PONE-D-21-11467

Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.

PLOS ONE

Dear Dr. Usman,

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. 

Besides the highly important reviewers' comments, we have the following additional remarks:

• Authors are encouraged to further clarify outcome variables and provide the questionnaire used in this study as supplementary file. 
• Authors should explain whether this questionnarre was anonymous or not?  
• Authors should provide unidentified raw data of the study. PLOS journals require that authors make all data underlying the findings described in their manuscript fully available, with exception when ethical or legal restrictions prohibit public sharing of data. Authors may upload their data to a public repository, or include their data as a Supporting Information file. If data cannot be made public, all restrictions and information necessary for submitting data requests should be outlined in the Data Availability statement, which will be published at the top of the article. 
• Authors are encouraged to include and discuss the folloowing relevant and recent publication "Briggs, D. C., & Eneh, A. U. (2020). Preparedness of primary health care workers and audit of primary health centres for newborn resuscitation in Port Harcourt, Rivers State, Southern Nigeria. The Pan African Medical Journal, 36, 68. " ext-link-type="uri" xlink:type="simple">https://doi.org/10.11604/pamj.2020.36.68.22164".

Please submit your revised manuscript by Oct 04 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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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-emailutm_source=authorlettersutm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Elsayed Abdelkreem, MD, PhD

Academic Editor

PLOS ONE

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2. 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.  If the original language is written in non-Latin characters, for example Amharic, Chinese, or Korean, please use a file format that ensures these characters are visible.

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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

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

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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

Reviewer #2: Yes

Reviewer #3: 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: No

Reviewer #2: Yes

Reviewer #3: 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: • Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.

• Abstract

• Abstract should be written in sections of introduction, method, result and conclusion.

• Under abstract it better to define first what mean by emergency preparedness for neonatal resuscitation rather than neonatal resuscitation.

• On line 23, why you proposed an hypothesis “We hypothesize that the high prevalence of asphyxia-related morbidity…”? While your title was preparedness for neonatal resuscitation? This is the same comment for introduction section.

• On line 33, include the confidence interval for the result of Healthcare provider’s knowledge, skills and facility preparedness.

• On line 37, what do you mean by weak state and what is your base line to say this?

• On line 55 to 57, you stated that “Even among health workers, the knowledge of neonatal resuscitation is poor, ranging between 2%–12%.[1] In addition, only 8%-22% of surveyed facilities have appropriate resuscitation equipment.[1]”, if these are known, why you study again?

• On line 77, you stated as your study will help for policy maker. Do you think that a single site cross sectional study can be influence policy makers?

• On line 105 to 109, why you used prevalence of knowledge only for sample calculation, while there are also practices and facility preparedness? Again your sample is different with abstract section (111 Vs 98 and 112 under result section), why this difference?

• On lone 108, you said that, “To increase precision, all healthcare workers who were

• 109 present at the training were included in the study.”, so why sample calculation is necessary in this case if you were collect data from all them?

• On line 114, you excluded those who did not provide consent. Do you think that unable to give consent is exclusion criteria? If yes, who were none respondents?

• On line 117, you used a semi-structured, self-administered questionnaire. Do you think that it is appropriate method self-administrated questionnaire for knowledge and practice? Why not you used interview administered?

• You are using skill, practice and proficiency exchangeable. Therefore, try to use one of it throughout the document.

• Under your analysis section include the p-value you used to select variable for multivariate analysis.

• Under table 1, check male sex is 405%?

• On line 209, you included attitude. But, there were not stated in the introduction or in method section about attitude. Why this happened/from where attitude came? Even no under operational definition and under measurement.

• On line 227, you said that level of practices…, is it a level? If yes, how much level is there?

• In discussion section, try to limit your discussion to your main objectives only.

• Try to copy edit for punctuation (most of your full stop is before your citation bracket in throughout the document).

Reviewer #2: The manuscript presents an analysis of provider and facility readiness for neonatal resuscitation in Kano state, Nigeria. The issue examined is very pertinent to address the variable and often slow progress toward global neonatal mortality targets. Limitations in the design of the research restrict its validity and generalizability, though the findings are illustrative of barriers encountered widely.

Abstract: The abstract accurately describes the study. The degree of precision in the percentages reported for adequate knowledge, practice, and facility preparedness could be reduced to whole numbers.

Introduction: It is very pertinent to highlight that Kano State has the highest NMR and thus the highest burden, as the most populous state. It might be useful to characterize the area further (urban/rural, geographic or political/social challenges).

Reference 9 presents a Delphi review that estimated the mortality reduction with neonatal resuscitation to be around 30%. More recent systematic reviews and meta-analyses provide information from actual trials (e.g. Dol J 2018).

While the hypothesis that poor neonatal emergency preparedness contributes to the high prevalence of asphyxia-specific mortality is valid, later discussion of the very low rate of in-facility delivery in the state reveals another major factor contributing to the burden. Addressing this aspect would give a more complete picture of the needs.

Methods: In the description of participants, it should be made clear that this was a convenience sample. Did the selection criteria for attending the workshop skew the participants toward those with low knowledge and skills, or perhaps did it skew toward more experienced clinical leadership?

In the sample size estimation, it is not clear what difference (of 10%) was being measured.

The data collection instrument regarding essential equipment and drugs inquired about several medications that are no longer recommended by ILCOR (International Liaison Committee on Resuscitation) for acute neonatal resuscitation (calcium, bicarbonate, naloxone).

The reliability of data on total number of deliveries and deaths within 24 hours and staff numbers would seem low if based on report from non-supervisory personnel.

What was the basis for considering a facility readiness score of 50% as sufficient to qualify a facility as well-equipped and prepared?

Results: The percentages of respondents could be rounded to whole numbers.

Discussion: When comparing the results to findings of other studies, there is frequent speculation on cause of differences – e.g. “In Ghana….mainly because all respondents were midwives…”. The demographic differences can be highlighted, but causation should not be implied. On page 19, “Western Nigeria reported…..probably because the score criterion….” and “….in Tanzania….probably because the latter study….” should be similarly revised.

The first paragraph of page 20 regarding strengths of the study over-estimates the strength of the design, as it was not a representative sample, nor was self-report validated by observation or triangulation. This paragraph should be revised or omitted.

The role of low utilization of health facilities for delivery should also be highlighted in the discussion. This may be linked to the inadequate knowledge, skills, and equipment in the facilities.

Conclusion: The conclusion appropriately highlights the value of information gained in the study.

Figures and Tables: Figure 2 adds little to the results as presented in the text, and it could be omitted.

References: References are current and complete.

Reviewer #3: PLOS ONE REVIEW COMMENTS

Many thanks for the opportunity to review this manuscript addressing an important topic that is key to improving newborn outcomes in a developing country. Neonatal resuscitation is key to the achievement of maternal and newborn health SDG targets on neonatal mortality globally. Overall, the manuscript is well written, paying attention to the existing literature and relating to the current findings. A few specifics comments to be addressed or clarified are as below

Abstract – nicely written and succinct

Introduction

- Line 47 “……one-fourth of these deaths…..” revise to …..a quarter of these deaths ….

- Line 55 – 57 “Even among health workers, the knowledge of neonatal resuscitation is poor, ranging between 2%–12%.[1] In addition, only 8%-22% of surveyed facilities have appropriate resuscitation equipment”…….please clarify whether these are global or Nigerian statistics

Methods

Study site

- Private hospitals were not included as part of the study. Does this mean they do not conduct any births since they were not included in the study? Refer to this related survey about Nigerian health care system at https://www.shopsplusproject.org/sites/default/files/resources/SHOPS%20Nigeria%20Private%20Sector%20Health%20Census_6.15.2014%20FINAL.pdf

- Any information on the proportion of births conducted in the three levels of health facilities would be useful to provide the context

Data collection

- How were study participants recruited/informed about the study?

- When and how were the study participants consented to participate in the study?

- When was the structured interview questionnaire administered?

- Who collected the data/administered the structured questionnaire?

Results

- Line 193: Age of participants is better presented by median given the age ranges and distribution

- Line 194 “The majority of the respondents (50.5%, n = 56)…..” this is just half the population and not the majority

- It would be useful to know if there were any differences in knowledge/skills scores between participants (66 from secondary hospitals + 45 from paediatric hospitals)

- Table 3: Bicarbonate….write the chemical name in full e.g. sodium bicarbonate

Discussion

- Well written and relates to other studies in the field to explain any similarities, variations and meanings of the findings

- Page 19, line 307 – 312: “On self-assessed reports of knowledge and facility preparedness, few respondents (8.5% and 32.4%) believed they had a below-average level of knowledge and preparedness, with 90% of the respondents reporting an above-average comfort level during resuscitation. This confirms that the majority of the healthcare providers lack insight into their deficient preparedness both at the individual and facility level, which is a significant barrier for self-motivated learning, improvement and capacity building.” This statement is confusing and unclear. Authors to review and clarify for ease of understanding

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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.

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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: Yes: Yitagesu Sintayehu

Reviewer #2: No

Reviewer #3: Yes: DUNCAN N SHIKUKU

[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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Attachments

Attachment

Submitted filename: PLoS ONE preparedness for neo resus Nigeria.docx

PONE-D-21-11467R1Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.PLOS ONE

Dear Dr. Usman,

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. Authors have adequately addressed most reviewers' and editorial comments. Just minor comments remain.

• In the conclusion: “The low level of respondents’ awareness, practice, and facility readiness demonstrates the current weak state of secondary health systems in Kano”. Conclusion has to be based on study findings. Since this study didn’t investigate the “state of secondary health systems in Kano”, authors are encouraged to revise this sentence (reducing its strength/certainty) (e.g., replacing demonstrates by suggests or indicates).
• In the abstract: “Respondents’ designation predicted good knowledge (aOR=0.08, 95% CI: 0.01–0.69; p= 0.01), but not practice”. Authors should better define/specify “designation” (e.g., physicians versus nurses/midwives).

Please submit your revised manuscript by Jan 13 2022 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-emailutm_source=authorlettersutm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Elsayed Abdelkreem, MD, PhD

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 #1: 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 #1: Yes

**********

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

Reviewer #1: 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: 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 #1: 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: (No Response)

**********

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Reviewer #1: Yes: Yitagesu Sintayehu

[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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PONE-D-21-11467R2Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.PLOS ONE

Dear Dr. Usman,

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. Specifically, in the conclusion/results "Respondents’ designation predicted good knowledge (aOR=0.08, 95% CI: 0.01–0.69; p= 0.01). In order to provide the readers with meaningful information, authors should specify "designation" (e.g.,physicians versus nurses/midwives).

Please submit your revised manuscript by Jan 31 2022 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-emailutm_source=authorlettersutm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Elsayed Abdelkreem, MD, PhD

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:

[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.

Facility and care provider emergency preparedness for neonatal resuscitation in Kano, Nigeria.

PONE-D-21-11467R3

Dear Dr. Usman,

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.

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Kind regards,

Elsayed Abdelkreem, MD, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: