PONE-D-20-22930

Towards stronger antenatal care: understanding predictors of late presentation to antenatal services and implications for obstetric risk management in Rwanda

PLOS ONE

Dear Dr. Schmidt,

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 see the comments from the reviewers below. The reviewers have requested further elaboration on the statistical analysis, how the methodology ties in with the aims, justification for specific choices in the methodology and analysis, as well as clarification on certain specific points.

Please submit your revised manuscript by Dec 28 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.

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,

Hanna Landenmark

Associate 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. "You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

3. 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.

4. Please ensure you have included the registration number for the clinical trial referenced in the manuscript.

5. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

[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: No

Reviewer #2: No

Reviewer #3: Partly

Reviewer #4: Yes

Reviewer #5: Yes

**********

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

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: 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: No

Reviewer #4: Yes

Reviewer #5: 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

Reviewer #4: Yes

Reviewer #5: 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: A secondary analysis was conducted with the aim of identifying factors associated with delayed initiation of antenatal care (ANC) and comparing the risks between those presenting early and late for care. Adjusting for clusters, backwards stepwise regression analysis were used to identify predictors of first ANC visit. The statistical methods are vague; therefore, the conclusions are unclear.

Major revision:

It seems that either logistic regression models should be used when predicting the dichotomies of ≥ 16 weeks or ≥ 24 weeks or linear regression models to predict the continuous value for week of ANC-1. Additionally, in the backward selection model it is common to include candidate predictors with univariate p-values ≤ 0.10.

Minor revisions:

Line 179: Chi-square tests are used to show association. Use logistic or linear regression models for prediction, even for univariate tests.

Reviewer #2: Abstract

The results are confusing. The study set out to assess factors associated with delayed initiation of the first antenatal visit, in lines 31-33. However, it is reporting factors associated with early initiation of antenatal care in part of the results section, rather than factors associated with late initiation of antenatal care, in lines 41-47.

• Educational attainment, prior spontaneous abortion and pregnancy testing were associated with earlier ANC-1 (p<0.001).

• Women with a prior preterm (p=0.024) or low birthweight (p=0.023) delivery were more likely to present before 16 weeks GA, while history of stillbirth or neonatal death were not associated with timing of ANC-1.

• Women presenting before 16 weeks GA were more likely to have no obstetric risk factors identified at ANC-1 (p<0.001).

In lines 49-54, the authors present a discussion, but do not have a clear conclusion. Also, the authors do not indicate how awareness of the importance of antenatal care would be increased. They also do not indicate how health system strengthening may be done to identify the suggested risk factors. They do not seem to have a conclusion. They state:

• Outreach efforts should focus on increasing mothers’ awareness of the benefits of ANC and emphasize the importance of early identification and management of pregnancy-related complications.

• While fewer risk factors were identified among women presenting less than 16 weeks, lower than expected rates were identified in the study population overall.

Main article

In lines 65-71, the authors state that many of the complications that lead to adverse outcomes can be maternal or neonatal outcomes can be prevented through early antenatal care, and mention hemorrhage as one of the factors, yet antenatal care may not mitigate hemorrhage-related maternal morbidity and mortality. Similarly, they suggest that antenatal care may reduce infection-related neonatal morbidity and mortality without any suggestion of how this can be achieved. This to me seems speculative, considering that most neonatal infection follow peripartum or postnatal complications.

In lines 84-93, the authors should provide an explanation of how many of the suggested factors lead to late presentation of antenatal care.

Methods

In lines 158-162, the authors need to indicate the definitions used for anemia, hypertension, proteinuria and diabetes, as well as how these variables were measured. Is it present/absent or a definite cut off?

In lines 171-178, the data analysis conducted is not clear. At analysis, the authors state:

Variables that were significantly associated with delayed presentation to ANC at the 172

�=0.05 level were retained for multivariable model building. This is too strict and erroneous, as

they should have included all variables with a p-value of less than 0.2 or even those with clinical

significance, such as complications in a prior pregnancy. The backward and stepwise method of

variable selection is also not clear.

Discussion

The discussion does not provide an explanation of how the suggested factors operate, for example educational attainement, parity, prior complications etc.

It is also not clear how parity as a moderator was assesed, when you view the results presented, as the stratified analysies compared primiparous and multiparous, rather than parity as an independent variable.

In lines 331-335, the authors state that : This investigation also examined differences in the obstetric risk factors identified at participants’ first ANC visit. Women presenting before 16 weeks GA were more likely to have no identified risk factors (“none”). This may be partially due to the fact that some obstetric risk factors, such as multiple births or hypertension, may be identified at a higher rate at later gestational ages. However, the focus of their stated objective was to assess factors associated with late antenatal attendance. Also, their explanation of of lack of identifiable risk factor is not clear to me.

The authors add, in lines 338-340, that: multiparous patients do not appear to be at lower

risk of pregnancy-related complications. Multiparous women should be encouraged to continue

to attend ANC, due to the risk of delayed identification of modifiable risk factors. This also is not clear to me.

The authors should comment, in the discussion, on the quality of antenatal care, that is activities conducted per visit, rather than the number and timing of antenatal care visits, and the influence of this on pregnancy outcomes (maternal and mneonatal outcomes).

Reviewer #3: 1. Abstract

� On line 41‘’Earning income’’: not clear

� Line 48, use conclusion instead of discussion

2. Introduction

� On page 6 line 112 ‘‘this analysis identified predictors of late (≥16 weeks GA)…’’. Why did you use 16 weeks of gestational age as a cut-off pint? WHO recommends pregnant women have to start their first ANC booking within the first 12 weeks of gestational age. See the following references.

� World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience [Internet]. Geneva, Switzerland; 2016. Available from: ttps://apps.who.int/iris/bitstream/10665/250796/.../9789241549912-eng.pdf

� Tuncalp Ӧ, Pena-Rosas J, Lawrie T, Bucagu M, Oladapo O, Portela A, et al. WHO recommendations on antenatal care for a positive pregnancy experience — going beyond survival. BJOG. 2017;124:860–2.

3. Methods

� From line 132-133, ‘‘only participants with completed ANC care records were included in the final analysis.’’ If this is the case, is it representative?

4. Analysis

� Data analysis is not well addressed and robust

� From line 165-166, ‘‘Chi-squared tests were performed to identify variables

significantly associated with late presentation to ANC.’’ why you preferred Chi-squared tests than odds ratios?

� Not clear on the selection of measures of association used. For instance, Chi-squared tests vs. Odds ratios.

5. Ethical consideration

� Line 198, ‘‘Written consent was obtained from all participants.’’ How did you secure it? Are all read and write to give you written consent?

6. Discussion

� Lacks author argument

7. Limitations

� Line 370, ‘‘we found that many clinical variables had poor quality.’’ many clinical variables specifically………had poor quality

Reviewer #4: Towards stronger antenatal care: understanding predictors of late

presentation to antenatal services and implications for obstetric risk

management in Rwanda

This study is of Public health relevance. The authors identified factors associated with delayed initiation of ANC and describe differences in the obstetric risks identified at the first ANC (ANC-1) visit between women presenting early and late to care.

I have the following comments

1. L36 & L172…authors claimed to have used “Cluster-robust standard error models”. This is a model estimation method and not a model in itself. In essence, you used logistic regression and controlled for the clustering effect of the health centres

2. What was the level of significance adopted?

3. What was the main study outcome and variables explored?

4. L127 …what were the controls

5. What is the rationale for grouping women aged 20 to 34 together? This is a critical age group where most pregnancy occurred. The behaviour of young adults (20-24 years) are very distinct from those aged 25-34 years. Authors should reanalyse

6. Important variables such as Type of marriage (monogamy/ polygamy) was, autonomy, decision making power by the women were excluded

7. Table 3: Why present both coefficient estimates and odds ratio? Delete the two columns on “Estimate (SE)”. It is redundant.

8. Did you adjust for multicollinearity among the explanatory variables?

9. Did authors assess the relationship between individual explanatory variables before choosing them as candidate variables in the multiple regression model?

10. It is usual to first do this assessment (bivariate regression) and include only the variables that were significant at a specified level (say 10 or 20%) before you run the multiple regression. The outputs of the bivariate regression are the odds ratio, sometimes called crude odds ratio (COR) while those from the multiple regression are called adjusted odds ratio (AOR)

11. Tables 4 and 5 should precede Table 3

12. Why were the risk factors in Tables 4 and 5 excluded from the regression model in Table 3? Were they insignificant?

13. There are typos and grammar issues

14. Authors should make the public health importance of this study clearer

Reviewer #5: Reviewer's report:

Initiating antenatal care (ANC) in the first trimester and identifying obstetric risk factors early are crucial for improving birth outcomes. Also, service providers’ knowledge of predictors of initiation of ANC has implications for obstetric risk management. This can help improve quality of care. However, English language needs some input; a few have provided.

General comments

1. The abstract convey what is in the manuscript

2. The data is sound.

3. The method section of the manuscript requires a major revision

4. The tables are genuine and well described

5. Some parts of the discussions needs revision to situate especially contrasting results in academic discourse

6. Conclusions reflect the results

I thus, recommend that the manuscript be accepted and the authors asked to revise the manuscript before publication.

Abstract

Word count =306

1. The title: Towards stronger antenatal care: understanding predictors of late presentation to antenatal services and implications for obstetric risk management in Rwanda

The title needs revision to cover early initiation of ANC (<16 weeks) since it is part of the analysis as shown in Table 1 and the conclusion

Introduction

1. P. 5, line 89: insert ‘as’ for the sentence read such as the practice of disclosing pregnancy after the second trimester.

2. P. 5, line 90-91: I suggest ‘poor experiences’ be replaced with ‘negative experiences’

3. P. 7, line 119-121: The authors should avoid repeating words sentences. The second ‘how’ in the sentence. I suggest: …, and inform messages tailored to multiparious and nulliparous women.

4. P. 7, 133: … completed ANC care… the ‘care’ is repetition and should be deleted.

Results

5. P. 10, line 203 and 206-208: By conversion, a sentence should not begin with a figure. I suggest the sentences should be re-written.

6. P. 15 and 16, Tables 1, 2, 3 and 4 and 5: The ‘p-values’. The ‘p’ should be capitalised as ‘P-values’

7. P. 16: Idetified is not necessary in Table 5

8. All the information in brackets in Tables 1, 2, 3 and 4 (≥ 16 weeks GA) and very late (≥ 24 weeks GA) is not necessary. They are already difined in the text.

9. I expect the authors to emphasise finding regarding the benefits of initiating ANC < 16 weeks.

Discussion

10. P. 17, line 276: Despite ongoing to increase early ANC attendance, that the .... ‘that’ should be deleted.

11. P. 17, 283-287: I suggest the authors look for evidence to explain and support their assertion that contribution to household income was a stronger predictor of delayed ANC-1. Also, could you please emphasise what your study adds?

12. P. 18, line 295: More effective strategy increase .... There should be ‘to’ as: ... strategy to increase ...

13. P. 18, line 300-302: However, barriers to continuing ANC care may emerge for women for whom ANC-1. The sentence should be: However, barriers to continuing ANC care may emerge for women for whom ANC-1. I suggest ‘ANC’ be deleted and ‘for whom’ replaced with ‘whose’

14. P. 19, line 333: why put ‘none’ into brackets. The sentence clear without ‘none’

15. P. 20, line 342: Despite conducting data strengthening activities, our investigation found lower than expected rates of obstetric risk factors were identified in the study population overall. ‘were identified’ is a repetition so need to be deleted.

16. P. 20, line 345-346: The sentence needs to be re-written to make comprehension easy for readers. I suggest: Other important screening results including diabetes and syphilis were systematically missing from the health record and thus were excluded from our final analysis.

17. P. 20, line 351: ... function of ANC care. ‘care’ is repetition and should be deleted.

18. P. 20, line 357: Delete the second ‘in’ in the sentence. i.e. This study also reported large gaps in provider knowledge, including the ability to …

Conclusion

19. The conclusion should also emphasise the benefits and predictors of early ANC attendance to inform interventions.

20. The conclusion early intervention is too unspecific as this vary in different cultures

21. The recommendation that community-based pregnancy testing could increase early pregnancy discovery and prompt earlier attendance at ANC clinics can be contested as the data does not show that late attendance is attributed to not being aware

**********

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: Yes: Daniel Kabonge Kaye

Reviewer #3: Yes: Tufa Kolola Huluka

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.

Attachments

Attachment

Submitted filename: Plos.docx

Attachment

Submitted filename: Comments to Authors Reviewer 5.docx

PONE-D-20-22930R1

Towards stronger antenatal care: Understanding predictors of late presentation to antenatal services and implications for obstetric risk management in Rwanda

PLOS ONE

Dear Dr. Schmidt,

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 May 15 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. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Adeniyi Francis Fagbamigbe, Ph.D

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.

[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 #1: (No Response)

Reviewer #3: (No Response)

Reviewer #5: (No Response)

**********

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

Reviewer #3: Yes

Reviewer #5: Yes

**********

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

Reviewer #1: No

Reviewer #3: Yes

Reviewer #5: 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 #3: 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 #1: Yes

Reviewer #3: 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 #1: Major Revision:

Tables 1 and 3: In the logistic model each characteristic will have only one p-value associated with it. In other words, p-values for each level of a characteristic should not be provided. Consider consulting a qualified statistician for assistance with reporting the results from logistic regression modeling.

Minor Revisions:

1- Express p-values more precisely than “p <0.05” and "p<0.01".

2- Line 228: Clarify the meaning of alpha=0.05.

3- The standard statistical term for average is mean.

4- Line 246: Provide a measure of dispersion for the mean of GA at presentation.

5- Clarify if the results presented in Tables 4 and 5 are based on univariate or multivariate models.

6- Spell out a number when it occurs at the beginning of a sentence.

Note: Line numbers refer to those in the tracked changes version of revision 1.

Reviewer #3: I appreciate the authors' effort because I have observed a significant improvement they made into this paper at this stage. The authors have also addressed the majority of my concern during their revision. But, still, I am not convinced in some cases.

1.For instance, regarding cutoff for “late” presentation, you referenced the cutoff used by the Rwandan Ministry of Health which is not standard or consistent with the cutoff used elsewhere. When I see published articles on this issue, the majority of articles published since 2018 used >12 weeks GA as “late” presentation. My concern here is that how yours compared with results obtained by this cutoff (>12 weeks GA)? In Rwanda, it may be OK.

2.Regarding the selection of measures of association, I am not clear with the reason why did you prefer reporting p-value than odds ratio? As you know p-value conveys a little information regarding the strength and direction of association compared with odds ratio. Additionally, even your p-value report is not consistent throughout. For instance, p<0.05, p<0.001, p=0.02, p=0.03,etc. When you report the p-value, report its exact value.

Reviewer #5: The manuscript is much improved, the text flows much better and almost all the issues raised have been addressed and acceptable for publiction.

However, there are a few spelling and grammar mistakes (eg missing words, incorrect verb conjugation, missing articles etc) Examples

P.3 line 42, by conversion a sentence should not begin with a figure

P.5 line 83, ‘greater’ not necessary in the sentence.

P.6 line 101, "of" is missing in …parity and history of uncomplicated …

P23 line 437 the sentence should start with ‘The’ and replace the second ‘CHW’ with ‘their’ to avoid repetition.

P23 line 441 replace ‘demonstrated’ with ‘demonstrate’

P.22 line 402-404

This sentence seem to belittle the WHO’s call for more ANC visits. The eight ANC visit required is expected to ensure that all the necessary education activities and screening is carried out more thoroughly. Though arguably the intention is to ensure that even if a pregnant woman misses some ANC appointments, at least she will benefit from the education activities and screening than having four with some deciding to go only once or twice.

P.23 line 442-445.

You did not assess quality of care at ANC clinics. Why let your concluding statement be on quality of care. As stated above I suggest that being the last sentence, it should rather echo WHOs’ call for increasing number of ANC visits and the CHW outreach programme used to vigorously sensitise pregnant women and communities on the need to initiate ANC in the first trimester. This is likely to increase the number of ANC visits and improve pregnancy and birth outcomes as shown by your results.

**********

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 #3: Yes: Tufa Kolola

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.

Attachments

Attachment

Submitted filename: Comment.docx

PONE-D-20-22930R2

Towards stronger antenatal care: Understanding predictors of late presentation to antenatal services and implications for obstetric risk management in Rwanda

PLOS ONE

Dear Dr. Schmidt,

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 Jul 17 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. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Adeniyi Francis Fagbamigbe, Ph.D

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 (if provided):

I recommend minor revisions. The Reviewer 1 has raised important statistical issue amongst others. This particular issue has been raised previously but was not attended to

Table 3: Provide the overall p-values for each factor and remove the p-values associated with each level.

In logistic regression and any other regression involving categorical variables, the variable can not have a p-value, rather, all its categories except the reference category should have p-values.

You have to specify the reference category for each variable, the odds ratio for the reference categories is always 1.oo and it wont have a p-value. For example in the Age variable, if 15-19 is the reference, then age wont have p-value, 15to 19 wont have pp-value but other categories must have p-values.

Kindly note that the editorial may have no other choice to reject the manuscript if you fail to correct this in this round

[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 #1: (No Response)

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 #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: No

Reviewer #3: 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 #3: 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 #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 #1: 1- Line 218: Clarify alpha=0.05. When factors are tested in models, p-values rather than alpha levels are generated.

2- Table 1: The results of the logistic regression models are not summarized in a sensible fashion. Based on the authors' explanation, I determined that the OR for age of 1.01 is associated with a one-year increment in age. Typically a 5 or 10 year increment in age is commonly provided when age is modeled continuously. Additionally, if the authors prefer to model age as a categorical factor, then the reference age group must be identified so the ORs have meaning. The reference group is the group to which all other groups are compared and is typically designated as the lowest or highest category. This table requires revisions, and I suggest using categorical representations of the factors and removing the continuous representation. My suggestion of providing an overall p-value and removing the level p-values still stands because a reader can determine which groups differ by carefully examining the 95% CI for the OR. If the CI does not contain 1, it differs significantly from the reference group.

3- Table 3: Provide the overall p-values for each factor and remove the p-values associated with each level.

Reviewer #3: (No Response)

**********

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 #3: Yes: Tufa Kolola

[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.

Towards stronger antenatal care: Understanding predictors of late presentation to antenatal services and implications for obstetric risk management in Rwanda

PONE-D-20-22930R3

Dear Dr. Schmidt,

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,

Adeniyi Francis Fagbamigbe, Ph.D

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: