PONE-D-21-18015Bottleneck Analysis of Maternal and Newborn Health Services in Hard-to-reach areas of Bangladesh using ‘TANAHASHI’ Framework’: an explanatory mixed method studyPLOS ONE

Dear Dr. Mohiuddin Ahsanul Kabir Chowdhury, 

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 all the points raised by the two reviewers during the review process.

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Gouranga Lal Dasvarma, PhD

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PLOS ONE

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Reviewer #1: Yes

Reviewer #2: Partly

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #2: No

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Reviewer #1: Chowdhury and co-authors conducted a Bottleneck Analysis of Maternal and Newborn Health (MNH) Services in Hard-to-reach (HtR) areas of Bangladesh using ‘TANAHASHI’ Framework’ in order to explore the possible remedial approaches. They explored five domains of the framework: availability, accessibility, utilization, adequate coverage and effective coverage by using an explanatory mixed method research approach and collected data from RDWs and stockholders. The study design is appropriate to address the stated research objectives. The data collection tools were the qualitative interviews (55) and structured questionnaire(n=2,768). The data were analyzed using descriptive statistics and thematic approach. Qualitative interviews of facility managers, local stakeholders, RDWs and health care providers (HCP) from village level, union level and sub-district level health facilities were conducted. The study was conducted in four different types of HtR areas (hilly, coastal, lowlands, and river islands). The authors found Antenatal care, under-5 care, and family planning service are available in all facilities while several bottleneck areas namely, availability of drugs; human resources; transportation; lack of knowledge regarding different essential services and health components, and out of pocket expenditure which affected the quality of health care provisions in HtR areas. The manuscript is well written and useful findings are revealed. However, I have a few concerns on the sections, introduction, methods and materials, data analysis and discussion which are given below:

1. Introduction : Authors could describe briefly how the health sytem is functioning in Bangladesh as a background to the strudy that can help reader to know the context and the significance of current research.

Line 56-58: It is good that authors can present the current MMR figure for Bangladesh (i.e.173 per 100000 live births in 2017) along with percent change in MMR during 1990-2016. It is also mentioned that the NMR was reduced from 52 to 30 deaths per 1000 live births between 1994-2017. According to WHO (2018) NMR is 17.1 deaths per 1000 live births. Figures need be checked.

2. Line 73-74: Though the authors assumed that failure in health system in HtR areas, it is not clear how the health situation was measured/ justifications are not clear (i.e., high MMR, NMR in HtR etc.,)

3. Study participants: It was mentioned that the study participants consisted of 2,768 recently delivered women (RDW), however, reference period should be mentioned as one year.

Sampling technique: For the quantitative data collection, authors can elaborate the sampling procedure to reflect sampling frame, sampling method (i.e. random, multi-stage process) that involved when drawing random samples from HtR areas.

5. For the qualitative component, the snowball sampling method was used, authors may explain why this method was employed to recruit participants.

6.Line 166, Data analysis: This could be stated as 'Methods of data analysis'

7. Results: Authors have presented findings of both quantitative and qualitative data pertaining to the five domains:availability, accessibility, utilization, adequate coverage and effective coverage which explained bottelneck areas in facilities in HtR areas. Overall findings address the research gaps and contribute to the exsisting quentum of knowledge.

8. Tables: Table 1, both numbers and percentages (%) are not necessary to present in the same table. if authors use only %s by mentioning number ( n=? in columns ) redear can better grasp the table.

9. It is good that authors could summarize the study findings in a way that can facilitate readers to grasp key findings such as indicating levels of facilities available, its magnitude by comparing national level facilities along with HtR areas.

10. Minor language errors were noted so that it is good that the manuscript could be copy edited before submitting the revised version.

11. Authors have explored a substantive literature related to the area of research and cited them properly.

Reviewer #2: Abstract: Authors might want to write it in structured format.

The authors wrote “Bangladesh being a low-and-middle income country, set targets for MNH aligning with Sustainable 24 Development Goals” ---how does a country’s income level matters here? Rewrite this sentence, I think it does not quite make sense to bring that ‘low-and-middle income’ category as a reason to set SDG targets.

Introduction

• “342 to 211 per 100,000 live births between 2000-2017, still over 800 women are dying from pregnancy and childbirth related complications”—where are these women dying and how frequently? Please specify a country, region or worldwide—where? And annually or over a certain period of time?

• Can authors clearly demonstrate the gap in a table/box? They might want to bring the annual rate of decline in MMR and NMR over the past (e.g. 1990 to 2017). Also include in the table the numbers on where we reach provided the similar rates of decline by 2030, and the rates required to reach the SDG targets.

• Can authors also talk about the gaps in health service coverage nationally vs in HtR areas, both for key maternal and neonatal interventions?

• The detailed description of Tanahashi framework might be omitted from introduction. Authors might want to demonstrate the figure in method section.

Materials and methods

• Did the authors go for 100% of the villages in the 4 HtR district? It is not clear.

• Use a reference for ‘explanatory sequential mixed-method design’.

• How did the data saturation work for different categories of participants? Having 1-2 sentences about authors’ practical insight into it could be useful.

• How was the ‘availability’ determined by interviews or observation of the records from all health facilities of the 4 districts? Please confirmed it. Also, how did you explore clients’ need? How did you define the actual volume of the clients in the study location?

• Please mention the total lists of unions in each HtR district? What is your reason to choose 3 unions from each HtR district?

• How did you define RDW? Is 2989 the all RDWs in the 36 villages?

• Did you select all facility managers and providers in the study areas? If not how did you select them for the interviews? You used snowball for local stakeholders, but how did you get the other qualitative participants in your study?

• In the tools section, you said you had IDIs with RDWs? And FGDs with community people? Can you mention how many IDIs and FGDs conducted in the method above?

• I would suggest you make a simple summary table with type of data collection methods, type of study participants, type of data collection tools, number of participants to make it easier for the readers to understand the types of data and different participants in your study.

• Your overall sampling process for quanti looks like ‘multi-stage convenient sampling’.

• In variable section, your key variables are those stated in Tanahashi framework. Please provide your working definition (clearly mention the operational definition used in your analysis) availability, accessibility, utilisation, and others. I would suggest a simple table again to list each sub variables by those key domain variables (availability, accessibility, utilisation, Adequate coverage and Effective coverage).

• Submit as additional files of all of your data collection tools.

Analysis

• Mention the key descriptive stats utilised.

• Mention the number of transcripts and people involved in analysing qualitative data.

• How did you check inter coder reliability as stated?

• Upload the primary code book and the master code list file as additional files.

• Provide a reason (maybe on method section above) on why FGDs, IDIs, KIIs—all of these needed in your study? There seems a big bulk of data—was it all necessary? If so why, for which aspects of your study? How did your principle of saturation worked out while you were collecting data using these many different methods?

Ethics

• Were the written consents taken from RDWs? There are nearly 15% who had never been to school as per your data. How did it work?

• Did you exclude any categories of RDWs for any ethical reasons? Such as those who had lost their babies recently??

• Did you collect written consents for all qualitative participants too? How did it work for FGDs?

Results

• Can you give a brief description on which level of the 29 health facilities are in your health system? You said only 13.7% were providing CS---were all 29 facilities eligible to provide CS as per your Ministry/Department of Health? The same for blood transfusion ! How many of the 29 facilities are Comprehensive Emergency Obstetric and Newborn Care providers?

• For each component analysis—how does a reader understand how many were supposed to provide that particular care component, say ‘Antenatal care’? For the HR it is clear as you mention the sanctioned posts.

• I would strongly suggest reorganizing the results as per the Tanahashi domain variables—be specific to mention your results as per the key domain variables of the framework you utilised. You can mention the socio-demographic characteristics of study participants—of both quantitative and qualitative participants at the start of the result section. In so doing, you can bring in the key qualitative information integrating together with the key domains of the Tanahashi model.

• Provide a list of key bottlenecks as per each domain in the model, maybe do so in a table. You have collected a lot of qualitative data—I think there could be plenty of info on bottlenecks.

Discussion

Needs further work. Once you have reorganized the result section well as per the model you used—you then can choose key points to interpret, elaborate and provide compelling discussion. Also, acknowledge the limitation of the convenient sampling you have utilised, and strengths of the range of data collection methods employed.

Conclusion: Authors need to write a brief conclusion separately.

Thank you for the great work.

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Reviewer #1: Yes: Sunethra Perera

Reviewer #2: No

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Submitted filename: Plos review_7 Jan.docx

PONE-D-21-18015R1Bottleneck Analysis of Maternal and Newborn Health Services in Hard-to-reach areas of Bangladesh using ‘TANAHASHI’ Framework’: an explanatory mixed method studyPLOS ONE

Dear Dr. Mohiuddin Ahsanul Kabir Chowdhury,

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 May 14 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.

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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.

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We look forward to receiving your revised manuscript.

Kind regards,

Gouranga Lal Dasvarma, PhD

Academic Editor

PLOS ONE

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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:

Dear Dr. Mohiuddin Ahsanul Kabir Chowdhury,

• It appears you have changed your affiliation to Asian University 10 for Women, Chittagong, Bangladesh since submitting the manuscript. The manuscript, if published will bear the name of the institute of your current affiliation, but you should acknowledge (in the acknowledgement section) that the work on the manuscript/paper was carried when you were working at the James P Grant School of Public Health, BRAC University, Dhaka, Bangladesh. The same comment applies to your c-author S M Monirul Ahasan, who has changed his affiliation from International Rescue Committee to World Vision.

• A thorough, professional editing for English is required before the manuscript is accepted for publishing. A few examples are given below, but have the entire manuscript edited.

Line 70 of Manuscript Revision#1: “…mortality rates have been increased…”. Delete the word “been”. Or, do you mean “…mortality rates will have increased…”?

Line 71: Re “neo-normal era”. How is this neo-normal era when Covid-19 is still raging?

Line 75: “…health services by poor population…”. Should be “…by the poor population…”

Reviewer#1:

• Table 3 (previously Table 1) shows the results for 29 facilities, but you selected 36 villages. Did all the selected villages not have a facility?

• Line 73-74: Though the authors assumed that failure in health system in HtR areas, it is not clear how the health situation was measured/ justifications are not clear (i.e., high MMR, NMR in HtR etc.,)

Academic Editor: Your response does not address the reviewer’s comments entirely. Please re-read the comments and address them appropriately.

Reviewer#2:

• “Can authors talk about the gaps in health service coverage nationally vs in HtR areas, both for key maternal and neonatal interventions?”

Academic Editor: Your response only states that gaps exist. But please state the extent of the gaps by stating respective figures.

• “Materials and methods”:

“Did the authors go for 100% of the villages in the 4 HtR district? It is not clear”.

Response: We did not go for 100% villages as mentioned in the sampling section where we mentioned that we visited randomly selected 36 villages of these districts. [Line 120-121]

Academic Editor: Please state why you decided to take 36 villages.

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Reviewers' comments:

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Bottleneck Analysis of Maternal and Newborn Health Services in Hard-to-reach areas of Bangladesh using ‘TANAHASHI’ Framework’: an explanatory mixed method study

PONE-D-21-18015R2

Dear Dr. Mohiuddin Ahsanul Kabir Chowdhury,

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.

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Kind regards,

Gouranga Lal Dasvarma, PhD

Academic Editor

PLOS ONE

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