? Did not mention on whether saturation has been reached or not.

3) The word National in the National Emergency Obstetric and Newborn Care was put as small letter. The letter 'N' should be in capital letter.

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Reviewer #1: Yes: Serebe Gebrie

Reviewer #2: No

Reviewer #3: No

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Community’s experience and perceptions of maternal health services across the continuum of care in Ethiopia: a qualitative study

PONE-D-20-38899R1

Dear Dr. Tiruneh,

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Kind regards,

Kingston Rajiah

Academic Editor

PLOS ONE

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