PONE-D-22-27435Barriers to accessing mother, new-born and child health services in urban Gambia during COVID-19: An interview-based qualitative study.PLOS ONE

Dear Dr. Bah,

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PLOS ONE

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Additional Editor Comments:

Relevant study that provides an insight on the perspective of women and healthcare workers on the indirect impact of COVID-19 and the mitigation measures on availability and use of antenatal and immunization services in the Gambia. Major edit

Comments

1. Title: Barriers to accessing mother, new-born and child health services in urban Gambia during COVID-19: An interview-based qualitative study

- Be clear on the objective of the study and be consistent throughout from title till conclusion

MNCH vs antenatal and immunization, these terms are not interchangeable. For one, MNCH includes curative services.

- ‘New-born’ replace with ‘newborn’ throughout

- ‘barriers to accessing...’ or ‘factors that influenced utilization of…’

- “The Gambia” versus “the Gambia” versus “Gambia” – choose one and be consistent

2. Abstract

- Introduction: Good to avoid terms that are not supported by data “least developed…, least researched…” , low-income country with limited research on ..

- Results: ‘.. relating to factors that were responsible for the reduction in the uptake of antenatal and immunisation services’ since the study did not measure if there was reduction or not of antenatal and immunization service uptake, a better phrase could be ‘… factors that influenced uptake (use) of antenatal and immunization services...’

3. Introduction

4. Methods

Data collection:

- Sample size, why 17 mothers? Did you expect saturation by then? Most were from the 2 hospitals and not so much from the 3rd public hospital and hardly any from the private practice. Was that intended or were you unable to get participants? In either case – this should be reflected in the discussion as limitation, and reasons why .

- How did you classify mothers who regularly versus not regularly used services? Were they asked different questions? Were there unique perspective ..? were you trying to see change from their norm in terms of use of service?

- Who conducted the interviews (were the interviewers trained, male/female, health worker/not hw)? Possible social desirability bias given that the interview occurred inside a health facility

- How long did the interview take per person?

- Were the tool used for interview translated/back translated or ? dedicated translator or were the authors/interviewers fluent in all three languages ?

5. Results

- ‘claimed’ has negative undertone suggest using words like ‘reported’ throughout

- ‘Fear of being quarantined’ is this similar to being asked to stay at home and to social distance. Good to differentiate and clearly state.

- Given your small sample size per health facility, it is possible that the respondents might be identified by health facility name. We often advise to not include name of hospital or say hospital 1 or 2 to avoid possible identification of interviewee and breach of confidentiality.

- Some of the interviewees were describing what they perceive was going on in their community – good to say that in your discussion section some of your findings were also the interviewees perspective of what was going on in their community and not a personal experience.

o “There were several people in my community who stopped taking their children for immunisation during the pandemic..”.

- Reference “WhatsApp”

- “misleading information” or “rumors” – trying to understanding if the respondents defined the information as “misleading’ or “rumor” ? as some of the health facilities were closed as described under paragraph Scaling down of MNCH services.

6. Discussion

- Hard to follow flow of this section. Suggest restructuring: main/key finding, interpretation of your findings/reflection of findings as it relates to other African and non-African studies, implications of the findings, strength/limitations of study, recommendation (what could be done differently in the future based on your findings).

- First sentence

o Given the small sample and lack of generalizability in Gambia suggest editing to say gives insight in Urban areas of Gambia.

- Second sentence

o ‘Factors responsible for reduction’… suggest rewording… the study does not measure reduction but rather factors that influenced decision to use or not use services.

- Line 8

o “physical barriers” .. suggest to say barriers

- ‘small” country as compared to ?

- Limitations: I would also think these were limitations

o The small sample size , unclear if saturation was researched

o The sampling method, selection bias as the pool of patients was drawn from hospital and does not include those who did not seek care at all.

o Urban centric as sample was from urban areas.

o Hence, findings not generalizable to Gambia but provides insight for the country.

7. Figure 1. Missing title of Figure. Not sure it adds value. Is it trying to capture framework or key findings and needs language edits “mistreatment by ..”

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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: Yes

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

Reviewer #1: Yes

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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: Yes

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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: This study qualitatively assesses barriers to MNCH in two regions of the Gambia during the COVID-19 pandemic through summer 2021. Participants provide both current and former barriers. This study may be of great interest to facilities and governments preparing for future surges of COVID-19 and new pandemics as well as facilities trying to establish pre-COVID-19 levels of care. In addition to the Gambia, findings of this study may be relevant to other low income countries, particularly in sub-saharan Africa.

Overall, the methods and findings of this study are clear. This study would benefit from some edits to tables so they can be understood without referencing the paper itself and some relatively minor clarifications in-text.

Intro comments

• “since the health of women and children is usually disproportionally affected during pandemics and conflicts” (page 2) I have no doubt this statement is true but was wondering if you could cite evidence for this statement?

• Not mandatory but may be helpful for the reader- “The country has an under-five mortality rate of 56 per 1,000 live births, an infant mortality rate of 42 per 1,000 live births and a neonatal mortality rate of 29 per 1,000 live births [26]. Concerning maternal deaths, the maternal mortality rate is 289 per 100,000 live births [26]” (page 2) do you have any global estimates that you could compare to so the reader doesn’t have to look that up themselves while reading?

• Add when data in table 1 are from to the title of the table (I assume they’re from 2019 since they match numbers from 2019 in introduction section). I suggest to also reference table 1 when speaking about 2019 indicators

• “The COVID-19 pandemic, which was declared a public health emergency in January 2020, reached the Gambia on 17 March 2020” (page 3) I suggest re-wording this to say that COVID-19 was first detected on 17 March 2020 since it may have been circulating in the Gambia before this

• Edits on table 2

1- Suggest re-naming table 2 “COVID-19 Cases in the Gambia Over Time” or something similar so we know cases in your heading are in fact cases of COVID-19

2- Make sure that all headings indicate that these are total #s of cases, deaths, etc.

3- Add a border to separate October to December 2020 and January to March 2021

4- In writing you state “by June 2020, only 48 new cases had been detected” (page 3) but table 2 says there were 45 cases April-June 2020, why are these numbers different?

5- Is this total cases in all of the Gambia or part of the Gambia, and is this all people in the Gambia or just the population of interest. Consider adding a footnote in your table to specify all of this. Is this limited to confirmed cases and is a confirmed case by PCR test only or antigen and PCR here?

• “evidence collected thus far suggests that the uptake of 4 antenatal and immunisation services declined considerably during the first wave of the pandemic” (pages 3-4). When did the first wave end in the Gambia?

Materials and methods comments

•What is the catchment area of these facilities? Are only people from the region of the facility or is it common for people in rural locations and outside of the region to visit one of these hospitals?

• Table 3:

1- Merge the two Kanifing LGA sub-headers so it looks like the Brikama sub-header

2- Center the #s in the respective cells as is done with prior tables.

3- Highlight the second total column. Also suggest to label them differently so they can be easily distinguished to someone reading table without the accompanying methods section.

• “Following this, to ensure the objectivity of the findings, the two researchers worked closely together in reviewing and defining themes” (page 5) so did both reviewers code everything and compare or did each reviewer work on something different and discuss? Please clarify.

Results:

• Results are presented in a cohesive manner- were there any instances where a single health facility or type (e.g. private vs public), or were all of these themes corroborated in all 4 facilities? E.g. was there a lack of PPE and meds in all facililies or just some? Public vs private differences may be noteworthy since public facilities in some low income settings are known to be more under-resourced

Discussion

• From my understanding, another limitation is not knowing how mothers and healthcare workers impressions on accessing MNCH before COVID-19. Some of these issues you discovered may be new, but I am left curious if some existed before the pandemic or were relevant during other outbreaks. I do see you cited Ebola also playing a role in misinformation, but I am interested if Ebola had implications on other factors too… may not be possible to know, so would acknowledge what you don’t know about other outbreaks in limitations.

Conclusions

• “as well as to the need to counter misinformation” (page 13) would also add the need to mitigate fears of the public since this was a big theme of yours.

• Any more specific thoughts on what the facilities and government can do if there’s a future uptick or different pandemic? E.g. maybe recommend things like stockpiling extra PPE, planning for essential med logistics in a pandemic, etc.

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Reviewer #1: No

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PONE-D-22-27435R1

Factors that influenced utilization of antenatal and immunization services in two local government areas in The Gambia during COVID-19: An interview-based qualitative study.

PLOS ONE

Dear Dr. Bah,

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.

We have added few comments to improve the manuscript and meet PLOS ONE’s publication criteria.

Please submit your revised manuscript by Jun 10 2023 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 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.

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,

Ribka Amsalu

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 minor grammatical errors and few more comments/suggestions.

1. Introduction section

Keep the mortality information as it is relevant for readers and makes a point that in countries that have high infant, child and maternal mortality the indirect impact of the pandemic can be severe. Minor edit - it is Maternal mortality ratio (not rate). 

2. Discussion section

"Temesgan and colleagues [14] found that mothers who were not required to obtain permission from their partners to access antenatal and immunization services during the pandemic had greater odds of accessing antenatal and immunization services than those who were required to seek permission" While an interesting finding I was not clear how the findings relate to the results of your study. 

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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 #1: All comments have been addressed

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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 #1: Yes

********** 

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

Reviewer #1: N/A

********** 

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

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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 #1: 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 #1: Topline comment:

• Check throughout paper that you are using plural verbs when referring to data, since you have more than one piece of data (i.e. use “data were” rather than “data was”)

Abstract

“we identified five main themes, ranging from individual factors to interpersonal, community, institutional and policy factors”

• Seems you identified more than five themes since each of these areas has more than one theme, suggest to instead say “we identified themes at five different levels: individual, interpersonal, etc” or something along this line for clarity.

Intro

“With the recent COVID-19 pandemic, the achievements made globally in improving mother”

• This statement implies that the pandemic is over, but there are still cases occurring globally,” consider rewording to “ongoing COVID-19 pandemic” or “COVID pandemic declared as a public health emergency on x date” or something similar.

“During the early phase of the pandemic there was a concern about the potential”

• very minor but would add comma after the word pandemic.

“The demands-side factors include movement restrictions, economic hardship”

• Minor but take out the s in demands here to keep language consistent

“However, despite these achievements in increased MNCH uptake, when compared to international rates, the maternal, newborn and child mortality rates in The Gambia remain very high”

• Suggest to remove the words “when compared to international rates” since you didn’t provide international rates in relation to MNCH uptake, this will leave the reader wanting international rates to compare to.

• You talk about MNCH and how it has improved over time, but then for mortality rates, you don’t mention change over time… is this because mortality hasn’t improved over time? Instead of focusing on mortality rates being high and not saying what they are high in comparison to (presumably it’s global rates but you don’t explicitly say this or what those global rates are), would focus on this rate not improving if this is true. I also recommend to consider why you even included mortality information in this paper if the focus is antenatal and immunization services and threats to improvement of this. Suggest to add a sentence to drive home why it matters in the context of this paper or delete this paragraph.

“On 27 March, the country declared a state of emergency, which included the closing of schools, non-essential shops, and places of worship, the prohibition of social gatherings of more than 10 people, and the limiting of the number of passengers on public transport”

• Did the state of emergency mandate these things? Suggest to change verb if this is what is meant.

“Between April and July 2020, the government introduced contact tracing and quarantine measures for suspected and confirmed cases, who were obliged to remain in hotels for 14 days.”

• So quarantine meant they were obliged to stay in a hotel? If this is what you meant, suggest to reword to “and quarantine/isolation measures for suspected and confirmed cases which obliged cases to remain in hotels for 14 days” And what about contacts… did they need to quarantine in a hotel?

• Also, isolation applies to cases to prevent spread of illness and quarantine applies to contacts who are not yet ill, so I suggest to check that you use these terms correctly throughout discussion on quarantine/isolation.

“To ensure confidentiality and anonymity, the interview data was anonymised.”

• The use of anonymous twice is redundant, maybe say data were de-identified before analysis. Also make sure you refer to data as plural rather than singular here and throughout the paper

“They were reported to have the highest prevalence of COVID-19 cases in the country [43].”

• Just looked at this citation and didn’t see anything about prevalence of COVID-19, seems like you may have cited the wrong source.

My prior comments on methods, results, discussion, conclusion have been resolved and I have no further comments at this time

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Reviewer #1: No

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Factors that influenced utilization of antenatal and immunization services in two local government areas in The Gambia during COVID-19: An interview-based qualitative study.

PONE-D-22-27435R2

Dear Dr. Abdourahman Bah

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.

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Kind regards,

Dr. Ribka Amsalu

Academic Editor

PLOS ONE