PONE-D-21-18428

Maternity waiting homes utilization and associated factors among childbearing women in rural settings of Finfinnee special zone, central Ethiopia: a community based cross-sectional study

PLOS ONE

Dear Dr. Amare,

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.

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Orvalho Augusto, MD, MPH

Academic Editor

PLOS ONE

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Additional Editor Comments:

This report contributes to the knowledge of utilization of maternity waiting homes (MWH) in rural Ethiopia and perhaps Sub-Saharan Africa. however , there are important issues that need to be addressed:

Major issue:

- It is unclear in the whole document who should use the MWH. Therefore, it is hard to appreciate the results. The introduction is written in a way that suggests, implicitly, every woman should use the MWH service. We expected that the study setting would cover the Police or Indications for MWH in Ethiopia.

Minor issues:

1. General

- Decimal places: put 1 decimal place for proportions, means, quantiles (medians, terciles and quartiles); and 2 decimal places for standard errors and deviations, odds-ratios and their confidence intervals.

- Please have some English revision.

2. Introduction

- Please see the major issue above

- Lines 54 and 55. What is this “highest maternal mortality” compared to? Ethiopia versus other countries? Or within Ethiopia?

- Line 71 remove the “in contrast”

3. Methods

- Please see the major issue above

- Lines 97 and 98: Why just focus on within 9.5 km of a health facility. How did this decision come about?

- Sample size considerations lines 106 to 108. This statement [The sample size for factors was calculated with Epi Info version 7 software with the an assumption of 95% confidence level, 5% margin of error and power of 80%] has no sense here or it is at least incomplete. What is the magnitude of association expected to be detected?

- Statistical software: please write the names correctly. EpiData [not Epi-data] and Stata [not STATA]. Please add proper citations for the software.

4. Results:

- Please when describing the mean (m) and standard deviation (sd) do not write “m ± sd” as in lie 163. Please make m (SD: sd) or something related.

- Why are the age categories using very strange groups in table 1 and 3? The data presented in this manuscript may be used in future for meta-analysis (for example) so please use more common group divisions as multiples of 5 (< 25, 25- 34, >- 35).

- Table 1: add mean, sd, median and interquartile range of age.

- Table 1: what means “Career woman” in occupation?

- The paragraph starting at line 170 opens with the “study showed” and it is repeated on line 173.. Please avoid this. That is interpretative. It would be OK in discussion not in the results section.

- Table 2: why the 4 is used for dichotomization of previous pregnancies?

- Table 2: please sort by frequency the “services received during the stay” and the “reasons not to use MWHs”.

- Table 3: remove the “N = 419 (64.98%)” and “N = 216 (34.02%)” from the header of the table. Add one column between MWHs and COR (95% CI) for proportion [prevalence] of MWHs use. Add a row for totals [here is where this 419 and 216 will be].

- Table 3: review the stars for the significant results. For example, in the column for the COR in the second category of age the confidence interval does not include the NULL. So why no star?

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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: No

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

Reviewer #1: 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

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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

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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: An interesting choice of topic. I hope you will find the comments useful in strengthening the manuscript and making it easier for the reader to judge the evidence presented.

ABSTRACT

• Line 22 – incomplete sentence, word missing

• Results: provide more specific details about how you measured (i) physical separation (“far” is too vague) and (ii) wealth (“rich” is vague). Indicate percentages of women reporting common services + indicate whether food was provided or not.

• Recommendation unclear – what do you mean scale up to women living far

BACKGROUND

General comments: (i) Existing literature on factors associated with MWH use in Ethiopia and other low-resource settings has not been adequately presented despite being available

(ii) There seems to an inherent assumption in this work that MWH stay is necessary for all pregnant women; however, they are a strategy to improve access for women who experience geographical barriers and in some cases who are expected to be at higher risk for complications. There has been no work carried out to determine what proportion of women fall into these categories in Ethiopia or indeed anywhere else, so how are the authors concluding that MWHs are under-used. Underutilization based on what? The target set in the HSTP of 80% of health centres having an MWH present is not useful here.

(iii)The literature cited regarding potential impact of MWHs has been overstated without any regard to the quality of that evidence.

Specific comments:

• Line 45 – what do you mean by equal access

• Line 47 – what do you mean the WHO “launches MWHs” – does not make sense

• Line 50 – MWHs do not provide obstetric care; they offer pregnant women a place to stay while they await birth. Obstetric care is only provided at the health facility which MWHs are associated with.

• Lines 51-52 – does not make sense. Are you trying to describe how MWHs could potentially be helpful in reducing perinatal mortality? Rephrase to make clearer.

• Line 52-53 – reference #6 had potential methodological issues that need to be considered. See https://bmcresnotes.biomedcentral.com/articles/10.1186/s13104-021-05501-2. (1) The studies included in the meta-analysis were old and generally poorly designed, they were all observational in nature and therefore have potential issues with confounding, all used health-facility based samples which reduces their generalisability to the wider population and the meta-analytic method chosen was unlikely to be appropriate for a complex intervention such as MWHs.

• Lines 54-55 is not strictly true because MWHs do not directly affect mortality or morbidity; these outcomes are highly dependent on the quality of care available at the health facility where these services are actually provided. All MWHs do is offer women an opportunity to come early, prior to the onset of complications (which usually only occur in about 20% of seemingly healthy pregnancies). You are overstating the role that MWHs play in mortality and health outcomes. Please rephrase this to more accurately reflect the role that MWHs actually play.

• Lines 57-58 – rephrase how the results from the systematic review (ref #7) and reference #8 are stated – they are currently misleading as they do not acknowledge the inherent limitations in the observational nature of these studies. They do not conclusively demonstrate the effectiveness of MWHs with respect to mortality or morbidity. Making such claims is very misleading.

• Line 56-57 – once again, the evidence is overstated using the same reference.

• Lines 63-66 – listing percentages (that are highly dependent on the setting and sample) are neither informative nor relevant to your study. What is more important is discussing what factors have been identified to be associated with intended use.

• Lines 67-70 – references 12 to 14 as you have stated in the previous paragraph relate to factors associated with intended use, so why are they listed as being related to actual use? Reference 15 describes factors related to actual use in Jimma –list those. What about evidence from qualitative work that provides insight into what might be driving use? You can’t simply exclude that because you are conducting a quantitative analysis.

METHODS

General comment: There are several fundamental elements of design that are unclear. In terms of analysis, inadequate details are provided about what the variables represent, how they were selected for the multivariable model and how the multivariable model accounted for the clustered nature of the data included.

Specific comments:

• Lines 87-89: what do you mean by 47% of women expected to deliver at a health facility? Is this a target set by the Zone? You have cited the DHS as a reference, so are you instead trying to indicate what the current level of health facility delivery is? This sentence is confusing as it seems to be mixing information about services provided at MWHs (bedding and food?) and levels of facility delivery in the area. Needs rephrasing for clarity.

• Lines 89-91 needs copy editing as it is unclear due to awkward sentence construction and grammatical issues.

• Lines 98-99: how did you establish how far women lived? Provide the exact details used to determine distances – how exactly they were measured, what type of distance, what the origin (starting point) and destinations (what health facility – nearest to women’s homes? Within their kebele of residence?) were and at what point in the study this was done. Did you obtain consent from women if you measured distances between their homes and a health facility?

• Lines 97-99: Why did you select 9.5km as part of your eligibility criteria? What evidence do you have that this criterion is relevant for your setting? Scott et al (2018) used this cut-off for their work in Zambia (https://pubmed.ncbi.nlm.nih.gov/30099401/) but had formative research to establish this as the distance they wanted to test out.

• Lines 103-105: why did you base your calculations on a study from Jimma Zone looking at intended use rather than the available study on actual use, which is your outcome of interest?

• Lines 105: Why did you select a design effect of 1.5? How do you know this is reflective of the level of correlation in outcomes in your setting? Provide some justification.

• Lines 108-109: what do you mean by the “maximum estimated sample size for the independent variable”? What independent variable?

• Lines 636: How did you arrive at a final figure of n=636 with the parameters that you provided?

• Lines 110-112: in lines 85-86 you indicated that there were n=153 kebeles within the 6 study districts, so how did you end up selecting 6 from a total of now 18 kebeles?

• Lines 112-114: Describe exactly what records are maintained by health extension workers and what information you used as your sampling frame. How up to date are these records? What is their coverage? What proportion of women living in these areas may not have used services at health posts and gone directly to hospitals or health centres (e.g., those living closer to health centres)? Ensure you acknowledge the limitations of this sampling frame in the appropriate sections.

• Lines 110-119: in what way was the distance criteria of 9.5km factored into the sampling? You seem to have selected women regardless of how far they lived. This is mismatch to what you previously described as your eligibility criteria (lines 97-99).

• Lines 113: How exactly did you conduct random sampling? Please provide brief details about what you did. You describe “ordering households” but that does not provide any information on how this was random.

• Lines 117-119: It’s unclear how you included a home next to the selected house – how could you be certain that there were eligible women living there? Also, please ensure that you acknowledge in the limitations section that this strategy potentially introduces selection bias into your sample as you are now including women who were available for interview rather than an actual random sample.

• Lines 121-122: Provide more details about whether you considered length of MWH stay and whether you made a distinction between MWH stay prior to birth (antenatal stay) and MWH stay after delivery (postnatal stay). Were these distinctions made in your outcome variable? If not, indicate that you did not and considered MWH use as any length of stay and any type of stay (antenatal/postnatal).

• Lines 123-125: Provide a list of specify sociodemographic and obstetric variables considered as independent variables as well as their operational definitions as per STROBE reporting requirements (how they are defined and how they are categorized). Also, provide some justification for the choice of these variables. Did you use existing studies from Ethiopia or other countries in sub-Saharan Africa looking at MWH use to select potential explanatory factors? If yes, provide references to these studies.

• Lines 125-128: Provide details about the methodology followed and some indication of the performance of the wealth index (truncation, clustering, correlation with asset ownership) as choice of assets influences household categorization and can potentially impact how accurately it reflects wealth. See https://pubmed.ncbi.nlm.nih.gov/28822980/. Also, the beginning of the sentence does not make sense – you can’t use PCA to “assess the wealth index”.

• Lines 128-129: Why did you opt to categorize wealth by tertile? Quartiles and quintiles are likely better at capturing subtle variation in household wealth that could potentially influence MWH use. Please provide a justification or any explanation for your choice.

• Lines 129-130: Recall bias refers to a systematic difference in the accuracy or completeness of exposure information between participants with and without the outcome of interest. Can you explain which independent variables you have included in your model are likely to have this as an issue and why this would likely differ between MWH users and non-users. Also, can you explain why you think 6 months is a more reliable recall time frame than 12 months or 3 months? How did you decide on 6 months?

• Lines 137-139:Why did you require 3 individuals to supervise 6 interviewers?

• Lines 144-145: Can you describe how you cleaned the data? Provide a brief sentence or two explaining what you did.

• Lines 146-149: Why did you rely on p-values from bivariable analyses to select variables? Can you provide justification as to why a strategy that has been described to be problematic (affects the stability of multivariable models, biases standard errors, can produce confidence intervals that are falsely narrow, can result in regression coefficients that are biased high, etc --see Ch4 in Harrell’s Regression Modelling Strategies for an in-depth explanation. This is also a useful paper: https://onlinelibrary.wiley.com/doi/full/10.1002/bimj.201700067) was selected instead of using potential explanatory factors identified in other studies?

• Lines 149-150: Confidence intervals do not “measure the degree …of association”. Please rephrase to accurately reflect what information confidence intervals provide i.e., provide insight into the precision of the association estimate.

• Provide a copy of the questionnaire used as supplementary material so that readers can see what information was collected and how.

RESULTS

• Line 162 – quoting the final number of participants is not helpful for the reader to gauge the level of response since a replacement strategy was used (lines 117-119). What you need to report is how many women were approached, how many were replaced and then the final number enrolled (n=635). 99.9% does not reflect your “participation rate” because you replaced anyone that was not available.

• Lines 164 – spelling error replace “leaving” with “living”. Please seek copy editing services to ensure that all grammatical errors and unconventional sentence construction issues are addressed.

• Lines 164-165: Specify what facility you are referring to here – nearest health facility of any level? Health centre with MWH in catchment of residence? When you describe physical separation (either as travel time or distance) you also need to specify origin and destination. See this paper that outlines problems with reporting that make it difficult to understand access issues in maternal and child health: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0184432

• Table 1 – what is a “career woman”- how was this defined? What categories of responses does it include?

• Table 1 – how was husband’s education attainment established? Did you ask women about this? It’s surprising that all women were able to answer this question.

• Table 1 – how was access to transportation measured?

• Table 1 – was any type of facility considered for the variable estimating travel time? Health post? Clinic? All health centres or health centres with MWHs? District hospital?

• Lines 174-176 – What was the question asked to women regarding reasons for non-use of MWHs? Were multiple responses possible? Also, whom did you ask the question to? All women? Women who live a specific distance from a health facility? What about women who live near a road or have easy access to transport.

• Table 1 – where was the health worker check conducted? Within the MWH or in the health centre as part of routine ANC? Provide more details about the MWH services received.

• Table 3 – it is likely that there is strong correlation between women’s age, gravidity and parity. Can you report what diagnostics you conducted to check correlation between these various variables as well as for the presence of multicollinearity in your multivariable model?

DISCUSSION:

General comment: There is a distinct failure here to acknowledge the fact that MWHs are not necessarily relevant for all women such as those with relatively good access to transport, those who live close to a health facility offering obstetric care, those who live along a road, those who live in a rural town, etc. What would be the justification of separating a pregnant woman from her household and support network for an entire week if she is able to access obstetric care when she goes into labour? What about the opportunity cost MWH stay presents – women absent from their homes and farms represents potential lost income and additional expenses incurred in organizing childcare and someone to take over domestic responsibilities. How has all this been factored into your findings?

Specific comments:

• Line 200-201: On what basis are you suggesting that use is low for this region? Your study has not established the denominator of women for whom MWHs are relevant or for whom stay would be most beneficial. There is no evidence provided of what proportion of the population experiences access barriers. Are you suggesting that 100% of women in Finfinnee should use MWHs? Direct comparison of simple percentages reported in surveys conducted in other parts of Ethiopia do not provide sufficient evidence to suggest that use is low in this setting. Please explain.

• Lines 221-223: Your conclusion that “MWHs service is being executed” is a little premature. How did you establish what sort of follow up was provided to MWH users? You have not provided any details whatsoever. Are you making this conclusion based on one question put forward to women? Did you assess what sort of follow up this was? Are you referring to “follow up by a skilled birth attendant” as judged by the use of a partograph for labour which is in the Ethiopia MWH national guidelines? What is your basis for concluding that MWHs are working as they should? Also, only 40% of users (Table 2) received meals – what did the rest do? Only 30% has access to clean water. These indicators all point to the MWH not meeting requirements which is to provide acceptable accommodation to pregnant women.

• Lines 223-224: Did you consider that perhaps lack of information among non-users was because HEWs and ANC nurses who are mainly responsible for referring pregnant women to MWHs do not discuss them with women who live close enough or do not have transport issues?

• Lines 228-232: What is more likely here is that your model has two highly correlated variables – older women are more likely to have more children. I would suggest you check to see if there is multicollinearity in the model and also justify what additional information is provided by including 3 variables that are conceptually related.

• Lines 228-245 – this entire paragraph is not very well written or thought out. It has a lot of conjecture and sweeping conclusions that are not supported by the data.

• Lines 246-257 is simply re-stating results with no additional information. Listing studies without any meaningful discussion also adds little value (lines 255-257).

• Limitations that should be discussed:

o Sampling frame constructed based on health post records which may not be up to date and could exclude a proportion of women who did not seek care at the health post either because they use health centre services directly or are unable to access any services due to distance or other barriers

o Potential selection bias in replacement of women with those that were available – you can discuss how much of an issue this might be depending on how many women you had to replace in this way

Lines 261-263 do not make sense. The outcome and dependent variable refer to the same thing, not to mention despite having said that causal relationships cannot be inferred from cross-sectional data, the entire discussion section and the conclusions does it any way.

• The conclusions are over-stated.

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Reviewer #1: No

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PONE-D-21-18428R1Maternity waiting homes utilization and associated factors among childbearing women in rural settings of Finfinnee special zone, central Ethiopia: a community based cross-sectional studyPLOS ONE

Dear Dr. Amare,

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 Jan 06 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 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,

Orvalho Augusto, MD, MPH

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

There are still outstanding comments to be resolved as the reviewer raises below.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

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

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: No

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: The manuscript entitled “Maternity waiting homes utilization and associated factors among childbearing women in rural settings of Finfinnee special zone, central Ethiopia: a community based cross-sectional study” is a revised version of what was previously submitted by the authors for consideration for publication. Although the authors have made attempts to improve the manuscript, there are still some concerns, which I have indicated below

General comment

The English used in the manuscript is not appropriate for PLOS ONE.

Abstract

It is not clear what the authors are communicating here. Are MWHs meant to improve access or they are strategies for improved access? What do the authors mean by “it is vital to use MWH for Ethiopia”? Improved access to service delivery alone does not solve the problem of high maternal mortality

Background

Line 51: Could authors write world health organization appropriately?

Line 54-56: Sentence is confusing and needs to be revised

Line 60: A bracket is opened but was not closed

Line 70-71: Sentence does not make any sense

Line 71-75: Authors can highlight the determinants of intention to use MWHs without having to refer to the variable names as they appeared in the study (ies). For example, attended ANC can be replaced with something like women who attended ANC or use of ANC. Authors should revise to align with the sentence structure used.

Line 79: Where are the qualitative studies? I believe references 14-16 are about utilization and not intention to use.

Methods

Line 93-94: Authors should break the sentence and continue with a new one.

Does it mean the 9 health centers do not have MWHs?

Line 107: delete far. Whether far or near is determined by the distance from the reference point

Line 112-114: in the introduction, a utilization rate of 7% was quoted, but a 38.7% is quoted for the sample size? Why did authors choose the latter instead of the former to calculate the sample size? What is the single population formula and what is the purpose of the design effect?

What justified the calculation of two sample sizes and ultimately settling on one? What do authors mean by sample size for factors?

In the selection of health facilities, did the authors take into consideration health facilities that did not have MWHs? Obviously that has a potential to influence utilization rate

Discussion.

The is evidence that the utilization of MWHs may not be the only solution to promoting maternal health in Ethiopia. From the study, even women who used MWHs did not get the full benefits; some did not get meals and some did not get clean water. What would be the benefit of using MWH to a woman when she is not assured of receiving what she is expected to get there?

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Reviewer #2: Yes: Dr Michael Boah

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PONE-D-21-18428R2Maternity waiting homes utilization and associated factors among childbearing women in rural settings of Finfinnee special zone, central Ethiopia: a community based cross-sectional studyPLOS ONE

Dear Dr. Amare,

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.

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We look forward to receiving your revised manuscript.

Kind regards,

Orvalho Augusto, MD, MPH

Academic Editor

PLOS ONE

Additional Editor Comments:

We are going now to a third revision and this manuscript and we still have so many English typos. Please a native English speaker to address this.

[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 #3: (No Response)

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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 #3: Partly

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

Reviewer #3: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Thank you for the opportunity to review your article. This is my first review and I noted the comments of a previous review.

The article reads easily and the maternal mortality in Ethiopia is really a concern. Thank you for attending to the language. There are still many errors throughout and I have pointed out some. Using a native English speaking editor is always best prior to submitting articles to international journals. The following aspects need to be attended to:

Background

L55-L57 Edit the language.

L57 - What does final week of pregnancy mean in this study as a term pregnancy is widely accepted as 37 completed weeks?

L60 - Remove the additional bracket.

L61 - What is the ideal maternal mortality? Place Ethiopia in the international perspective.

L61-L63 - What was the maternal mortality prior to implementation of the MWHs?

L71-L80 - Many studies have been conducted on MWHs and the facilitators and barriers to use of the MWHs are known. The significance of the research problem is stated in L81-L88, but is not clear.

Study design and setting

L92 - What is a community-based cross-sectional study? The study design is not described and applied to this study.

L93-L94 - The population was 649 403. Indicate the specific year.

L97 - Approximately how many births are conducted in each kebele and what type of healthcare is present?

L107 - Why should the mothers live 9.5km away?

L119 - What is AOR 2.4?

L128 - Correct the language in the sentence 'The sampling interval...'

Study variables

L140 - There is a word missing in the sentence 'The obstetrical...'

L140 - L145 - How were the factors selected in the questionnaire? Describing the construction of the research tool is very important as it affect the validity and reliability of the study.

The results are well presented and clear.

Obstetric characteristics of respondents

L196-L202 - There is an overuse of adverts. Please remove some.

Discussion

I am concerned about the depth of the discussion. A discussion needs to be aligned with your results. I cannot differentiate between the sociodemographic characteristics, obstetric characteristics and factors associated with MWH utilization. The role of the healthcare provider is still not clear as well as the benefits of use of the MWH for the women. Perhaps create three headings in the discussion section and arrange the content below each.

L224-L225 - Correct the language in the sentence starting with 'The study showed...'

L225-L226 - The actual use in this study is compared to the intended use in other studies. There must be similar data available.

L227-L228 - Correct the language in the sentence starting with 'The studies in Benchi Maji...'

L232-L234 - Correct the language

L234-L235 - Correct the language. The sentence does not flow well.

L258 - Correct the language.

L256-L266 Correct the language of the sentence 'This might be the effect...'

L282 - Add 's' to the word 'result'.

L293 - 'Housewife women' is not appropriate English.

Acknowledgements

L302 - The word 'admire' is not appropriate English.

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If you choose “no”, your identity will remain anonymous but your review may still be made public.

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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.

Maternity waiting homes utilization and associated factors among childbearing women in rural settings of Finfinnee special zone, central Ethiopia: a community based cross-sectional study

PONE-D-21-18428R3

Dear Dr. Amare,

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,

Orvalho Augusto, MD, MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #3: (No Response)

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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 #3: Yes

**********

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

Reviewer #3: 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 #3: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: 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 #3: Thank you for the much improved article. The discussion section now focuses on utilization of maternity waiting homes. There are however aspects that have not been addressed. In addition, altering the text brought forth new linguistic errors.

- L114 - The distance of 9.5 km from the maternity home is sill not clear.

- L161 - The quality control of data collection was addressed. The validity and reliability of the new questionnaire is not described. Validity includes internal and external validity and one expects face and content validity, construct validity and criterion validity. Were experts used during development of the questionnaire?

- L178 - How many records could not be used?

- L262 - Change to 'fewer than four' women.

Below some of the language errors:

- L38 - include 'are' before 'significantly'

- L39-40 - Rephrase the sentence

- L84-86 - Rephrase the sentence

- L90 - Insert 'determine' before 'factors'

- L121 - Move [23] in the middle of the sentence towards the end of the sentence

- L233 - Insert 'during' before 'their childbirth'

- L239 - Remove 'were' after 'pregnant women'

- L248 - 'utilization' should be 'utilized'

- L254 - Remove 'service'

- L254 - 'Did not' instead of 'didn't' (Correct all)

- L262 - Sentence not clear - rephrase

- L271 - Change 'farmer' to 'farmers'

- L272-276 - Rephrase poor language

- L313 - Include 'was' after 'SD'

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No