PONE-D-20-37280

Association between antenatal care utilization pattern and timely initiation of postnatal care checkup: Analysis of 2016 Ethiopian Demographic and Health Survey

PLOS ONE

Dear Dr. Gizachew Tadesse Wassie,

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.

Refer to the comments below.

Please submit your revised manuscript by Mar 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Mohd Noor Norhayati, M.B.B.S., M.Comm.Med., Ph.D.

Academic Editor

PLOS ONE

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Additional Editor Comments:

To relook into the linkage between the use of antenatal care and postnatal care. And among those with postnatal care, to differentiate between home and institutional deliveries. And the connection with these two settings for childbirth.

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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

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

Reviewer #1: Yes

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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

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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

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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: General comments:

The authors have highlighted a critical issue in Ethiopia: low prevalence of timely use of postnatal care. They hypothesize an association between antenatal care and postnatal care and use a nationally representative dataset to test that association. However, the paper is missing a critical analysis and discussion of the expected pathway/linkages between use of antenatal care and postnatal care; this re-analysis and re-write would be necessary in order to make useful recommendations for future study or intervention.

Major comments (should be addressed before publication)

1. The manuscript would benefit from a detailed description of what the authors think the theory of effect is here. How would ANC affect PNC? Are they both driven by a confounder that affects access? Is the experience of ANC (e.g. quality of care) driving the decision to go for PNC? Are current covariates included because they are confounders or just trying to soak up variation? A description and a DAG would be helpful for understanding the importance of this analysis, what it might mean, and for the analytic choices made.

a. Note, assessing counseling as a predictor of PNC could provide more strength to the hypothesis shared in the discussion section :“Because ANC is a time when mothers are educated about childbirth and childcare practices, those who follow the ANC guidelines might be better informed about PNC guidelines.”

b. Also in the discussion, the following assertion can be tested using DHS data and therefore should be tested if you want to discuss it in the discussion: “Increased numbers of antenatal visit might give opportunities to women to learn about birth preparedness, potential complications during pregnancy and labor”

2. Given the very large difference between those who delivered in an institution versus home, I would recommend stratifying those populations. Who got a postnatal visit among those who delivered in an institution, and who among those who delivered at home? This ties again into the theory of change – does ANC lead more women to deliver in an institution, which then leads them to have a timely PNC visit, or does ANC lead to increased PNC regardless of institutional delivery? Note that this phrasing is causal, because I’m thinking about theory, but this analysis will only look at associations not causation.

3. Again, depending on your theory of change, it is likely that one pathway through which ANC could affect PNC use is through quality of care (the authors allude to this in the last paragraph of the introduction). The analysis would be strengthened if this hypothesis were tested as well. The authors could create a quality of care index based on the services reported as received during ANC (while patient report is not the gold standard for these process of care measures, it might provide some indication of quality of care).

4. Discussion: please discuss how 36.9% of women gave birth in the health facility, but only 16.5% had a postnatal check-up within two days. Are women being discharged without a postnatal check-up? How long after delivery does the check up have to occur to be considered “postnatal”? This second question ties into the confusion above of discussing hemorrhage and birth asphyxia in relation to postnatal care. It would be helpful to see the question from the DHS that this analysis is based on (does it mean that ~half o the people who delivered in the facility answered “no” to the question “Did anyone check on your health while you were still in the facility?” The authors discuss that women are supposed to stay for 24 hours, so this issue of women who deliver in a health facility not receiving a PNC visit seems to be one of quality of care, not of the woman’s choice or access.

5. The paper focuses entirely on the first postnatal visit – is it possible to also look at subsequent visits?

6. Together with the careful theory of change discussion requested above, I think the paper would benefit from a careful read to make sure there is no causal language implied. Without understanding the pathways through which ANC and PNC are associated, it’s hard to know if increasing ANC would meaningfully impact PNC (the authors do include this in their limitations section, which is great).

Minor comments (to improve clarity)

1. Introduction: the first and second sentence almost seem at odds with one another. Hemorrhage and birth asphyxia within the first day would be most affected by delivery at a health facility. Maybe adding other causes of morbidity and mortality that would also be affected by the subsequent postnatal visits would be helpful.

2. Figure 1: It’s helpful to break out the women who were not eligible (didn’t deliver in past two years) from those who had

3. Table 1: Is education the highest level completed? Please clarify in the table

4. Sample characteristics: The sentence “Nearly half (42.2%) of the women were multiparous (had two or more pregnancy).” is misleading. I suggest reporting the number of primiparous women (preferable), or report the full number of multiparous, which according to the table would be 42.2%+37.4%

5. Typo in the aOR for secondary education, missing the decimal place (164)

6. Discussion: this sentence seems to confuse multiparous with grand multiparous, which appears to be the comparison group in table 1 “Primiparous women were 66 % less likely to utilize postnatal checkup timely as compared with multiparous women.”

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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.

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Reviewer #1: No

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PONE-D-20-37280R1

Association between antenatal care utilization pattern and timely initiation of postnatal care checkup: Analysis of 2016 Ethiopian Demographic and Health Survey

PLOS ONE

Dear Dr. Wassie,

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 Aug 08 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,

David Teye Doku

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.

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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: (No Response)

Reviewer #3: 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

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

Reviewer #2: Yes

Reviewer #3: Yes

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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

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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

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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 effectively addressed the majority of the reviewer comments. However, a few important concerns remain unaddressed. These include the following:

1. An important comment by the reviewer "A description and a DAG would be

helpful for understanding the importance of this analysis, what it might mean, and for

the analytic choices made" was not addressed.

2. On the sample characteristics, the comment "Sample characteristics: The sentence “Nearly half (42.2%) of the women were

multiparous (had two or more pregnancy) ” is misleading" was not addressed as claimed by the authors. Here, I believe the reviewer wanted authors to directly state 42.2% as this figure cannot be considered as "nearly half".

3. The "Highest educational level" in Table 1 should also be replicated in Tables 2 and 3 as well as under the "Study variable".

4. This is very important. Some of the journal format guidelines were not adhered to by the authors. For example,

the in-text citations are expected to be in square brackets but not round. Ultimately, reference no. 4 "postpartum-complications[1]" was poorly cited and should be checked and fully provided. This also applies to reference numbers 21 (https://doi.org/10.11564/28-3-638) and 22 in the reference list.

Finally, the journal requires authors to provide the "Declarations" (Authors’ contributions, funding, competing interests, Availability of data and materials among others) in the editorial manager system but not in the manuscript as provided by the authors. Authors have to address this to avoid possible delay in the publication of their paper.

Reviewer #3: Authors have carefully addressed almost all the issues raised by reviewers in the first review process. However, the additional comments below should be addressed to enhance the quality of the paper.

General comments:

There are some few grammatical errors in the manuscript including missing commas, missing function words and dots. E.g. (lines; 41, 75, 82-83, 136, 175-175, 217 etc.). Authors should carefully read through the work and correct all grammatical errors in the papers.

The sentence on line 41-42 should be changed to “Chi-square test and multivariable logistic regression analyses were used to...”

The sentence on line 164 should also be changed to “Multiple logistic regression analyses was performed…”

Authors should avoid the use of complex sentences which are difficult to understand e.g. (lines 88-89)

Authors should be clear on the marital status of participants. What does the “Yes” and “No” categories of the marital statuses of participants in the results represent? E.g. Married or Single

The “None” as a category of educational status in the result section should be changed to “No formal education”

The sentence on line 202- 203 should be changed to …women who had secondary and above education (aOR: 1.64; 95%CI: 1.03-2.60) compared to those who had no formal education…”

Authors should briefly discuss how similar or different their study results are in relation to other studies. Thus, what are the evidence in literature of which results in this study is consistent with? (Lines 217-218, lines 231-232, line 239, lines 245-246, line 254

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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

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PONE-D-20-37280R2

Association between antenatal care utilization pattern and timely initiation of postnatal care checkup: Analysis of 2016 Ethiopian Demographic and Health Survey

PLOS ONE

Dear Dr. Wassie,

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 Sep 24 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,

David Teye Doku

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):

Language checking and thorough editing is recommended.

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Reviewers' comments:

[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.]

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Association between antenatal care utilization pattern and timely initiation of postnatal care checkup: Analysis of 2016 Ethiopian Demographic and Health Survey

PONE-D-20-37280R3

Dear Dr. Wassie,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

David Teye Doku

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: