An assessment of the quality of antenatal care and pregnancy outcomes in a tertiary hospital in Ghana

Seth Amponsah-Tabi; Edward T. Dassah; Gerald O. Asubonteng; Frank Ankobea; John J. K. Annan; Ebenezer Senu; Stephen Opoku; Ebenezer Opoku; Henry S. Opare-Addo

doi:10.1371/journal.pone.0275933

Peer Review History

Original SubmissionMarch 14, 2022
15 Jul 2022 Decision Letter - Muhammad Tarek Abdel Ghafar, Editor PONE-D-22-07633An assessment of the quality of antenatal care and pregnancy outcomes in a tertiary hospital in GhanaPLOS ONE Dear Dr. Amponsah-Tabi, 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 Aug 29 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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In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. 4. Please amend either the abstract on the online submission form (via Edit Submission) or the abstract in the manuscript so that they are identical. 5. 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. [Note: HTML markup is below. Please do not edit.] 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes Reviewer #3: I Don't Know Reviewer #4: No ****** 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 ****** 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 ****** 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: ABSTRACT: Line 33 should read---structured questionnaires as well as a review of their medical records. METHODS: In line 166, the authors should specify the language/languages used to interview the patients and in line 188, the type of consent obtained from them. RESULTS: In page 11, table 1, under the variable age -the interval of the ages should be uniform. In the text the authors should explain what they mean by pre-eclampsia with severe features. RFERENCES: Numbers 9 and 11 do not seem complete Reviewer #2: RESULTS: The results were in relevant graphics and tables. Table 1 (Attachment): it is not clear if this table reflects the total scores or number of participants as it concerns malaria prevention and maternal education; the sum of the figures in these columns are more than 950 ( the total number of participants). This will need to be reviewed as the criteria for scoring are clearly stated and no single person can have more than one score. DISCUSSION: This section is well written. However, the authors did not emphasize the importance of malaria infection as a cause of anaemia in pregnancy in the tropics. The author in concluding advised the Government to ensure that pregnant women receive high quality ANC through health education and care but did not mention the training and retraining of health workers, and improvement of health facilities Reviewer #3: This article provides good insight to the poor quality of antenatal care in the given area. However there needs addition of more details in the methodology. Like what were the recommended interventions during ANC visits? What were the investigations or supplements given? Though it maybe written in the additional file it is better to add main interventions in the methodology. Also, was the developed tool validated and pretested? In the results section, table 4 shows total 31 still births but the total of poor and average ANC care does not cumulate to the same. Please check the numbers. I would also like to know why were other outcomes not measured like preterm birth, which depends a lot on antenatal care. Knowing the number of preterm babies amongst the LBWs would be beneficial. Reviewer #4: It seems that this article may reflect the actual circumstance in sub-Saharan Africa. Data collection has been from KATH, second largest hospital in Ghana, also seems high reliability. To prevent the maternal and neonatal serious complications, ANC is well-known to be beneficial. However, the increase of ANC coverage has not correlated to the decrease in number of maternal and fetal death. This article has written well with adequate discussions. However, some uncertain points remain. Please correct or answer the points as follows; Minor revision: In Table 4, the number of stillbirth in average and poor quality of ANC groups suggest 26 and 23, respectively. However, the total number suggested 34. You should re-count or check the actual number. Major revision: #1. Despite the number of ANC attendance is around 15,000 yearly, only 950 participants enter the study. The observation period suggested 5 months, so we suppose the major ANC attendance has been ruled out in some reasons. If it is true, this must be the fundamental problem. #2. The number of participants seems to be full of variety, e.g. age, occupation, education level and gravity. In Table 2, it remains unknown that aORs has actually calculated considering the number of people constitution shown in Table 1. If possible, I would like you to describe the additional comment. #3. The score of ANC and adverse mother or fetal outcome seems to be correlated. However, the scoring system of ANC seems to remains several concerns to be improved. For example, the Hemoglobin (HB) analysis suggests more than twice with normal result and low HB level with intervention are both 2 points. However, in late preterm period, we often experience that many pregnant women with iron supplementation still remain anemic status. Several other items also should validate the equivalency of points. ****** 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: Yes: Shreyashi Aryal 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: PLOS ONE article reviewed COMMENTS ON ARTICLE.docx https://doi.org/10.1371/journal.pone.0275933.r001
Revision 1
4 Sep 2022 Author Response REVIEWER 1 #1: ABSTRACT: Line 33 should read---structured questionnaires as well as a review of their medical records. Response: Thanks for drawing our attention. Correction carried out in revised manuscript METHODS: In line 166, the authors should specify the language/languages used to interview the patients and in line 188, the type of consent obtained from them Response: a. Interview was conducted in English language and Asante Twi (most common local dialect) as depicted in the revised manuscript. b. Written consent was obtained before enrolling each participant RESULTS: In page 11, table 1, under the variable age -the interval of the ages should be uniform. Response: The anomaly is well noted. Necessary changes have been effected in the revised manuscript. In the text the authors should explain what they mean by pre-eclampsia with severe features. Response: pre-eclampsia with severe features has been explained in the revised manuscript. REFERENCES: Numbers 9 and 11 do not seem complete Response: Thanks for drawing our attention. The references have been completed in the revised manuscript. REVIEWER 2 Q1: Table 1 (Attachment): it is not clear if this table reflects the total scores or number of participants as it concerns malaria prevention and maternal education; the sum of the figures in these columns are more than 950 (the total number of participants). This will need to be reviewed as the criteria for scoring are clearly stated and no single person can have more than one score. Response: The attached table depicts the proportions or percentages of participants who were recipients of a particular intervention. This was the not the main scoring criteria but gives information on the availability of these interventions as some quality assessment from literature looked at these percentages to connote quality care. The figures in the column can be more than the total number of participants. Q2: DISCUSSION: This section is well written. However, the authors did not emphasize the importance of malaria infection as a cause of anaemia in pregnancy in the tropics. The author in concluding advised the Government to ensure that pregnant women receive high quality ANC through health education and care but did not mention the training and retraining of health workers, and improvement of health facilities Response: (a). Thanks for the prompting. Malaria as an important cause of anaemia in pregnancy has been added to the discussion. (b). Training and retraining of health workers have been discussed in the revised manuscript. REVIEWER 3 Q1. Reviewer #3: This article provides good insight to the poor quality of antenatal care in the given area. However there needs addition of more details in the methodology. Like what were the recommended interventions during ANC visits? What were the investigations or supplements given? Though it may be written in the additional file it is better to add main interventions in the methodology. Response: Details of recommended interventions have been added to the methodology. Q2. Also, was the developed tool validated and pretested? Response: The tool was developed from a combination of tools used in Europe and Africa. Pretesting was done. Q3. In the results section, table 4 shows total 31 still births but the total of poor and average ANC care does not cumulate to the same. Please check the numbers. Response: The anomaly has been corrected. Thanks for notification. Q4. I would also like to know why were other outcomes not measured like preterm birth, which depends a lot on antenatal care. Knowing the number of preterm babies amongst the LBWs would be beneficial Response: I agree with the submission. The study however did not collect data on those that were preterm or full term. This may be a limitation. Thank you. REVIEWER 4 MINOR REVISION In Table 4, the number of stillbirths in average and poor quality of ANC groups suggest 26 and 23, respectively. However, the total number suggested 34. You should re-count or check the actual number Response: The error in table 4 concerning the number of stillbirths has been noticed and corrected. Thanks for the notification. MAJOR REVISION #1. Despite the number of ANC attendance is around 15,000 yearly, only 950 participants enter the study. The observation period suggested 5 months, so we suppose the major ANC attendance has been ruled out in some reasons. If it is true, this must be the fundamental problem Response: The number of participants enrolled into the study was based on the estimated sample size which has adequate power to achieve the desired effect. During selection, the 950 participants were systematically sampled minimizing selection bias. #2. The number of participants seems to be full of variety, e.g. age, occupation, education level and gravity. In Table 2, it remains unknown that aORs has actually calculated considering the number of people constitution shown in Table 1. If possible, I would like you to describe the additional comment Response: Thanks for the comment. Table 1 shows the sociodemographic and reproductive health factors of all study participants. Table 2 however shows good quality ANC which is the outcome of interest. The odd ratios were calculated based on the number of clients who had good quality care. #3. The score of ANC and adverse mother or fetal outcome seems to be correlated. However, the scoring system of ANC seems to remains several concerns to be improved. For example, the Hemoglobin (HB) analysis suggests more than twice with normal result and low HB level with intervention are both 2 points. However, in late preterm period, we often experience that many pregnant women with iron supplementation still remain anemic status. Several other items also should validate the equivalency of points. Response: There is no universal quality scoring system for ANC. This is an attempt to define and score quality based on national and international standards. There may however be portions of this scoring system that can be improved based on further recommendations and studies. Thanks for the notification. Attachments Attachment Submitted filename: ANC QUALITY.docx https://doi.org/10.1371/journal.pone.0275933.r002
27 Sep 2022 Decision Letter - Muhammad Tarek Abdel Ghafar, Editor An assessment of the quality of antenatal care and pregnancy outcomes in a tertiary hospital in Ghana PONE-D-22-07633R1 Dear Dr. Amponsah-Tabi, 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, Muhammad Tarek Abdel Ghafar, M.D 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 #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: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know 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 #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 #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: (No Response) Reviewer #4: The revised manuscript seems well improved. The response comments to reviewers are also precise and polite. Thank you for the committed works. ****** 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 #4: No ******** https://doi.org/10.1371/journal.pone.0275933.r003
Formally Accepted
3 Oct 2022 Acceptance Letter - Muhammad Tarek Abdel Ghafar, Editor PONE-D-22-07633R1 An assessment of the quality of antenatal care and pregnancy outcomes in a tertiary hospital in Ghana Dear Dr. Amponsah-Tabi: 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 Muhammad Tarek Abdel Ghafar Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0275933.r004

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