PONE-D-22-25845Reduction in maternal mortality ratio varies by district in Sidama Regional State, southern Ethiopia: Estimates by cross-sectional studies using the sisterhood method and a household survey of pregnancy and birth outcomesPLOS ONE

Dear Dr.Aschenaki Zerihun

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Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #1: Reduction in maternal mortality ratio varies by district in Sidama Regional State, southern Ethiopia: Estimates by cross-sectional studies using the sisterhood method and a household survey of pregnancy and birth outcomes

Abstract section

1.Under background section you said that “Maternal mortality studies conducted at national level do not provide estimates useful for monitoring maternal mortality at lower administrative level.” Do you think this is the reason to conduct this study? I don’t think? The gap of study is not in line with the aim, please check it?

2.Under method section: The study was conducted with men and women aged 15- 27 49 years, why you include men? Under this section it is better to add how you analysis the data?

3.How many woreads were included in your study? Do your intention to make comparison between remote district and town admiration? What do you mean remote district? How many district were remote? What is the implication of this comparison? Why you did not compare urban and rural district?

4.Under conclusion section: “The high MMR with district level variations” How many district were compare to show variations?

Introduction

1.Line 49-50: “Despite these achievements, in 2017, there were an estimated 14000 maternal deaths with corresponding maternal mortality ratio (MMR) 401 per 100,000 live births (LB). From where you get this, I did not see any references? Also you reported 2017 which is old there are a lot of change in Ethiopia after this period, why you show the updated figures?

2.From line 63 to 73: you describe about indirect sisterhood method to measure maternal mortality. What make this study from previously conducted study? Please clear show as the gap what this study will add?

Method section

3.Line 114-115: you said that “Thirdly, from each kebele, we sampled 6 limatbudin and finally selected 37 households from each limatbudin” why 6 limatbudin? Why 37 households? Add references?

4.Sample size: your calculated sample size after adding 10% non-responses was 14,300 respondents. But, you assume 8880 household are sufficient? What was the base for your assumptions? For me this is difficult to accept your assumptions?

5.In line 174 : you said that 2024, what is 2024 indicated? Do you mean the age between 20 to 24? Check it

6.Why you did not include those aged between 10 to 14 years?

7.How we know Aroresa district is the remote district, what about Aleta Chuko? Daela?

8.Generalizability issues? Can we make generalizability for urban and rural districts?

Reviewer #2: Review Report

I would like to thank the authors for submitting their manuscript to PLOS ONE and for the opportunity to review it.

The manuscript presents the results of population based cross-sectional study assessing the variations in reduction of maternal mortality ratio in Sidama Regional State, southern Ethiopia. The manuscript is well written and comprehensible. Adequate statistical methods were used. These are my further comments/suggestions:

•Key words were missing from the abstract of the paper, although included in the system.

•The introduction section is well written but only 12 studies were reviewed, the authors should think of reviewing various global and local studies.

•The description of the study setting lacks some important factors of the region which can be related to MM like the topography, literacy status, health service coverage....

•Minor editorial issue in page 6 line number 103, remove the s from the word appropriates

•What was done if any of the selected household lacks an eligible participant? It should be written.

•The reason why the authors selected Diploma level teachers as data collectors is not clear for me; would it have been better if they selected health professionals?

•Number of men and women study participants reported in the result description and reported in the table 1 were different? Needs revision.

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Reviewer #1: Yes: Negussie Boti Sidamo

Reviewer #2: No

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Reduction in maternal mortality ratio varies by district in Sidama National Regional State, southern Ethiopia: Estimates by cross-sectional studies using the sisterhood method and a household survey of pregnancy and birth outcomes

PONE-D-22-25845R1

Dear Dr. Zerihun,

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,

Anteneh Fikrie, MPH

Academic Editor

PLOS ONE

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