Evolution of the quality of prenatal care in the primary network of Brazil from 2012 to 2018: What can (and should) improve?

Elaine Tomasi; Thales Moura de Assis; Paulo Guilherme Muller; Denise Silva da Silveira; Rosália Garcia Neves; Everton Fantinel; Elaine Thumé; Luiz Augusto Facchini

doi:10.1371/journal.pone.0262217

Peer Review History

Original SubmissionApril 7, 2021
1 Sep 2021 Decision Letter - Emma K. Kalk, Editor PONE-D-21-11493 Evolution of the quality of prenatal care in the primary network of Brazil from 2012 to 2018: what can (and should) improve? PLOS ONE Dear Dr. TOMASI, 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. ============================== The authors present the findings of the Brazilian National Program for the Improvement of Access and Quality in Primary Care (PMAQ) reviews of primary care antenatal services at 3 time points between 2012 and 2018. On-going evaluation of public services to which this analysis contributes is important for improvements in quality of care. However, this manuscript is conceptually and methodologically unclear and not suitable for publication is its present form. Please respond to the comments of Reviewers 2 and 3 and to my own suggestions in the attached document which detail some of these concerns. ============================== Please submit your revised manuscript by Oct 16 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'. 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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, Emma K. Kalk Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf. 2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. Additional Editor Comments (if provided): See attached document [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Partly Reviewer #3: No ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: I Don't Know ****** 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: No Reviewer #3: No ****** 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: No ******** 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: Manuscript prepared by researchers with experience in the evaluation of services and actions in primary health care, with a significant number of publications with a similar theme. They present a consistent overview of the development of prenatal care over three valid evaluation cycles covering Brazil as a whole. Justification adequate, consistent and supported by updated literature in this field of knowledge. Methodology adequately described and able to support the presentation of results. The data presented support central statements such as the coexistence between good coverage of prenatal care in Brazil and a worrying reduction in the procedures necessary for the prevention and cure of diseases of high incidence during pregnancy. The conclusions are supported by the data presented and the limitations of the study are adequately presented. Reviewer #2: Prezados autores, Inicialmente, gostaria de parabenizá-los pelo excelente estudo. Venho sugerir alguns pequenos ajustes para melhoria da produção: Introdução: Incluir as recomendações do PHPN e Rede Cegonha para qualificação do Pré-natal no Brasil. Tornar mais clara a situação do PMAQ (não mais vigente), já que desde dezembro de 2019 foi instituído um novo modelo de financiamento da APS brasileira, o Programa Previne Brasil pela Portaria nº 2.979. Materiais e Métodos: Quais os critérios de inclusão e exclusão adotados? Também senti falta de mais detalhes sobre a amostragem e recrutamento das mulheres: Qual o local das entrevistas e de que forma foram abordadas? Houve estudo piloto do instrumento de coleta? Como as 41 instituições de ensino superior se organizaram para a coleta de dados? Foi realizado cálculo amostral? Em relação aos aspectos éticos, houve utilização do TALE às menores de 18 anos, além do TCLE para seu responsável legal? Discussão: Senti falta de discutir alguns dos resultados do estudo ... e de trazer mais comparações dos achados com outros estudos nacionais e internacionais ... Ademais, como os autores entendem as diferenças das Regiões brasileiras nos resultados do pré-natal? Em um dos parágrafos da discussão, faz-se necessário melhorar a descrição do novo modelo de financiamento da APS no Brasil. O Programa Previne Brasil realizará repasses financeiros com base em três critérios: a) captação ponderada (cadastros das pessoas), b) pagamento por desempenho (sete indicadores, que são distribuídos em pré-natal, saúde da mulher, saúde da criança e doenças crônicas e avaliados quadrimestralmente) e c) incentivo para ações estratégicas. Em relação ao pagamento por desempenho, o repasse dependerá dos resultados alcançados por cada equipe em um conjunto inicial de sete indicadores, dentre os quais os 3 primeiros são referentes ao pré-natal. Foi mantido o início precoce (até a 20ª semana), realização de 6 ou mais consultas, dos exames para sífilis e HIV e o atendimento odontológico na gestação. Conclusões: Entendo ser importante acrescentar sugestões de possíveis estratégias que a APS poderia adotar para melhoria da qualidade do pré-natal no Brasil. O que os autores visualizam que ainda poderia ser feito, em termos de gestão interfederativa e de assistência às gestantes brasileiras, para garantia de um pré-natal qualificado? O Previne Brasil reforçou essa responsabilização da gestão e profissionais de saúde pelas pessoas que assistem ... Como os trabalhadores da APS poderiam se organizar para melhorar os resultados/alcançar as metas dos indicadores de pré-natal? Respeitosamente, Avaliador Reviewer #3: I think the performance of health care systems is an important topic and country examples like this one should be published. However, overall I found this article underdeveloped conceptually and very difficult to follow. The stated purpose of the paper is to “describe the temporal evolution of the coverage and quality of prenatal care performed in primary care in Brazil…” but key concepts like quality are not well articulated or defined. There is no clear discussion in the introduction of what the authors mean by quality (at the moment there is a brief mention of quality on line 61 that is followed directly by a reference to access) and then very little in the methods to show how these concepts were reflected in study design, data collection and analysis. A clearer explanation of the PMAQ and the indicators developed is needed to contextualise the study and provide information for the reader. Regarding the methods, what is the sampling approach and how were participants selected? What proportion of the eligible population does this sample represent in each of the districts and therefore how can we interpret the meaning of these findings? I am confused by statements like: Line 107 “A total of six dichotomous outcomes (no; yes) were selected” because I am unclear how this statement relates to the previous paragraph which refers to interviews. And again, Line 113 "Four educational guidelines were 113 evaluated (no, yes)" Line 118 "The indicators used in the analysis were validated by the technical areas of the Ministry of Health. – It would be useful to have more details about this Sentence beginning Line 119 does not seem to be finished. Needs restating for clarity. 124 - ‘prevalence of outcomes’ was calculated. What does this mean? 157 – “Considering the prevalence of the indicators over the period, a positive evolution was observed for…” Until the conceptual and methodological issues are clarified, I do not think I can provide useful comments on the discussion. At present, parts of the discussion that refer to explanations for change in indicators over time such as the paragraphs beginning on LIne 286 and Line 319 require references. ******** 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:** José Marcos de Jesus Santos Reviewer #3: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] 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: PONE-D-21-11493.docx https://doi.org/10.1371/journal.pone.0262217.r001
Revision 1
20 Oct 2021 Author Response Response to the academic editor COMMENT: The overall style is not clear and there are some grammatical errors. This is possibly due to translation into English. ANSWER: We would like these few problems with the language to be pointed out so that we can fix it. COMMENT Introduction: I suggest contextualizing the study in Brazil’s antenatal services and health care structures at the time of the reviews. You have not made clear that the PMAQ is a pay for performance scheme and how this works (also noted by reviewer 2); you should distinguish between the different service packages. I would not previous review findings and existing regional differences. ANSWER: We added content about PMAQ in the Introduction and also in Methods. COMMENT Methods: As noted by reviewers 2 and 3, many methodological details are absent. The methodology is partially described. It would be useful to have a summary or table of the relevant antenatal care guidelines. While each review may be cross-sectional, the analysis is more longitudinal at the 3 time points. ANSWER: We added content in Methods. COMMENT Please motivate for the selection of the 6 outcomes and the exclusion of others. At which antenatal visits were the elements of “physical examination”, “education” and “lab tests” required? ANSWER: We rewritten the methods; there was no mention in the instruments to which prenatal consultations the elements were questioned; the question was, for example: "In the prenatal consultation(s), did the health professionals examine your mouth?" COMMENT 117: what does this sentence mean? Is there a reference? “The indicators used in the analysis were validated by the technical areas of the Ministry of Health.” ANSWER: The text has been modified to make it clearer. COMMENT 120: please use an alternative term to ‘skin colour’. Maybe ethnicity? And I suggest dropping the word, ‘yellow’. If these terms are necessary, are they part of the official language of the Dept of Health? If so, I suggest stating that ethnicity was characterised using the formal classification of the Department. ANSWER: Changes made to the text and table 1 COMMENT Results Need to include uncertainty ranges for all measures. Is the Annual change in Table 2 a risk difference? Between Cycles I and III? Is it the β-value of the regression? ANSWER: Confidence intervals are already presented for the main measure (annual change); the measure is not a risk difference, it is an average rate of change between cycles, the β-value of the regression, and represents the increase or decrease in percentage points; for example, for the first indicator, of six or more appointments, the average rate was negative, there was an average decrease of 2.25 percentage points between 2012 and 2018 in the proportion of women who had six or more medical appointments during pregnancy. COMMENT There a very small changes in proportion, perhaps the p-value is due to the large numbers? Do the you think the changes are clinically or programmatically significant? ANSWER: The changes reflect the actions taken by the health teams, within the scope of their possibilities and incentives received as a result of the Program. It is believed that the PMAQ was able to induce important improvements in almost all investigated indicators, especially in the teams' work process. This can have both clinical and programmatic impact. Small changes in proportions that were already high were expected COMMENT What has the addition of Cycle III data added to that already published? The changes between cycles II and III are small and maybe the less interesting observations in the study. ANSWER: The inclusion of data from cycle III marks the end of the program and points to the continued growth that would be expected with the continuity of the PMAQ. COMMENT You have not made clear that the PMAQ is a pay for performance scheme. This certainly limits the generalization of the findings to services outside the PMAQ scheme. ANSWER: The PMAQ was not a typical pay-for-performance program as the financial resources were not transferred directly to professionals, as in other countries, but were transferred to municipal managers. Response to the reviewer 2. COMMENT Introdução: Incluir as recomendações do PHPN e Rede Cegonha para qualificação do Pré-natal no Brasil. Tornar mais clara a situação do PMAQ (não mais vigente), já que desde dezembro de 2019 foi instituído um novo modelo de financiamento da APS brasileira, o Programa Previne Brasil pela Portaria nº 2.979. ANSWER As recomendações do PNPH e da Rede Cegonha foram incluídas; também foram esclarecidos aspectos sobre o fim do PMAQ e sua substituição pelo Programa Previne Brasil. COMMENT Materiais e Métodos: Quais os critérios de inclusão e exclusão adotados? Também senti falta de mais detalhes sobre a amostragem e recrutamento das mulheres: Qual o local das entrevistas e de que forma foram abordadas? Houve estudo piloto do instrumento de coleta? Como as 41 instituições de ensino superior se organizaram para a coleta de dados? Foi realizado cálculo amostral? Em relação aos aspectos éticos, houve utilização do TALE às menores de 18 anos, além do TCLE para seu responsável legal? ANSWER: Todas as respostas a estas perguntas foram acrescidas na seção de Métodos. COMMENT Discussão: Senti falta de discutir alguns dos resultados do estudo ... e de trazer mais comparações dos achados com outros estudos nacionais e internacionais ... Ademais, como os autores entendem as diferenças das Regiões brasileiras nos resultados do pré-natal? ANSWER: Não foram localizados resultados comparáveis em outros estudos nacionais e internacionais. As diferenças regionais são decorrentes de históricas desigualdades socioeconômicas que afetam o sistema de saúde como um todo. Foram acrescentadas referências para estes resultados. COMMENT Em um dos parágrafos da discussão, faz-se necessário melhorar a descrição do novo modelo de financiamento da APS no Brasil. O Programa Previne Brasil realizará repasses financeiros com base em três critérios: a) captação ponderada (cadastros das pessoas), b) pagamento por desempenho (sete indicadores, que são distribuídos em pré-natal, saúde da mulher, saúde da criança e doenças crônicas e avaliados quadrimestralmente) e c) incentivo para ações estratégicas. Em relação ao pagamento por desempenho, o repasse dependerá dos resultados alcançados por cada equipe em um conjunto inicial de sete indicadores, dentre os quais os 3 primeiros são referentes ao pré-natal. Foi mantido o início precoce (até a 20ª semana), realização de 6 ou mais consultas, dos exames para sífilis e HIV e o atendimento odontológico na gestação. ANSWER: Foi melhorada a descrição do Programa Previne. COMMENT Conclusões: Entendo ser importante acrescentar sugestões de possíveis estratégias que a APS poderia adotar para melhoria da qualidade do pré-natal no Brasil. O que os autores visualizam que ainda poderia ser feito, em termos de gestão interfederativa e de assistência às gestantes brasileiras, para garantia de um pré-natal qualificado? ANSWER: Nossas conclusões já apontam estas sugestões. Response to the reviewer 3 COMMENT The stated purpose of the paper is to “describe the temporal evolution of the coverage and quality of prenatal care performed in primary care in Brazil…” but key concepts like quality are not well articulated or defined. There is no clear discussion in the introduction of what the authors mean by quality (at the moment there is a brief mention of quality on line 61 that is followed directly by a reference to access) and then very little in the methods to show how these concepts were reflected in study design, data collection and analysis. A clearer explanation of the PMAQ and the indicators developed is needed to contextualise the study and provide information for the reader. ANSWER: We've added arguments in the introduction and methods to fulfill this request. References for this conceptual contribution were also added. COMMENT Regarding the methods, what is the sampling approach and how were participants selected? What proportion of the eligible population does this sample represent in each of the districts and therefore how can we interpret the meaning of these findings? ANSWER: We've added answers to these questions in the Methods section. COMMENT I am confused by statements like: Line 107 “A total of six dichotomous outcomes (no; yes) were selected” because I am unclear how this statement relates to the previous paragraph which refers to interviews. And again, Line 113 "Four educational guidelines were 113 evaluated (no, yes)". ANSWER: A new wording was made to clarify these doubts. COMMENT Line 118 "The indicators used in the analysis were validated by the technical areas of the Ministry of Health. – It would be useful to have more details about this. ANSWER: The sentence that generated the doubt was deleted and other explanations were added. COMMENT Sentence beginning Line 119 does not seem to be finished. Needs restating for clarity. ANSWER: Corrected COMMENT 124 - ‘prevalence of outcomes’ was calculated. What does this mean? ANSWER: A new wording was made to clarify these doubts. COMMENT Until the conceptual and methodological issues are clarified, I do not think I can provide useful comments on the discussion. At present, parts of the discussion that refer to explanations for change in indicators over time such as the paragraphs beginning on LIne 286 and Line 319 require references. ANSWER: References have been added in both paragraphs. Attachments Attachment Submitted filename: Response to Reviewers.docx* https://doi.org/10.1371/journal.pone.0262217.r002
15 Nov 2021 Decision Letter - Emma K. Kalk, Editor PONE-D-21-11493R1Evolution of the quality of prenatal care in the primary network of Brazil from 2012 to 2018: what can (and should) improve?PLOS ONE Dear Dr. TOMASI, 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. Thank you for your revisions; the manuscript is now much clearer. Minor queries:line 140: what is TALE? The abbreviation has not been spelled out or explained.line 159 and Table 1: please delete the descriptor, 'yellow'. Indigenous is sufficiently clear.Tables: please indicate that 'Annual % change' is average annual % change. Please submit your revised manuscript by Dec 30 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: https://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, Emma K. Kalk 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 #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: 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 #2: No ****** 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 ****** 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: Prezados autores, As considerações da minha revisão foram atendidas, satisfatoriamente. As recomendações do PHPN e da Rede Cegonha foram incluídas na Introdução, além de esclarecidos aspectos sobre o fim do PMAQ e sua substituição pelo atual Programa Previne Brasil. A seção Métodos trouxe maior detalhamento quanto aos procedimentos realizados, e a Discussão teve o acréscimo de outros estudos/achados sobre a temática. Frente ao exposto, sou favorável à aprovação/aceite do manuscrito na versão atual. Parabéns pelo estudo! ****** 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: Yes:** José Marcos de Jesus Santos [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. https://doi.org/10.1371/journal.pone.0262217.r003
Revision 2
19 Dec 2021 Author Response Dear Dr.Emma Kalk Acadêmica editor / PLOS ONE In relation to the manuscript PONE-D-21-11493, on behalf of the authors, I send the answers to each questioned point in the Minor Queries, in order to qualify our manuscript. COMMENT: line 140: what is TALE? The abbreviation has not been spelled out or explained. ANSWER: TALE means free and informed consent term; is the term corresponding to the consent form for minors under 18; the sentence was dropped as it was not really necessary. Information about informed consent is already in the last paragraph of the Methods section: “All participants signed the Informed Consent Form”. COMMENT: line 159 and Table 1: please delete the descriptor, 'yellow'. Indigenous is sufficiently clear. ANSWER: The descriptor 'yellow' was deleted in the text and Table 1. COMMENT: Tables: please indicate that 'Annual % change' is average annual % change. ANSWER: In the tables 2 and 3 the expression was corrected to “average annual % change” Best regards Elaine Tomasi Attachments Attachment Submitted filename: Response to Reviewers 2021dec19.docx https://doi.org/10.1371/journal.pone.0262217.r004
20 Dec 2021 Decision Letter - Emma K. Kalk, Editor Evolution of the quality of prenatal care in the primary network of Brazil from 2012 to 2018: what can (and should) improve? PONE-D-21-11493R2 Dear Dr. TOMASI, 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, Emma K. Kalk Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0262217.r005
Formally Accepted
7 Jan 2022 Acceptance Letter - Emma K. Kalk, Editor PONE-D-21-11493R2 Evolution of the quality of prenatal care in the primary network of Brazil from 2012 to 2018: what can (and should) improve? Dear Dr. Tomasi: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Emma K. Kalk Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0262217.r006

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