PONE-D-22-01899Women's multidimensional empowerment index and essential newborn care practice in Bangladesh: the mediating role of skilled antenatal care follow-upsPLOS ONE

Dear Dr. Kanchan Kumar Sen, 

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Gouranga Lal Dasvarma, PhD

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PLOS ONE

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Thank you for the opportunity to review this manuscript. The topic is important for public health issue, especially in maternal and child health. I have some comments to improve the manuscript:

Introduction: The topic of empowerment has to be introduced in this section. How is women empowerment defined? Is there a framework used to define women’s empowerment components? This must be justified and supported by literature.

Methods: Explain why author used weighting approach to create the empowerment component.

Results: In Table 2, column 4 is not clear.

Discussion:

There could be more a more detailed comparison of the results here with previous results. As we go from the top quartile of empowerment to the bottom quartile, how large is the change in the probability of SANC or ENC in other studies? Even if the other studies use different methods and different empowerment measures, it should still be possible to the infer the differences between the top and bottom quartiles in these studies.

Policy implications are not clear.

Conclusions drawn are supported by findings.

Reviewer #2: This is a useful and innovative study with potential policy implications. It is not certain to this reviewer whether the idea of using antenatal care-visits as a mediating factor between women’s empowerment and essential newborn care is completely new, but it is a refreshing approach, especially in measuring women’s empowerment from a multi-dimensional angle. However, there are several points, stated below, which need to be addressed satisfactorily before the manuscript may be considered for publication.

General comments:

• Language editing: The manuscript must be professionally edited for English, particularly for use of articles such as “the” and tense. The manuscript is supposed to describe and explain the findings of a current research, yet some of the sentences read as if they are reporting past research.

• Writing style. The style of writing is often too cryptic, especially in the presentation of tables. Table and figure headings should be self-explanatory, and the source of all the tables and figures must be noted. Even if the tables and figures are drawn by the authors based on their analysis of data, these should be mentioned as such.

• Statistical analyses of data: In general, the idea of calculating the direct and indirect effects of women’s empowerment on ENC practice is noteworthy. However, please confirm whether it was necessary to adjust for complex design in conducting logistic regression on data extracted from BDHS 2017-18, which is based on complex sampling. Please also explain what was involved in “wrangling” the data, as BDHS 2017-18 data must have been cleaned before being released for use.

Specific comments:

• Lines 14-15, and 138-139. Please explain why only home births are considered in this research. According to Bangladesh Demographic and Health Survey 2017-18 (BDHS 2017-18. Chapter 9), almost one half (49%) of the births in the preceding three years were delivered at a health facility.

• Line 58. “intrapartum, conditions of labour”. Do you mean intrapartum conditions of labour (i.e. no comma)?

• Lines 142-154. Re initial care for babies after birth: Does “cord care” include Used safe

delivery kit/bag or boiled blade during delivery, Applied chlorhexidine after umbilical

cord was cut and tied (BDHS 2017-18 report Table 9.24? Re joint groupings. Where have you shown in your manuscript the joint groupings for safe cord care and optimal thermal care respectively, reported from previous studies?

• Lines 156-162. Re components of women’s empowerment index. Why is women’s education used as a barrier to accessing healthcare and not as a part of household decision making autonomy? How valid is the assumption to consider household assets as proxy for women’s assets, when in fact household assets are most likely to be held jointly with husbands and possibly members of the extended family?

• Lines 162-166. What is the justification of assigning equal weights to each dimension? Why did you not use Factor Analysis and find the weights from Factor Loadings?

• Lines 177-185. Formula for individual score. Please re-write the formula as it does not contain the symbol ‘n’ (noted in Line 180) and symbols denoting the weights of indicator and dimension.

• Lines 191-196. Re the new WHO guidelines about at least eight Skilled ANC (SANC) visits. The new guidelines were formulated in 2016. In your analysis you have applied the new recommendations to births and pregnancies occurring in the three years preceding the survey, which was conducted in 2017-18, i.e. births and pregnancies occurring during 2015-2018 or before. As such, many births and associated SANC visits (or non-visits) must have happened before the new guidelines came into effect (when at least 4 SANC visits were recommended). Under such circumstances how justified are you in considering a cut-off of less than 8 and 8 or more SANC visits in analysing the mediating effects of skilled antenatal care?

• Line 198. “gender of index child”. It appears from an inspection of Table 2 that the index child is the child whose antenatal care is the subject of this study. As such, selecting “gender of the index child” as a control variable does not make sense because it is not possible to know the gender of the child at the antenatal stage, unless tests like ultrasound or amniocentesis are done, which most women would not have done in this case. Therefore, this variable should be removed from the list of control variables and the analysis should be re-done.

• Lines 207-211. Statistical Analysis. Please confirm whether it was necessary to adjust for complex design in conducting logistic regression on data extracted from BDHS 2017-18, which is based on complex sampling. Please also explain what was involved in “wrangling” the data, as BDHS 2017-18 data must have been cleaned before being released for use.

• Table 2. Please make the table heading self-explanatory by stating the covariates of which indicator you have presented in the table based on what test. Please also provide, in parentheses the range of values of Low, Average and High Women’s Empowerment Index. What values are shown under the column heading “Good ENC Practice”? Are these the point estimates of each variable and their 95% Confidence Intervals? Please write the source of this table (and other tables and figures). If this table is based on your own calculations, then please write the source somewhat as this: “Computed by the authors based on their analysis of BDHS 2017-18 data”.

• Fig 1. (Should write in full, as “Figure 1”). Please calculate if possible, the Direct Effect of MEI on ENC Practice, and the effects of MEI on Skilled ANC and Skilled ANC on ENC Practice respectively and show them in the diagram.

• Fig 2(a).This figure (and its parent table in BDHS 2017-18-Table 9.24) appears a little confusing with respect to cord care and nothing applied to cord, both of which are indicators of cord care. Therefore, please explain how 86.7% of home delivered births in the last three years had Used safe delivery kit/bag or boiled blade during delivery, applied chlorhexidine after umbilical cord was cut and tied and 44.1% had nothing applied to cord. Should these two percentages not add to 100?

• Fig 2(b). “ENC practice is considered as a binary random variable, where 1 indicates good ENC and 0 for the poor ENC. A newborn is said to be received good ENC if all five components were practiced; whereas the practice is poor if he/she missed any of the components”. (Lines 151-164 of this manuscript). In the context of this definition, please explain the five categories of ENC practice displayed in Fig 2(b).

• Please also examine all the other diagrams (and tables) and check them for missing information or lack of clarity.

• Lines 410-422. In conclusion you have recommended “that a woman should be highly empowered …”. Can you suggest what specific measures should be taken to make women highly empowered in order to possess “not less than 75% of empowerment”?

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Reviewer #1: No

Reviewer #2: No

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PONE-D-22-01899R1Women's multidimensional empowerment index and essential newborn care practice in Bangladesh: the mediating role of skilled antenatal care follow-upsPLOS ONE

Dear Dr. Kanchan Kumar Sen, 

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. These are only minor comments and should be able to be addressed in less than a week.

==============================

PONE-D-22-01899R1  Kanchan Kumar Sen

• Reviewer#2 - Comment 10. “Lines 191-196.”Re the new WHO guidelines about at least eight Skilled ANC (SANC) visits. The new guidelines were formulated in 2016. In your analysis you have applied the new recommendations to births and pregnancies occurring in the three years preceding the survey, which was conducted in 2017-18, i.e. births and pregnancies occurring during 2015-2018 or before. As such, many births and associated SANC visits (or non-visits) must have happened before the new guidelines came into effect (when at least 4 SANC visits were recommended). Under such circumstances how justified are you in considering a cut-off of less than 8 and 8 or more SANC visits in analysing the mediating effects of skilled antenatal care?” is not addressed satisfactorily (Lines 231-240 of the revised manuscript). Please explain the reason why you have considered a cut-off of less than 8 and 8 or more SANC visits while the previous guideline of 4 skilled ANC visits was still followed when most of the births included in your study took place.
• Reviewer#2 – Comment 16. Your response “It has ben taken care of”. How have you taken care of it? Have you removed Figure 2(b) and retained Figure 2(a) as the only Figure 2??

Please submit your revised manuscript by Feb 25 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,

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:

Thank you for revising the manuscript. Two minor comments still remain to be addressed as follows:

PONE-D-22-01899R1 Kanchan Kumar Sen

• Reviewer#2 - Comment 10. “Lines 191-196.”Re the new WHO guidelines about at least eight Skilled ANC (SANC) visits. The new guidelines were formulated in 2016. In your analysis you have applied the new recommendations to births and pregnancies occurring in the three years

preceding the survey, which was conducted in 2017-18, i.e. births and pregnancies occurring during 2015-2018 or before. As such, many births and associated SANC visits (or non-visits) must have happened before the new guidelines came into effect (when at least 4 SANC visits

were recommended). Under such circumstances how justified are you in considering a cut-off of less than 8 and 8 or more SANC visits in analysing the mediating effects of skilled antenatal care?” is not addressed satisfactorily (Lines 231-240 of the revised manuscript). Please

explain the reason why you have considered a cut-off of less than 8 and 8 or more SANC visits while the previous guideline of 4 skilled ANC visits was still followed when most of the births included in your study took place.

• Reviewer#2 – Comment 16. Your response “It has ben taken care of”. How have you taken care of it? Have you removed Figure 2(b) and retained Figure 2(a) as the only Figure 2??

[Note: HTML markup is below. Please do not edit.]

[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.

Women's multidimensional empowerment index and essential newborn care practice in Bangladesh: the mediating role of skilled antenatal care follow-ups

PONE-D-22-01899R2

Dear Dr. Kanchan Kumar Sen, 

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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