PONE-D-22-01981Factors associated with anaemia in pregnancy: A retrospective cross-sectional study in northern GhanaPLOS ONE

Dear Dr. Abaane,

Thank you for submitting your manuscript to PLOS ONE. I sincerely apologise for the unusually delayed review timeframe.

Your manuscript has been assessed by one reviewer. After careful consideration of their comments, 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. In particular, please ensure that you have updated the introduction and discussion with references to all relevant literature on this topic, and include a thorough discussion of the new information that your study provides relative to the published literature.

Please note that we have only been able to secure a single reviewer to assess your manuscript. We are issuing a decision on your manuscript at this point to prevent further delays in the evaluation of your manuscript. Please be aware that the editor who handles your revised manuscript might find it necessary to invite additional reviewers to assess this work once the revised manuscript is submitted. However, we will aim to proceed on the basis of this single review if possible.

Please submit your revised manuscript by Feb 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.

We look forward to receiving your revised manuscript.

Kind regards,

Emily Chenette

Editor in Chief

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. You indicated that you had ethical approval for your study. In your Methods section, please ensure you have also stated whether you obtained consent from parents or guardians of the minors included in the study or whether the research ethics committee or IRB specifically waived the need for their consent.

3. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

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

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

**********

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

Reviewer #1: No

**********

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

**********

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

**********

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 paper reports the factors associated with anemia at first antenatal booking, 28 weeks of pregnancy, and 36 weeks of pregnancy in the Bolgatanga Municipality, Northern Region of Ghana. I have the following comments:

1) Line 1 (Title): The Bolgatanga Municiaplity is a small part of what we know as northern Ghana, which includes 5 regions, namely the Northern, Savanna, North-East, Upper East, and Upper West regions. Thus, authors should insert "Bolgatanga Municipality" in the title, so it reads: "Factors associated with anaemia in pregnancy: A retrospective cross sectional study in the Bolgatanga Municipality in northern Ghana".

2) Line 35: It would be helpful to include the mean (or median) gestational weight at registration.

3) Line 36-38: Authors' use of "after haemodilution" is confusing. Why not use something like "after WHO adjustment" or simply "using anemia cut off of 11.0 g/dl" versus "using anemia cut-off of 10.5 g/dl"?

4) Line 39-40: Authors should use was/were "associated with increased odds" or "associated with decreased odds" .....

5) Line 90-92: Readers do not believe that "only two studies done elsewhere" (Refs 46 and 47) have ever reported the hemoglobin concentration and anemia status of women at more than one time point during pregnancy?

6) Line 92-94: This (in addition to Line 90-92) is a poor description of study rationale and appears to suggests that authors are not familiar with the Hb/anemia literature of pregnant women in Ghana. I can give you at least one of such studies in Ghana:

Adu-Afarwuah S, Lartey A, Okronipa H et al. (2017) Impact of small-quantity lipid-based nutrient supplement on hemoglobin, iron status and biomarkers of inflammation in pregnant Ghanaian women. Maternal & Child Nutrition (2017), 13, e12262..

Was the primary aim of the study not to determine the factors associated with anemia at first antenatal booking, 28 weeks of pregnancy, and 36 weeks of pregnancy in the Bolgatanga Municipality?

7) Line 124-126: In line 110, "haemoglobin checked at registration was only about 52% at 36 weeks of gestation". So, given this "retrospective cross-sectional study", did authors randomly select participants from among those with Hb values at all 3 time points (first book, 28 wk, and 36 wk)?

8) Line 132-134: This is a "retrospective" study, so this part is confusing, i.e., "a structured questionnaire was used to collect data on household food security and additional sociodemographic characteristics including household assets, that were not captured in the medical records." Authors should describe clearly how the women were contacted for the survey. Were the hospital records reviewed before or after the survey? For a "retrospective cross-sectional study", were all participants enrolled after 36 weeks of pregnancy?

9) Line 142-143: At what time point (in terms of gestational age) were the women contacted? Were (some) women contacted before 36 wk of pregnancy? If so, how is this a "retrospective" study?

10) Line 155-156: Comparison of means at 3 time points: it is confusing how they used a dependent (paired) t-test here. Please provide more details on how the analyses were organized.

11) Line 158-159: Comparison of percentages at 3 time points. Please provide details of how the analyses were organized, eg, (1 v 2, 1 v 3, and 2 v 3?.

12) Line 160-162: Please describe how the predictors were selected for the final binary regression models.

13) Table 3: What are the P-values comparing?

14) Table 4 is very confusing:

a. Why did authors decide to separate non-anemic versus anemic women? Was this part of the objective, in addition to examining mean Hb concentrations at the 3 time points?

b. What are the "adjusted" and "unadjusted" Hb values? How was the adjustment done?

I see the comparisons were: Registration vs 28 wk, Registration vs 36 wk, and 28 wk v 36 wk. I'm sure readers this presentation boring; the table is long and difficult to follow (with the use of "adjusted" and "unadjusted" Hb). Maybe should consider using a line graph to present these data.

15) Table 5: How did authors select predictor variables for the logistic regression models? Did they simply throw all the background socioeconomic and food insecurity, etc., variables into the models? That is why this table is so big.

**********

6. 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

**********

[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 anaemia in pregnancy: A retrospective cross-sectional study in the Bolgatanga Municipality in northern Ghana

PONE-D-22-01981R1

Dear Dr. Donatus Nbonibe Abaane

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,

Mpho Keetile, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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

**********

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 Response)

**********

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

**********