PONE-D-22-19638Factors associated with receipt of adequate antenatal care during pregnancy among women in Rwanda: A population-based cross-sectional studyPLOS ONE

Dear Author,

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. ==============================

ACADEMIC EDITOR: 

• Please format the manuscript according to the journal requirements https://journals.plos.org/plosone/s/submission-guidelines.
• Please refer to PLOS ONE downloadable sample files to ensure that your submission meets the journal formatting guidelines
• Please ensure you have followed STROBE guidelines for cross-sectional studies 
• Pease make sure that ALL abbreviations are explained in the main text. Line 55 in the introduction - "ANC" abbreviation is not defined.

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

Please submit your revised manuscript by September 10, 2022. 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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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.

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We look forward to receiving your revised manuscript.

Kind regards,

Gulzhanat Aimagambetova

Academic Editor

PLOS ONE

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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: Partly

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: 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: No

Reviewer #2: 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

Reviewer #2: No

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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: Authors in the current study made great efforts to assess the receipt of adequate ANC among pregnant women in the study area and its associated factors. However, I do have some concerns over the methods, results and discussion part which I think need to be addressed before this can be published. Although I am not a statistician, I tried to think in a logical manner as far as results are concerned. So, I apologies, if my lack of expertise in this field has led to confusion. My comments are as follows:

Major comments:

1. Regarding the study design, I understood (line no.99) that the current study used the data from RDHS(a cross sectional survey). If it is so, the current study cannot be a cross-sectional study, I feel. The study used part of data from 2019-20 RDHS, therefore, it could be a secondary analysis, as observed in a similar study conducted and published in 2016 by Rwabufigir BN et al. (ref 18 of the current version of the manuscript) where they clearly mentioned about the study design. Please relook into their study design and rewrite accordingly. If my understanding is not correct, please clarify.

2. Under study variables, the manuscript discussed that no. of visits was coded (line no. 121). But, the manuscript failed to interpret these findings. I am trying to think louder on this particular variable. Somehow, this variable may allow the policy makers to think about the bottlenecks in the delivery of adequate ANC services, thereby, they can plan some interventions like providing resources, IEC or awareness etc. For instance, even if X no of pregnant women completed atleast four visits of ANC, whether all of these X subjects received adequate ANC (in terms of others components-time of first visit and receipt of the four components).

I assume that authors included all these three components under one variable named ‘Adequate ANC’. However, results can be more appreciated if the manuscript provides these estimates as well. If you disagree of this point, please justify. If agree, kindly present all the missing data.

3. Under the statistical analysis of methods section, kindly elaborate the variables (line no. 145) and factors that are considered in the bivariate analysis. Like demographics, socio economic characters etc.

4. Results section:

a. Kindly rewrite the title of Table 1. It would be better to mention this descriptive statistics in the methods sections rather than in the title. As these are demographics and socio-economic characters of study population, kindly relook into it.

b. To bring the uniformity in the age groups and make them comparable, it is advisable to split the last group “35-49 years” into two groups as ‘35-44 years’ and ’45 years and above’. If agreed, the further calculations in the Table 2 and Table 3 will also be varied accordingly.

c. When I go through the results, there is a slight confusion in the number of participants considered in the multivariate analysis. Throughout the manuscript, the study aimed at identifying the factor associated with the adequate ANC services. In the Table 1, it was already estimated that 27.6% of study population received adequate ANC. If author wants to represent the demographic and socio-economic characters of adequate ANC received population, the sample size cannot be 6039 (n) i.e., try to avoid the inadequate ANC population. If author wishes to represent characters of all (n=6039) participants, the title of Table 2 should not include the word ‘adequate ANC’. Indeed, my suggestion would be to merge the Table 1 and 2 and change the results interpretation accordingly. Kindly address.

d. The current study aimed to estimate the factors associated with adequate ANC, but not the ANC utilization in the study area, if I am not wrong. Therefore, total population (n=6039) cannot be used in multivariate analysis (provided in Table 3), when the Adequate ANC was found to be on 27.6% (n=1691). Accordingly, results, discussion and conclusion of the study may vary. I strongly suggest taking recommendation/expert opinion from Biostatistician on this matter.

e. It is advisable to categorize birth order variable as 1, 2, 3 and 4 and above. Accordingly find the association.

5. In the discussion section, from 204-206, there is a problem in the references quoted. 18th reference is on post natal care. In line no. 206, I think, 17th reference to be quoted instead of 18th reference in the current version of manuscript. Kindly relook into these references (i.e.17, 18, &19) and address properly. Also kindly make necessary changes in the order of references as appropriate.

Minor comments:

1. Since the current study has not performed the correlation tests, the term co-variates in line no. 115, 129 may be replaced with variables.

2. In Table 2, kindly relook into the percentages provided under the following variable-

a. Age group & Education (calculation is not correct)

b. Health Insurance & Distance (please make it to 100%)

3. In line no. 204, references (supposed to be 17,18) are in wrong order.

4. Suggestion to change the title: since antenatal care provides during pregnancy, slight corrections may be made in the title like Factors associated with adequate antenatal care among pregnant women in Rwanda......... If this study is not a primary study conducted by the authors, population based cross-sectional study can be replaced with better terms to make it more appropriate.

5. References: strictly adhere to the journal guidelines.

Reviewer #2: topic is interesting enough to attract the readers’ attention. Nevertheless, authors should clarify some points and improve the discussion, as suggested below.

Authors should consider the following recommendations:

- Manuscript should be further revised in order to correct some typos and improve style.

- Authors should ad further details to discuss, at least briefly, the role of first trimester screening for fetal aneuploidies, especially in advanced maternal age (authors may refer to: PMID: 27442264; PMID: 25027820).

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Reviewer #1: Yes: Dr Kayala Venkata Jagadeesh

Reviewer #2: No

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.

PONE-D-22-19638R1Factors associated with receipt of adequate antenatal care among women in Rwanda: A secondary analysis of 2019-20 Demographic and health survey dataPLOS ONE

Dear Dr. Olive Tengera,

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 March 13, 2023. 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,

Gulzhanat Aimagambetova

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.

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 #2: 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

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: 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 #2: 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

Reviewer #2: 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: Thank you for addressing the comments. Kindly look into following observations made:

1. In the methodology, You mentioned about Chi square test under statistical analysis. However, no where it is mentioned in the results section. Have authors only considered for estimating p-value? Kindly justify.

2. Kindly re-looks into the interpretation of results at line 184-186. This result may be interpreted other way round.

3. In the Table-3 title, can we not use 'ANC utilization' instead of 'ANC Status'. Because the interpretation of results given in table-3 are all about receiving ANC. Kindly relook into it.

4. References were not written properly. Please strictly adhere to the journal author guidelines. For example, ref 11 is not written completely. There are other issues in rest of the reference. Kindly cross check all the reference again.

Reviewer #2: I carefully evaluated the revised version of this manuscript.

Authors have performed the required changes, improving significantly the quality of the paper.

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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.

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Reviewer #1: Yes: Dr Kayala V Jagadeesh

Reviewer #2: No

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PONE-D-22-19638R2Factors associated with receipt of adequate antenatal care among women in Rwanda: A secondary analysis of 2019-20 Rwanda Demographic and Health SurveyPLOS ONE

Dear Dr. Tengera,

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 May 04 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,

Gulzhanat Aimagambetova

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.

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: 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

**********

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: (No Response)

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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: Thank you for addressing the comments. However, I have following observations in the manuscript:

1. In the Methodology, at line 138 under Ethics approval, a minor language correction is required. Kindly, you may use ‘which was’ instead of ‘and’ (before registered).

2. In title of table-2, does the sub-heading ‘adequacy ANC received’ or ‘Adequacy of ANC received’? Please use appropriate sub-heading.

3. A suggestion from my side about a point that starts at Line 181 till 184 as follows –

‘Women from a middle and rich wealth indexes had higher odds of receiving adequate ANC ((AOR=1.24: CI=1.04-1.48; p=0.018) and (AOR=1.37: CI=1.16-1.61; p<0.001) respectively) compared to women from poor household wealth index’

4. Point starts at end of line no. 189 till 191 is misinterpreted, as per the results provided in Table-3 regarding distance to health facility. Kindly re-look into it.

5. At line 261, current study is not directly providing recommendations on interventions. Perhaps, it helps in identifying the factors associated with ANC. Accordingly, it may help health care system to identify the interventions and implement them to improve ANC in the study area. If you agree, kindly re-write the statement (at end of line 261 and 262)

6. References: Total references quoted in the text are 40, whereas under references sections, authors have listed 41. Please check and correct it.

7. Authors are also requested to adhere to Journal author guidelines while writing the reference. In most of the references, month was written. For example, look at ref. no. 4, 16, 17, 18 and others. Please cross check all the references again.

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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

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[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.

Factors associated with receipt of adequate antenatal care among women in Rwanda: A secondary analysis of 2019-20 Rwanda Demographic and Health Survey

PONE-D-22-19638R3

Dear Dr. Olive Tengera

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,

Gulzhanat Aimagambetova

Academic Editor

PLOS ONE

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: 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

**********

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

**********

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 comments. Please check the references again, as page numbers are either missing or written incorrectly/typo in some references provided.

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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: Kayala Venkata Jagadeesh

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