PONE-D-20-36739

Timely initiation of antenatal care and its associated factors among pregnant women in Sub-Saharan Africa: A multicounty analysis of Demographic and Health Surveys.

PLOS ONE

Dear Dr. Alem,

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. In particular, editing of the text and a number of point in the Mat and Meth section and results analysis section.

Please submit your revised manuscript by 2 months. 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,

Isabelle Chemin, PhD

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 suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.  

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services.  If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Upon resubmission, please provide the following:

• The name of the colleague or the details of the professional service that edited your manuscript
• A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)
• A clean copy of the edited manuscript (uploaded as the new *manuscript* file)

3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

4. We noticed you have some minor occurrence of overlapping text with the following previous publications, which needs to be addressed:

- https://jepha.springeropen.com/articles/10.1186/s42506-020-00041-2 (Background, paragraph 3, sentence 2)

- http://jogh.org/documents/issue202001/jogh-10-010502.pdf (Background, paragraph 3, sentence 2)

- https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-017-0412-4 (Discussion, paragraph 8, sentence 4)

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

[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: Partly

**********

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

Reviewer #1: 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

**********

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: 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: PONE-D-20-36739

Timely initiation of antenatal care and its associated factors among pregnant women in

Sub-Saharan Africa: A multicountry analysis of Demographic and Health Surveys.

This article describes timely initiation of antenatal care in sub-Saharan Africa and its associated factors. I think this is an important paper. However, I believe it would benefit from proof reading as I have noted several typos and grammatical errors. The methods seem strong but their descriptions needs to be improved.

Abstract

Background

1. “Mothers who attend ANC timely are fully benefited from its preventive and curative services.”

change to:

Mothers who begin attending ANC in a timely manner, can fully benefit from preventive and curative services.

Results

2. please use a consistent number of decimals throughout the paper. E.g.,: 37.99% (95% CI: 37.79-38.19), ranging from 14.50% in Mozambique to 68.60% in Liberia.

3. “women from the community with medium education (AOR = 1.45; 95%CI: 1.35, 1.51), and women from the community with high education (AOR = 1.50; 95%CI: 1.33, 1.68) “

Not clear what women from the community with medium education? Do you mean women living in communities in the 2nd tertile of education for example?

4. “However, women who wanted their pregnancy later (AOR = 0.84; 95%CI: 0.82 ,0.86), wanted no more (AOR = 0.80; 95%CI: 0.77, 0.83)”

I think there is a word missing after no more…

Conclusion:

5. SSA recorded a lower overall prevalence of timely initiation of ANC. Please change to:

SSA recorded a low overall prevalence of timely initiation of ANC.

6. “community women’s education”: please reword this is not clear.

7. “Therefore, more effort should be done to improve women’s education, wealth status of a household and family planning to prevent unwanted pregnancy and and then to improve the timely initiation of ANC.” This conclusion needs to be revised. Improving women’s wealth status is not an actionable strategy for public health practicioners. Please revise.

Background section

8. The background addresses maternal mortality at length. However, antenatal care does not have a strong relation to maternal deaths. Rather, it is quality intrapartum care that more strongly determines whether the mother survives. Quality ANC however, can have an important effect of fetal health and neonatal survival. Could the authors revise the background section to address the importance of ANC with more nuance, commenting on the importance of ANC to prevent miscarriages and stillbirths among others.

Please also remove the sentence: “ANC is the most important determinant of pregnancy outcomes”

9. The sentence: “85% of mothers start their ANC follow up earlier compared to below 45%...” is not clear. Do you mean that 85% start in the first trimester? Please revise.

Methods

10. Can you please describe how you selected these 36 surveys? Did you have a cut off date? Did you include all SSA countries?

11. Please change “ever had of a terminated pregnancy” to ever had a pregnancy terminated

12. Please change working status to employment status

13. perception of distance from the health facility (big problem/not a big problem) is not a community level factor. It is an individual level factor that is influenced by the woman’s ability to travel.

14. Please explain how you calculated community-level wealth. The following sentence is confusing: the proportion of women in the poorest and poorer quantiles in the community. What are “poorer” quintiles? 1 to 4?

Statistical analysis

15. The multi-level model is not clear. The authors should describe whether they used a random intercept or random slope model. and what level of clustering was used? The PSU, region or the country?

16. The first model (empty model) should contain the random effect. Is that what the authors did? Please revise the description.

17. Can you explain what deviance is? And why is model III in brackets after this sentence?

“To select the best-fitted model deviance was used and the

model with the lowest deviance was selected (model III).”

18. Please explain how you obtained the ICC (also known as variance partition coefficient in a logistic model)

19. Please describe what you mean by Median Odds Ratio (and include a reference for readers not familiar with the term).

20. I don’t see any benefit to running model 2 separately (community level variables only). I would recommend model 1: empty model, model 2: model with individual variables only and finally full model 3 with individual and community variables. The authors can then comment on the change in community-level variable as variables are added in. please cite: Intermediate and advanced topics in multilevel logistic regression analysis Peter C. Austin and Juan Merlo

Results

21. How did you pool results across countries? DHS sampling weights are not meant for multi-country comparisons. Each country should either be weighted equally or should be re-weighted based on population size for example. Another option would be to list result as: exposure to media ranged from X% in Botswana to X% in Rwanda.

22. Same comment for the regression models. Did you include sampling weights? Please also explain whether you pooled all the data together or ran models separately in every country…

23. This doesn’t seem correct: Most participants had attained higher education (n = 9,335, 40.0%). According to a quick internet search: only 6 percent of people in sub-Saharan Africa are enrolled in higher education institutions compared to the global average of 26 percent. Source: http://www.aaionline.org/wp-content/uploads/2015/09/AAI-SOE-report-2015-final.pdf

24. Replace three-fourth to three quarters

25. Table 2: According to table 2 it is 4% that have achieved higher educaiton. Not 40%. Please review table 2 and make sure all calculations are correct.

26. Community women’s education: in the table is described as low, medium, high. However, this is simply the % of women in the community who have achieved primary school. This is misleading, as primary education is not a “high” education achievement. Therefore I would recommend replacing with first, second and third tertile. Or by the actual range of % of women who achieved primary school e.g., <15%, 15%-40%, >40%.

27. Prevalence of timely initiation of first ANC visit in SSA: replace counties to countries.

28. Figure 1: please rank the countries by timely ANC initiation.

29. In table 3, please insert” reference” for PCV under the 1st model.

Discussion

30. The conclusions and policy implications need substantial improvement. Improving women’s wealth status is not an actionable strategy for public health practitioners. Please remove this recommendation. The authors should discuss what can be done to promote earlier access to antenatal care in SSA and the kinds of strategies to target poorer/less educated women and their communities, more at risk to starting ANC late. There must be literature on this. And others must have tested strategies to achieve this.

31. In the background and discussion sections, please also expand on the benefits for mothers, but particularly newborns, of starting ANC in the first trimester of gestation. For example, detecting and treating different infections (e.g., malaria, syphilis, HIV etc.) early in the pregnancy can have substantial effects on improving fetal and newborn outcomes. Providing nutritional supplements and vitamins can also improve fetal and newborn outcomes. E.g., folic acid in the first trimester is crucial.

32. Please add a paragraph on the need for ANC to be of good quality in order to have any effect. Poor quality ANC, even if started early, is unlikely to improve health outcomes. There are many references on quality of antenatal care and inequities in ANC access and quality.

Other references possibly of interest: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457794/#:~:text=Parity%2C%20number%20of%20alive%20children,pregnancy%20approval%20by%20a%20spouse.

https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-14-287

https://www.hindawi.com/journals/aph/2017/1624245/

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246230

**********

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

[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-20-36739_revisions.docx

Timely initiation of antenatal care and its associated factors among pregnant women in sub-Saharan Africa: A multicountry analysis of Demographic and Health Surveys.

PONE-D-20-36739R1

Dear Dr. Alem,

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,

Isabelle Chemin, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The manuscript was significantly improved after the first round of review

Reviewers' comments: