PONE-D-22-30184Folate deficiency among women of reproductive age in Ethiopia: a ​systematic review and meta-analysisPLOS ONE

Dear Dr. Berhe,

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Additional Editor Comments:

Dear authors,

After a period of initial checks and thorough peer review, we come up with the review result. The manuscript has a merit for publication but it has many technical and other major issues which need to be addressed during the revision. Once, you addressed the requested suggestions at satisfactory level, decision on the manuscript will be made.

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Academic editor

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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

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: Dear Plos ONE team of editorials, thank you for the chance given to me to review a manuscript titled “Folate deficiency among women of reproductive age in Ethiopia: a systematic review and meta-analysis”. One third of global women experience iron deficiency anemia and the study will have a paramount importance for the design and implementation of appropriate public health interventions and will fill the gap of literature on the field. I should also appreciate that the study is well referenced. The following are my comments;

1. The criteria for the inclusion and exclusion of the articles should be refined and clear cut. The identified article for assessing (a) serum concentration (b) for assessing folate deficiency should go together

2. Have you included only Pregnant women or non-pregnant women or both? How many are institutional and how many are community based?

3. Are you studying for clinical or epidemiological significance or both or?

4. When do we say folate deficiency is called “major public health problem” globally and in Ethiopia?

5. In case when there is ambiguity between the two independent extractors who had decided?

6. Where are the other search engines like other Universities repository and Addis Ababa University and EPHA joint publication Ethiopian Journal of Health development and Jimma University’s Journal of Health Sciences…etc

7. Where is the sub-group analysis based on the age, residence, education status of the participants

8. The result and the discussion contents should contain what it tends to contain.

9. The recommendations are already under implementation. Hence, do you have other innovative recommendations drawn from your findings?

10. The language and the statistics need mainly refinement. The language needs major revision

Reviewer #2: It’s a well-written and interesting study.

Abstract

1. Include the full names of the following abbreviated databases, AJOL, VMNIS, GHDx

2. Right the full names of WHO

3. The recommendation should consider planned and implemented innervations aimed to reduce folate deficiency. The interventions you suggested are already within the government's focus. However, there are shortcomings in the coverage, translating fortification policies into actions. The recommendation should be rewritten in light of this.

4.

Introduction

1. The introduction should clearly state why folate deficiency has been considered a public health problem, especially among women of reproductive age.

2. Mention what are the currently implemented (iron-folic acid supplementation) and planned interventions (fortification).

3. The last paragraph should be focused on folate deficiency only.

4. You have stated that “However, evidence on the prevalence of FD among WRA are not strong enough to the level policymakers could develop evidence-based intervention strategies in the country except for folic acid supplementation for pregnant women who visit health facilities for antenatal care follow-up.” However, the Ethiopian Standard Council endorsed the mandatory fortification of edible oil and wheat flour on 10th June 2022, with the currently available evidence. This seems to be in contradiction with your claim. In light of this rewrite the above-mentioned section. You can find this information through this link https://www.nutritionintl.org/news/all-news/government-endorses-mandatory-food-fortification-prevent-high-burden-neural-tube-defects-ethiopia

Method

Search strategy

1. It has been mentioned that Addis Ababa university instructional repositories have been used. This is a great approach to identifying unpublished studies. Makes sure that the thesis or dissertation you have identified has not been published and cross-check for duplication.

2. Other major national universities' institutional repositories and research institution repositories should also be included in the search strategy.

Eligibility criteria

3. Mention how studies from the same survey have been handled

4. In line 107 remove “NOT”, since you haven’t used this boolean operator in the search strategy

Result

5. in line 175 remove “Id”

6. summarise characteristics of studies and participants in table format

7. correct table 1, has been split into two places

8. Table 1 has been cited on line number 225, however, this paragraph is not related to the findings reported in table 1.

9. Throughout the manuscript replace “participants” with woman of reproductive age (WRA)

10. Table 1 has been cited on line number 277, however, this paragraph is not related to the findings reported in table 1

11. Perform a sub-group analysis based on the laboratory method used to asses folate concentration If adequate studies can be found within the subgroups.

12. Please include types of laboratory methods used to analyse folate concentration as a covariate in the meta-regression.

13. Discuss further the similarity and difference in mean serum folate concentration and folate deficiency with studies from other nations; explain the similarity and difference from the perspective of implemented interventions aimed at reducing folate deficiency.

14. From lines 391 to 393 you have stated that “All the included studies into the meta-analysis were cross-sectional, and temporal relationship could not be established between the covariates and the outcome variables”. Remove these statements as the aim of this systematic review and meta-analysis is not to establish causality or explore folate deficiency determinants.

15. You have mentioned that different laboratory assays are used. Discuss how the difference in laboratory assays used may affect your finding, and comparability of studies.

Conclusion

16. Rewrite the concussion making it clear and concise

17. In line 403 replace “women” with women of reproductive age

18. From lines 403-404 you have stated that “Additionally, the pooled prevalence of FD was reported in one-fifth of the women, indicating its public health significance in Ethiopia.”. It is also possible to justify why folate deficiency is public health problem from the perspective of neural tube defect

19. You have recommended multiple interventions targeting folate deficiency among these interventions fortification has been proven to be the most effective one. On your recommendation, more emphasis should be given to fortification interventions.

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Reviewer #1: No

Reviewer #2: No

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Folate deficiency among women of reproductive age in Ethiopia: a systematic review and meta-analysis

PONE-D-22-30184R1

Dear Dr. Gebremichael,

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,

Abdu Oumer

Academic Editor

PLOS ONE

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