Factors influencing quality nutrition service provision at antenatal care contacts: Findings from a public health facility-based observational study in 21 districts of Bangladesh

Sk Masum Billah; Nazia Binte Ali; Abdullah Nurus Salam Khan; Camille Raynes-Greenow; Patrick John Kelly; Md. Shahjahan Siraj; Sufia Askari; Purnima Menon; Shams El Arifeen; Michael John Dibley; Phuong Hong Nguyen

doi:10.1371/journal.pone.0262867

Peer Review History

Original SubmissionMay 19, 2021
28 Oct 2021 Decision Letter - Sharon Mary Brownie, Editor PONE-D-21-16534Determinants of quality nutrition service provision at antenatal care contacts: findings from a public health facility-based observational study in 21 districts of BangladeshPLOS ONE Dear Dr. Sk Masum Billah, 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 December 12, 2021. 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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Please confirm that this does not alter your adherence to all PLOS ONE policies on sharing data and materials, by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests). If there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared. Please include your updated Competing Interests statement in your cover letter; we will change the online submission form on your behalf. 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: Yes Reviewer #3: Yes Reviewer #4: Yes Reviewer #5: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes Reviewer #5: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes Reviewer #5: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes Reviewer #5: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The study has addressed an important public health issue for Bangladesh, and other LIMCs. However, one thing should be noted, the four factors which were finally revealed as independent determinants (logistical readiness of the facilities, HCP’s knowledge on maternal nutrition, better HCP-client communication, and use visual aids or ANC card) are essential pre-requisite for delivering quality nutrition service. If the pre-requisites are not fulfilled, it is not possible to deliver quality service. So, in discussion and conclusion sections of the papers should focused on the other factor (service provider: Doctors/paramedics/CHCP) as it is not a prerequisite like other four factors. Considering these issues, the authors should revised the term 'Determinants' used in the Title and introduction section. Reviewer #2: ANC is the classic best entry point for counseling expecting mothers on proper nutrition, danger signs of pregnancy and monitor the health of the mother and the fetus. The authors looked at a critical health system fitness to provide quality nutrition services for pregnant women. The research questions are relevant and the methodology is sound. The results are clearly described and the implications well discussed. Just one curious question. What did the authors think was the reason for the finding that the quality of nutrition services given during the 2nd and 3rd trimester was better than the one during the 1st trimester? I know that some misperception or misunderstanding from the provider side was mentioned. A bit more explanation would be great, if possible. Reviewer #3: This manuscript will be a useful addition to our knowledge of nutrition services provided during pregnancy, especially for ANC in Low and Low Middle Income Countries. I have a few clarification/suggestions that should be addressed; Lines# 23 to 25. Definition is not clear. What is being counted? Will weight measurements done twice and anemia measurements done two times in one woman across pregnancy be counted as equivalent to weight measurement done once and and anemia measure done three times in another women? Lines# 64 and 65. Some information is missing. Rephrase the statement for clarity. Line#175. typo. Table 1: Haemoglobin testing tool. Was it expected that sub-districts and community clinics will be better than district hospitals? Are they special programs/interventions that are being run by the health authority in Bangladesh that focus on resourcing rural and sub-district hospitals as compared to district hospitals? In most LMICS we see that district level hospitals are better equipped that rural clinics. Table 1: What does "ANC utilization per day" mean? What was the effect of clients (pregnant women) educational status on the outcome variables? Figure 2 B: should the items add up to 100%? Currently it adds up 99%. Reviewer #4: Methods Upon what basis districts were selected? Line 109:Better to mention Upa Zilla as sub district is non existent Please mention how anaemia was defined Conclusion: Need to make brief depending upon objective Reviewer #5: General comments This manuscript is very interesting having very important findings, but the paper required same professional proofreading to edit the entire paper for language, grammatical, spelling, and punctuations to improve the paper for publication. Once the authors are able to address the concerns appropriately, the manuscript can be published. The four main target variables (maternal weight measurement, anaemia assessment, nutrition counselling and iron-folic acid (IFA) supplementation) for this study was not properly addressed and exhausted, need to elaborate more. Methods Page 7, line 133 – 137 the paragraph “We conducted the assessment in 231 facilities, and in 184 facilities, we observed ANC services provided on the assessment days. We interviewed 217 health care providers who offered ANC services at the facilities on the day of the visit, and we observed 1296 ANC consultations. We excluded 54 observations due to missing information about the health care providers, the client’s characteristics, or the exit interview” is not clear, need to be reconsidered or rephrased. Result Page 10 line 213 & 2014 the sentence “On average, clients who received ANC from the facilities were 23 years old and had eight years of schooling” is not clear, need more explanation?. Page 14, table 4 are highly congested and it crosses one page requires rearrangement or division into two table or more. Discussion Grammatical, spelling, and punctuations improvement is required in this section Overall comment There are some areas need corrections; such as rephrasing, grammatical, spelling, and language. Kindly review issues raised and if possible get a trained English proof reader to edit the entire manuscript. ****** 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: No Reviewer #3: No Reviewer #4: No Reviewer #5: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: PONE-D-21-16534 Due 22 Oct.pdf https://doi.org/10.1371/journal.pone.0262867.r001
Revision 1
27 Nov 2021 Author Response Response to reviewers' comments Reviewer #1: 1. The study has addressed an important public health issue for Bangladesh, and other LIMCs. However, one thing should be noted, the four factors which were finally revealed as independent determinants (logistical readiness of the facilities, HCP’s knowledge on maternal nutrition, better HCP-client communication, and use visual aids or ANC card) are essential pre-requisite for delivering quality nutrition service. If the pre-requisites are not fulfilled, it is not possible to deliver quality service. So, in discussion and conclusion sections of the papers should focused on the other factor (service provider: Doctors/paramedics/CHCP) as it is not a prerequisite like other four factors. Considering these issues, the authors should revised the term 'Determinants' used in the Title and introduction section. Response: Our study hypothesizes that facility readiness, health care providers, the process of care, and client characteristics all contribute to the provision of high-quality nutrition services at antenatal care contact. We examined a variety of variables in each category (including provider types) and identified which of those variables are associated with (or may influence) high-quality service. We have revised our title and introduction, replacing the term “Determinants” by “Factors influencing”. In the discussion, we have included practice variations among different types of providers and essential programmatic inputs to mitigate the practice gap (page 19, lines 354-362) and now have included them in the conclusion (page 23 lines 444-445). Reviewer #2: 1. ANC is the classic best entry point for counseling expecting mothers on proper nutrition, danger signs of pregnancy and monitor the health of the mother and the fetus. The authors looked at a critical health system fitness to provide quality nutrition services for pregnant women. The research questions are relevant and the methodology is sound. The results are clearly described and the implications well discussed. Response: Thank you for your comments on our manuscript. Just one curious question. What did the authors think was the reason for the finding that the quality of nutrition services given during the 2nd and 3rd trimester was better than the one during the 1st trimester? I know that some misperception or misunderstanding from the provider side was mentioned. A bit more explanation would be great, if possible. Response: We have discussed some possible explanations in the discussion (page 21, lines 404-412). The difference in the quality of nutrition service across different trimesters of pregnancy is mainly due to the providers' perception gap and self-prioritisation of some services over others. For instance, among the four service components included in the quality of nutrition service during ANC, weight measurement and provision of IFA supplements were poorer in the 1st trimester compared to women in the 2nd and 3rd trimesters. Sometimes health care providers choose not to offer IFA in early pregnancy fearing iron’s adverse effect on foetal development. Similarly, sometimes they disregard physical measurement and weight assessment during early pregnancy. It is unlikely that the client’s demand or choice for service played a big role in this case, as clients often lack knowledge/perception of good quality care and what to anticipate from service providers when seeking health care in low and middle-income settings. Reviewer #3: This manuscript will be a useful addition to our knowledge of nutrition services provided during pregnancy, especially for ANC in Low and Low Middle Income Countries. Response: Thank you for your encouraging comments on our manuscript. 1. I have a few clarification/suggestions that should be addressed; Lines# 23 to 25. Definition is not clear. What is being counted? Will weight measurements done twice and anemia measurements done two times in one woman across pregnancy be counted as equivalent to weight measurement done once and and anemia measure done three times in another women? Response: We counted the number of the selected four services provided at each ANC consultation as the ‘quality nutrition service’ indicator from observation of the ANC consultations. It was a cross-sectional study, and we observed ANC service consultation for a woman only once. To avoid confusion, we have revised the text as: “We considered four essential nutrition services at each ANC contact including maternal weight measurement, anaemia assessment, nutrition counselling and iron-folic acid (IFA) supplement provision. We defined a composite ‘quality nutrition service’ outcome by counting the number of services (out of four) provided at each ANC from observation data” (page 2, lines 23-26). 2. Lines# 64 and 65. Some information is missing. Rephrase the statement for clarity. Response: We have rephrased the sentence to improve clarity (page 4, lines 65-68). “Another challenge is ensuring the quality of nutrition interventions provided at ANC contacts, without which programmes will not fully harness the benefits of these interventions on maternal and child nutrition outcomes. Moreover, a recent study reported incomplete readiness of healthcare facilities to provide nutrition interventions during ANC (51%).” 3. Line#175. typo. Response: We have corrected the typo (page 10, line 203) 4. Table 1: Haemoglobin testing tool. Was it expected that sub-districts and community clinics will be better than district hospitals? Are they special programs/interventions that are being run by the health authority in Bangladesh that focus on resourcing rural and sub-district hospitals as compared to district hospitals? In most LMICS we see that district level hospitals are better equipped that rural clinics. Response: In general, districts and sub-district level facilities have better readiness than union-level health facilities and community clinics. However, the availability of logistics and tests to provide ANC service is expected to be similar across all tiers of facilities. One explanation of poorer on-site readiness of haemoglobin testing at the district and sub-district hospital is out of the Tallquist strips due to high client load and availability of other advanced diagnostic facilities at district and sub-district levels. Health care providers sometimes refer the clients to these diagnostic labs for haemoglobin testing rather than doing the rapid test onsite. We did not consider the availability of advanced diagnostics tests for anaemia outside of ANC consultation as HCPs can recommend the test but do not take a decision if the test is done afterward. However, we have included the following text in the limitation (pages 22-23, lines 437-439) “Fourth, we assessed only the on-site availability of rapid haemoglobin testing kits at the ANC room which might under-estimate the haemoglobin testing capacities at district and sub-district hospitals as some of them may have advanced diagnostic tests for anaemia.” 5. Table 1: What does "ANC utilization per day" mean? Response: ANC utilization per day means the average number of ANC services provided on a day at the facility. We have now clarified this in Table 1 (page 11) 6. What was the effect of clients (pregnant women) educational status on the outcome variables? Response: We did not find any association between the client’s educational status and the quality of nutrition service provided at ANC. We have reported this in table 3. Education was not associated with any of the four selected nutrition services in the bivariate analyses and we did not include it in the multiple regression model presented in Table 4. 7. Figure 2 B: should the items add up to 100%? Currently it adds up 99%. Response: We have corrected the rounding error in Figure 2B. Reviewer #4: 1. Methods Upon what basis districts were selected? Response: We have expanded the text on district selection as follows (page 5-6, lines 103-111): “We selected the districts based on comparability of population density, literacy rate, housing characteristics, people in the lowest wealth quintile, access to a safe drinking water source, electricity connection, improved sanitation, coverage of childhood immunization, ANC, skilled birth attendance, postnatal care and modern methods of family planning, under-five mortality rate and childhood stunting prevalence. We created a score for each district by principal component analysis of these variables. Then, we applied nearest neighbour matching of district’s PCA score to match two intervention districts with one non-intervention district. Finally, we selected seven matched groups of districts (each having two AINNS intervention districts and one non-intervention), which had the minimum difference in the PCA score.” 2. Line 109:Better to mention Upa Zilla as sub district is non existent Response: We have added upazila health complexes and mentioned sub-district hospitals in parenthesis in line 123 on page 6. However, we have used sub-district hospital throughout the paper for the ease of understanding of the global audience. 3. Please mention how anaemia was defined Response: We have defined anaemia screening as (page 8, lines 169-171): “Screening for anaemia included assessing blood haemoglobin level either using Tallquist paper onsite, by previous laboratory investigation or examining eye or palm (clinical assessment)”. 4. Conclusion: Need to make brief depending upon objective Response: We have revised the conclusion and made it relevant only to the study objectives and findings (page 23, lines 445-454). Reviewer #5: General comments 1. This manuscript is very interesting having very important findings, but the paper required same professional proofreading to edit the entire paper for language, grammatical, spelling, and punctuations to improve the paper for publication. Once the authors are able to address the concerns appropriately, the manuscript can be published. Response: We have proof-read the manuscript and corrected typos and grammatical errors. 2. The four main target variables (maternal weight measurement, anaemia assessment, nutrition counselling and iron-folic acid (IFA) supplementation) for this study was not properly addressed and exhausted, need to elaborate more. Response: We have elaborated the definitions of four target variables for quality of nutrition service in lines 164-174 on page 8: “We considered weight assessment performed if the HCPs took the weight of pregnant women using either a digital or analogue weighing scale”. “Screening for anaemia included assessing blood haemoglobin level either using Tallquist paper onsite, by previous laboratory investigation or examining eye or palm (clinical assessment). Provision of nutrition counselling included HCPs providing messages on dietary diversity, quantity and types of nutritious food. We defined IFA provision as HCPs distributing IFA supplements during the ANC consultation; however, we did not include HCPs prescribing IFA to be bought from outside pharmacies”. 3. Methods Page 7, line 133 – 137 the paragraph “We conducted the assessment in 231 facilities, and in 184 facilities, we observed ANC services provided on the assessment days. We interviewed 217 health care providers who offered ANC services at the facilities on the day of the visit, and we observed 1296 ANC consultations. We excluded 54 observations due to missing information about the health care providers, the client’s characteristics, or the exit interview” is not clear, need to be reconsidered or rephrased. Response: We have rephrased the text as (page 7-8, lines 149-157): “We assessed the readiness to provide ANC services in 231 facilities (Fig 1). ANC services were not sought in 47 out of the 231 facilities on the assessment days; thus, we observed 1295 ANC service consultations at 184 facilities. We had complete background information from 201 HCPs who offered ANC services on the day of the visit. We excluded 53 observations from the analysis due to missing information on HCPs or the client characteristics. Finally, we included 1,242 observations of ANC service consultation provided by 201 service providers at 179 facilities in the analysis for this paper”. 4. Result Page 10 line 213 & 2014 the sentence “On average, clients who received ANC from the facilities were 23 years old and had eight years of schooling” is not clear, need more explanation?. Response: We have rephrased the text as (page 12, lines 241-242): “Clients who received ANC from the facilities had a mean age of 23 years (SD±4.3 years) and had a mean eight years (SD±2.9 years) of schooling”. 5. Page 14, table 4 are highly congested and it crosses one page requires rearrangement or division into two table or more. Response: We have divided Table 4 into two tables (Table 4 and Table 5). 6. Discussion Grammatical, spelling, and punctuations improvement is required in this section Response: We have corrected grammatical, spelling and punctuation errors. 7. Overall comment There are some areas need corrections; such as rephrasing, grammatical, spelling, and language. Kindly review issues raised and if possible get a trained English proof reader to edit the entire manuscript. Response: We have revised accordingly. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0262867.r002
14 Dec 2021 Decision Letter - Sharon Mary Brownie, Editor PONE-D-21-16534R1Factors influencing quality nutrition service provision at antenatal care contacts: findings from a public health facility-based observational study in 21 districts of BangladeshPLOS ONE Dear Dr. Sk Masum Billah, 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 15 January 2022. 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, Sharon Mary Brownie 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. Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: (No Response) Reviewer #2: All comments have been addressed Reviewer #3: All comments have been addressed Reviewer #4: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes Reviewer #4: 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: An interesting and important modifiable and independent service related factor revealed in your results is the TYPE OF PROVIDER. In your abstract, you have mentioned it nicely as- Although nurses provided services of similar quality to the physicians, paramedics were 23% (aIRR: 1.23, 95% CI: 1.06-1.42) and community health care providers were 32% (aIRR: 1.32, 95% CI: 1.12-1.57) more likely to provide quality nutrition services. However, this factor has not been addressed at all in the discussion. As I have mentioned earlier (In the first review, this is the only important influencing factor/determinants and this need to be highlighted/explained in the DISCUSSION. Reviewer #2: The study is useful. The findings are relevant. I re-confirm my opinion that the manuscript is clearly written, the methodology is sound and results are well discussed. Reviewer #3: Go over the manuscript carefully to correct any grammatical issues and enhance ease of reading. For instance, you can summarize the conclusion to less than half the current length. Reviewer #4: manuscript titled Factors influencing quality nutrition service provision at antenatal care contacts: findings from a public health facility-based observational study in 21 districts of Bangladesh. I had reviewed first and made few comments. All comments were addressed properly. It is satisfactory ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No Reviewer #3: No Reviewer #4: 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-21-16534_R1 Dated 10 Dec 21.pdf https://doi.org/10.1371/journal.pone.0262867.r003
Revision 2
4 Jan 2022 Author Response Reviewer #1: An interesting and important modifiable and independent service related factor revealed in your results is the TYPE OF PROVIDER. In your abstract, you have mentioned it nicely as- Although nurses provided services of similar quality to the physicians, paramedics were 23% (aIRR: 1.23, 95% CI: 1.06-1.42) and community health care providers were 32% (aIRR: 1.32, 95% CI: 1.12-1.57) more likely to provide quality nutrition services. However, this factor has not been addressed at all in the discussion. As I have mentioned earlier (In the first review, this is the only important influencing factor/determinants and this need to be highlighted/explained in the DISCUSSION. Response: We agree with the reviewer that the type of HCPs is an important factor influencing the quality of nutrition service. We have now highlighted this in the discussion and proposed some possible explanations in the following additional text (page 19, lines 339-351): “Lower-level providers who mainly offer services at lower-tier facilities provided a better quality of nutrition service than physicians and nurses at higher-tier facilities. Previous studies from LMICs including Bangladesh have also reported that lower-level providers had similar or better compliance with standard maternal and child out-patient care than higher-level providers [1, 2]. All physicians and nurses in our study provided services at the district and subdistrict hospitals where HCP shortage is a challenge [3]. These physicians and nurses often provide service under high workload pressure, are responsible for multiple tasks and manage patients with complications [4, 5]. In such situations, HCP often prioritise curative health services over preventive nutrition services such as counselling and weight assessments for weight gain monitoring [5]. We also found nutrition counselling was lower at facilities where a higher number of ANC services were provided, and this occurs mostly at district and subdistrict hospitals. The role of the higher-level providers should be clarified based on WHO and national recommendations for nutrition services during pregnancy. Further in-depth qualitative assessment is necessary to better understand provider attitudes and motivation factors influencing their provision of nutrition services.” Reviewer #2: The study is useful. The findings are relevant. I re-confirm my opinion that the manuscript is clearly written, the methodology is sound and results are well discussed. Response: We appreciate the positive comment from the reviewer. Reviewer #3: Go over the manuscript carefully to correct any grammatical issues and enhance ease of reading. For instance, you can summarize the conclusion to less than half the current length. Response: We have checked the manuscript thoroughly and corrected grammatical errors and language. We have summarized the conclusion (Pages 22-23, lines 422-435). Reviewer #4: manuscript titled Factors influencing quality nutrition service provision at antenatal care contacts: findings from a public health facility-based observational study in 21 districts of Bangladesh. I had reviewed first and made few comments. All comments were addressed properly. It is satisfactory. Response: We thank the reviewer for the encouraging comment. 1. Amoakoh-Coleman M, Agyepong IA, Zuithoff NP, Kayode GA, Grobbee DE, Klipstein-Grobusch K, et al. Client factors affect provider adherence to clinical guidelines during first antenatal care. PLoS One. 2016;11(6):e0157542. 2. Hoque DE, Arifeen SE, Rahman M, Chowdhury EK, Haque TM, Begum K, et al. Improving and sustaining quality of child health care through IMCI training and supervision: experience from rural Bangladesh. Health Policy Plan. 2014;29(6):753-62. 3. Organization WH. Bangladesh health system review: Manila: WHO Regional Office for the Western Pacific; 2015. 4. Joarder T, Tune SNBK, Nuruzzaman M, Alam S, de Oliveira Cruz V, Zapata T. Assessment of staffing needs for physicians and nurses at Upazila health complexes in Bangladesh using WHO workload indicators of staffing need (WISN) method. BMJ Open. 2020;10(2):e035183. 5. Saha KK, Billah M, Menon P, El Arifeen S, Mbuya NV. Bangladesh National Nutrition Services: Assessment of Implementation Status: World Bank Publications; 2015. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0262867.r004
7 Jan 2022 Decision Letter - Sharon Mary Brownie, Editor Factors influencing quality nutrition service provision at antenatal care contacts: findings from a public health facility-based observational study in 21 districts of Bangladesh PONE-D-21-16534R2 Dear Dr. Sk Masum Billah, 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, Sharon Mary Brownie Academic Editor PLOS ONE Additional Editor Comments Reviewer recommendations have been addressed. https://doi.org/10.1371/journal.pone.0262867.r005
Formally Accepted
13 Jan 2022 Acceptance Letter - Sharon Mary Brownie, Editor PONE-D-21-16534R2 Factors influencing quality nutrition service provision at antenatal care contacts: findings from a public health facility-based observational study in 21 districts of Bangladesh Dear Dr. Billah: 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 Professor Sharon Mary Brownie Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0262867.r006

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