Spatial distribution and predictive factors of antenatal care in Burundi: A spatial and multilevel baseline analysis for the third burundian demographic and health survey

Emmanuel Barankanira; Arnaud Iradukunda; Nestor Ntakaburimvo; Willy Ahishakiye; Jean Claude Nsavyimana; Emmanuel Nene Odjidja

doi:10.1371/journal.pone.0272897

Peer Review History

Original SubmissionJuly 28, 2022
20 Sep 2022 Decision Letter - Mary Hamer Hodges, Editor PONE-D-22-21281Spatial distribution and predictive factors of antenatal care in Burundi: a multilevel analysis and spatial baseline for the third Burundian demographic health surveyPLOS ONE Dear Dr. Iradukunda, 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 respond to each comment made in detail. ============================== Please submit your revised manuscript by Nov 04 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. 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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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: 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. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for giving me this chance to review this article. The manuscript is important and has merits. However, I have the following issues to be addressed by the authors; 1) Which BDHS did you exactly used? You said the second in the method part of the abstract section and the third in other sections. Please, be consistent on the phase of BDHS you used for this manuscript. 2) In the background of the abstract section you wrote this “Therefore, this study sought to understand the spatial distribution and predictive factors of antenatal care (ANC) among women aged 15 to 49 years with a medical doctor in Burundi.” The word understand, bolded one, is not measurable or it is not action verb. Hence, replace it by the other appropriate action verb. 3) To be in line with the PLOS ONE’s guideline, replace the word “background” by the word “Introduction”. Do this both in the abstract and in the Introduction section of the manuscript. 4) In the method section, you wrote it “Methods”. However, it is not in accordance with the PLOS ONE’s guideline. Replace it by “Materials and Methods”. 5) In the “study variables” part you didn’t write about the community level variables. It is necessary to include these variables, for you have done multilevel analysis. 6) Write about the methodology of multilevel analysis, the parameters and the number of models fitted in the data management and analysis part. 7) There are grammatical errors which need to be corrected. Example in the result section under the socio-demographic subsection you wrote this “The proportion of women who consults”….. make the verb consults plural i.e “The proportion of women who consult”…. 8) Avoid italicizing words in some sections. Example in the Spatial distribution of ANC prevalence part of the result section you wrote the “figure below” in italics form. 9) In the predictive factors part of the result section you wrote this “Table4 gives the odds ratio (OR), the 95% confidence interval (CI) and the p-value associated with the explanatory variables when “antenatal care” with a medical doctor is the dependent variable .” The sentence doesn’t give any sense. Please, rewrite it! 10) You wrote unnecessary details about table 4. It seems discussion. Avoid explaining the result in the result section. You need simply present the table. Then, explain and discuss it in the discussion section. Reviewer #2: The manuscript is technically sound and also the data supports the conclusion. Correct statistical analysis was used. The authors made all data underlying the findings in their manuscript fully available with out restriction. Reviewer #3: I applaud the authors for adding significantly to the body of knowledge to improve maternal health in low-and-middle-income countries. Below I outline my comments Introduction The authors did not provide any background knowledge of maternal health in Burundi. For example, What are the current ANC uptake rates in Burundi? What are the underlying factors and determinants of ANC uptake in Burundi? What is the health care environment in Burundi? How does Burundi compare with other African countries? Methods What is “forimilar?” I am unsure why the second Burundi DHS was used instead of the third. Please clarify and report the year the Burundi DHS was collected. Please expand on the study variables. Report the variables alongside their multi-levels (individual, household, etc.). Without referencing the tables, readers should be able to tell what variables were measured. Create subheadings, so the readers understand what and how it was done. See https://doi.org/10.3390/healthcare9101389, for example. Results Because the authors did not describe the variables in detail, it isn't easy to understand the result section. For example, the results discuss the prevalence in different regions. However, because this information was not introduced earlier, it becomes challenging to contextualize the results. The authors report ORs of below 1.00 as an increase in likelihood. Check the paragraphs below in “Table 4. Univariate analysis of associated factors with ANC.” Please rewrite the result section and the method section, so it flows. Describe the methodological sequence in the method section and report the same in the result section. Discussion The discussion should be contextualized to aid understanding. For example, it appears that the Bujumbura region is a high-income region, but without any context, this information can only be assumed. The authors should consider the international readership of this journal in their discussion. When discussing the spatial results, I recommend the authors use generally acceptable languages. For example, “we found a high prevalence of ANC uptake in urban areas, such as Bujumbura.” The paragraphs beginning with “The use of antenatal care….and antenatal care in a health center is a sign…” seems isolated and do not flow with the overall discussion and result. Which of the finding supports this paragraph? Is this sentence reporting a finding from this current study “Due to lack of knowledge, young women make less use of maternal health services and consult late and then less than four times”? Lastly, the authors should use an editing service to correct punctuation, spacing, and other minor grammatical errors. ****** 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: Yes: Denekew Tenaw Anley Reviewer #2: No 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. 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Revision 1
15 Nov 2022 Author Response Dear Editor, Thank you for the further comments. Below is an overview of changes made to the manuscript and rebuttals (where applicable) Response to reviewer comments Peer Reviewer 1 Reviewer #1: Thank you for giving me this chance to review this article. The manuscript is important and has merits. However, I have the following issues to be addressed by the authors; 1) Which BDHS did you exactly used? You said the second in the method part of the abstract section and the third in other sections. Please, be consistent on the phase of BDHS you used for this manuscript. Response 1: Thank you for your comments. We used the second demographic health demographic dataset. As we plan a similar study using the third DHS dataset, the most recent in Burundi, we used the second in order to have results of Burundi second DHS as baseline for the DHS the third data set. Moreover, no spatial analysis focused prediction of ANC prevalence in unsampled areas have been conducted on Burundi DHS dataset. 2) In the background of the abstract section you wrote this “Therefore, this study sought to understand the spatial distribution and predictive factors of antenatal care (ANC) among women aged 15 to 49 years with a medical doctor in Burundi.” The word understand, bolded one, is not measurable or it is not action verb. Hence, replace it by the other appropriate action verb. Response 2: Thank you for the comments. Changes have been made in the main manuscript. 3) To be in line with the PLOS ONE’s guideline, replace the word “background” by the word “Introduction”. Do this both in the abstract and in the Introduction section of the manuscript. Response 3: Thank you for the comments. Changes have been made in the main manuscript. 4) In the method section, you wrote it “Methods”. However, it is not in accordance with the PLOS ONE’s guideline. Replace it by “Materials and Methods”. Response 4: Thank you for the comments. Change have been made in the main manuscript. 5) In the “study variables” part you didn’t write about the community level variables. It is necessary to include these variables, for you have done multilevel analysis. Response 5 : Thank you for the comment. Change have been made from title to the whole content of manuscript. We replaced “multilevel analysis” with “multivariate analysis.” 6) Write about the methodology of multilevel analysis, the parameters and the number of models fitted in the data management and analysis part. Response 6: Thank you for the comment. Changes have been made. 7) There are grammatical errors which need to be corrected. Example in the result section under the socio-demographic subsection you wrote this “The proportion of women who consults”….. make the verb consults plural i.e “The proportion of women who consult”…. Response 7: Thank you for the comment. Change is made in the main manuscript. 8) Avoid italicizing words in some sections. Example in the spatial distribution of ANC prevalence part of the result section you wrote the “figure below” in italics form. Response 8: Thank you for the comment. Change is made in the main manuscript. 9) In the predictive factors part of the result section you wrote this “Table4 gives the odds ratio (OR), the 95% confidence interval (CI) and the p-value associated with the explanatory variables when “antenatal care” with a medical doctor is the dependent variable.” The sentence doesn’t give any sense. Please, rewrite it! Response 9: Thank you for the comment. Change is made in the main manuscript. 10) You wrote unnecessary details about table 4. It seems discussion. Avoid explaining the result in the result section. You need simply present the table. Then, explain and discuss it in the discussion section. Response 10: Thank you for the comment. Change is made in the main manuscript. Peer Reviewer 2 Reviewer #2: The manuscript is technically sound and also the data supports the conclusion. Correct statistical analysis was used. The authors made all data underlying the findings in their manuscript fully available without restriction Response: Thank you for the comments. We really appreciate it. Peer Reviewer 3 Reviewer #3: I applaud the authors for adding significantly to the body of knowledge to improve maternal health in low-and-middle-income countries. Below I outline my comments Introduction The authors did not provide any background knowledge of maternal health in Burundi. For example, What are the current ANC uptake rates in Burundi? What are the underlying factors and determinants of ANC uptake in Burundi? What is the health care environment in Burundi? How does Burundi compare with other African countries? Response: Thank you for your comments. There is a scarity of published evidence from East African countries (especially from Burundi and South Soudan), maternal health service utilization remains persistently low. The health care environment in Burundi is that Burundi experienced disparity in health care services access, including maternal services, due to the low number of health centers and health care delivers, particularly in rural areas. More details have been made in the main manuscript: page 2: L19-25. Methods What is “forimilar?” Response: Thank you for the comment. We correct this grammatical error by “for similar” I am unsure why the second Burundi DHS was used instead of the third. Please clarify and report the year the Burundi DHS was collected. Please expand on the study variables. Report the variables alongside their multi-levels (individual, household, etc.). Without referencing the tables, readers should be able to tell what variables were measured. Create subheadings, so the readers understand what and how it was done. See https://doi.org/10.3390/healthcare9101389, for example. Response: Thank you for your comments. We clearly mentioned all the reasons to use 2010 Burundi DHS instead the third Burundi DHS in the Materials and Methods section of this study (page 2:L40-45. This one was carried out in 2010. Results Because the authors did not describe the variables in detail, it isn't easy to understand the result section. For example, the results discuss the prevalence in different regions. However, because this information was not introduced earlier, it becomes challenging to contextualize the results. The authors report ORs of below 1.00 as an increase in likelihood. Check the paragraphs below in “Table 4. Univariate analysis of associated factors with ANC.” Please rewrite the result section and the method section, so it flows. Describe the methodological sequence in the method section and report the same in the result section. Response: Thank you for your comments. Changes have been made in the main manuscript: -We mentioned all variables categories. We also created two variables’ group of individual and community level. -For the early introduction of the prevalence in different regions, a full description was already in the material and methods section -Results and methods sections are now rewritten: Discussion The discussion should be contextualized to aid understanding. For example, it appears that the Bujumbura region is a high-income region, but without any context, this information can only be assumed. The authors should consider the international readership of this journal in their discussion. When discussing the spatial results, I recommend the authors use generally acceptable languages. For example, “we found a high prevalence of ANC uptake in urban areas, such as Bujumbura.” The paragraphs beginning with “The use of antenatal care….and antenatal care in a health center is a sign…” seems isolated and do not flow with the overall discussion and result. Which of the finding supports this paragraph? Is this sentence reporting a finding from this current study “Due to lack of knowledge, young women make less use of maternal health services and consult late and then less than four times”? Lastly, the authors should use an editing service to correct punctuation, spacing, and other minor grammatical errors. Response: Thank you for your wonderful comments. We reviewed the whole discussion section. We rephrase all these sentences.________________________________________ Title:- Spatial distribution and predictive factors of antenatal care in Burundi: a multilevel analysis and spatial baseline for the third Burundian demographic health survey #Accept with Major revision General comments The entire section of the manuscript contained missing/incomplete words. Response: Thank you for the comment. We revised all missing and incomplete words. Abstract The methods used to present findings (table, graphs, text, etc.) should be indicated in the abstract section. Response: Thank you for the comment. Changes have been made in the main manuscript. The authors should describe the analysis techniques used to determine the determinant factors for ANC. The authors should describe the method used to report the effect size as well as the level of significance in the abstract section Response: Thank you for the comment. Analysis techniques and methods used to determine the size effect have described. Background: The authors should revise the background section Methods. Response: Thank you for the comment. The background is revised. In the title you have stated the analysis as a multilevel analysis and spatial baseline for the third Burundian demographic health survey, but I have not seen any evidence in the method as well as in the result section that you have done a multilevel analysis, what was your intention to say a multilevel analysis? Response: Thank you for the comment. The multilevel analysis have been stated in the methods section and done in the results section. In the method section, study variables part, the authors didn’t state about their dependent variable. Also the independent variables from previous studies should have to be merged and presented in a single paragraph. Response: Thank you for the comment. The dependent variable is stated on Page 1.L34-35. Also, we considered both individual- and household-level factors in our study based on theoretical and practical significance and the availability of the variables in the dataset. Results In the result section, on the sub section of Predictive factors of antenatal care, the authors have stated ANC with a medical doctor as a dependent variable. As per the DHS guide, women receiving antenatal care from a skilled provider for the most recent birth will be considered as having antenatal care. What is the reason behind choosing only ANC with a medical doctor? Response: Thank you for the comment. According for previous DHS reports (https://dhsprogram.com/pubs/pdf/FR253/FR253.pdf ), most of women attended antenatal clinics, but in many cases, during these clinics, essential tests are not performed and women do not receive important information about the risks of pregnancy. Those crucial information are supposed to be given by high qualified healthcare providers (a Medical doctors) prompt us to consider ANC with a Medical doctor In the result section, on the sub section of Predictive factors of antenatal care, replace the word univariate analysis by univariable analysis. Also replace the word multivariate analysis by multivariable analysis. Response: Thank you for the comment. Changes have been made in the main manuscript. In the result section, education level and the delivery place were reported as a significant predictor of ANC. unless it is a previous delivery, how place of delivery affects ANC utilization? Response: Thank you for the comment. With delivery place variable, we mean here that the previous delivery place(s) play (s) a significant role in the ANC use and delivery place for the future pregnancy. Better to present the spatial distribution in a scientific way and report important results. For example, rather than doing the “Spatial distribution of health centers in Burundi” give emphasis for your outcome variable. Response: Thank you for the comment. Spatial distribution of health centers in Burundi was presented jointly with the ration of population per health center. The disparities in term of HC should be one of the determinants of insufficient ANC use. Moreover, as we our outcome is about to have ANC with medical doctor. These medical doctors not found anywhere, but at their respective health Centers. Moreover we gave emphasis on our outcome variable in the results and discussion section. https://doi.org/10.1371/journal.pone.0272897.r002
26 Dec 2022 Decision Letter - Mary Hamer Hodges, Editor Spatial Distribution and Predictive Factors of Antenatal Care in Burundi: A Spatial and Multilevel Baseline Analysis for the Third Burundian Demographic and Health Survey PONE-D-22-21281R1 Dear Dr. % arnaud Iradukunda%, 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, Mary Hamer Hodges, MBBS MRCP DSc 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 #1: All comments have been addressed Reviewer #3: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #3: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #3: (No Response) ****** 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 #3: (No Response) ****** 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 #3: (No Response) ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: (No Response) Reviewer #3: (No Response) ****** 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: Yes: Denekew Tenaw Anley Reviewer #3: No ******** Attachments Attachment Submitted filename: My comments.docx https://doi.org/10.1371/journal.pone.0272897.r003
Formally Accepted
3 Jan 2023 Acceptance Letter - Mary Hamer Hodges, Editor PONE-D-22-21281R1 Spatial Distribution and Predictive Factors of Antenatal Care in Burundi: A Spatial and Multilevel Baseline Analysis for the Third Burundian Demographic and Health Survey. Dear Dr. IRADUKUNDA: 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 Prof. Mary Hamer Hodges Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0272897.r004

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