PONE-D-21-13246

Auditing the Antenatal Care Referral and Management of Pre-Eclampsia among Health Facilities in Zanzibar- A Protocol for Cross Sectional Study

PLOS ONE

Dear Dr. Rashid,

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 Oct 17 2021 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: http://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,

Frank T. Spradley

Academic Editor

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. Please include additional information regarding the survey or questionnaire to be used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If the original language is written in non-Latin characters, for example Amharic, Chinese, or Korean, please use a file format that ensures these characters are visible.

3. Please state how you will validate the questionnaire prior to testing on study participants. Please provide details regarding the validation group within the methods section.

4. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Greetings,

I commend the authors for selecting a very important research area dealing with maternal and child health in a developing country.

This protocol has many dark areas which need to be addressed:

1. The document is full of English language grammatical errors, which should be corrected.

2. Scientific English language need to be improved throughout the paper.

3. Please use uniform method of references in paper.

4. Please elaborate the method sections for following points.

• Please describe who will collect data.

• Please add duration of study.

• Rewrite the dependent and independent variables, presently this part is written haphazardly.

• Please state the guidelines/definitions explicitly those are being used at your peripheral hospital while managing hypertensive disorder in pregnant women. Also state whether these guidelines are uniformly followed at all centers or there are some differences in the protocols.

• Please state whether some training/orientation program exist for the peripheral health workers for providing antenatal care.

• Please describe the process to avoid hospital bias.

• Please describe groups for statistical analysis and how the comparison will be performed.

Best wishes,

**********

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

[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.

PONE-D-21-13246R1Auditing the Readiness of Healthcare Facilities in Antenatal Care Referral and Management of Pre-Eclampsia in Zanzibar- A Protocol for Cross Sectional StudyPLOS ONE

Dear Dr. Rashid,

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.

The manuscript has been evaluated by one reviewer, and their comments are available below.

Whilst the manuscript is improved, the reviewers have raised a number of concerns that still need attention. 

Could you please revise the manuscript to carefully address the concerns raised?

Please submit your revised manuscript by Jun 19 2022 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,

Sebastian Shepherd

Staff Editor

PLOS ONE

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors,

I would like to commend you for revising the manuscript and adding some clarity to the proceedings of research. At the same time, I would urge to the authors to make up following necessary changes in the protocol:

1. Introduction section

i. Please focus this part on the facts according to title of you study. Don’t repeat the WHO guidelines and available treatment options. Explain what the deficiencies or berries in implementations of these guidelines in your area or hospitals are and how you can rectify them.

ii. Line 90-92, please insert the year to which this data belongs, page 3.

iii. Please add reference to the statement made in line 149-150, page 5.

2. Study area section

i. Line 208-215, page 8; This statement is repetition of last paragraph of introduction part. So, it can be omitted.

3. Variable definition sections

i. Please don’t repeat the definition of pre-eclampsia (line 262-264, and line 272-276 at page 10. This section needs to be worked on and rephrased.

ii. Authors still have not made it clear how information will be collected in tool, whether it will be a smartphone or computer based form or a printed questionnaire will be kept at the hospitals.

iii. Similarly, there will be different categories of health care workers like medical graduates, nursing staff and other paramedical staff at each hospital. Authors should explain how they will prevent bias while collecting information from them.

4. Independent variables

i. This section as whole need to be rewritten, sentences is framed very badly. e.g line 298. Page 11; The tool will be adopted from [29] and will be little modified to suit the current study.

Other comments

i. Authors are requested to work on English language in manuscript. Although, they have improved a lot, but much more needs to be done. Please use uniform method of writing pre-eclampsi/eclampsia instead of writing PE/E or full form randomly. Similarly use blood pressure instead of writing Blood Pressure.

ii. Authors have not improved reference section. Some references are incomplete. e.g. Reference number at 4, 6, 7, 9, 18, 21, and 25. Please rewrite them.

Best regards.

**********

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

[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.

PONE-D-21-13246R2

Auditing the Readiness of Healthcare Facilities in Antenatal Care Referral and Management of Pre-Eclampsia in Zanzibar- A Protocol for Cross Sectional Study

PLOS ONE

Dear Dr. Rashid,

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 Mar 05 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,

Jasbir Singh, M.D.

Guest Editor

PLOS ONE

Additional Editor Comments:

Dear authors,

Thank you for your kind patience and cooperation during entire review process.

Please revise manuscript was per comments received from reviewer/s.

Reviewer 1

I would like to authors for revising the manuscript and adding some clarity to the proceedings of research. At the same time, I would urge to the authors to make up following necessary changes in the protocol:

1. Introduction section

i. Please focus this part on the facts according to title of you study. Don’t repeat the WHO guidelines and available treatment options. Explain what the deficiencies or berries in implementations of these guidelines in your area or hospitals are and how you can rectify them.

ii. Line 90-92, please insert the year to which this data belongs, page 3.

iii. Please add reference to the statement made in line 149-150, page 5.

2. Study area section

i. Line 208-215, page 8; This statement is repetition of last paragraph of introduction part. So, it can be omitted.

3. Variable definition sections

i. Please don’t repeat the definition of pre-eclampsia (line 262-264, and line 272-276 at page 10. This section needs to be worked on and rephrased.

ii. Authors still have not made it clear how information will be collected in tool, whether it will be a smartphone or computer based form or a printed questionnaire will be kept at the hospitals.

iii. Similarly, there will be different categories of health care workers like medical graduates, nursing staff and other paramedical staff at each hospital. Authors should explain how they will prevent bias while collecting information from them.

4. Independent variables

i. This section as whole need to be rewritten, sentences is framed very badly. e.g line 298. Page 11; The tool will be adopted from [29] and will be little modified to suit the current study.

Other comments

i. Authors are requested to work on English language in manuscript. Although, they have improved a lot, but much more needs to be done. Please use uniform method of writing pre-eclampsi/eclampsia instead of writing PE/E or full form randomly. Similarly use blood pressure instead of writing Blood Pressure.

ii. Authors have not improved reference section. Some references are incomplete. e.g. Reference number at 4, 6, 7, 9, 18, 21, and 25. Please rewrite them.

Best regards.

Reviewer 2

PLease see the enclosed file for comments( track changes). TITLE NEEDS REVISION.

SYNTAX / TECHNICAL PROBLEM.

The objective is NOT OK,

Reviewer 3

I must congratulate the authors for planning a very apt study. I have attached my comments as annotation in the attached pdf.

Few of the comments are as follows:

Abstract

• Future tense has to be used at some places.

Introduction

• Minor grammatical corrections required

• The more recent data from Zanzibar should be quoted

Methods

• The bullets could be replaced by plain text

• Sample size estimation

• The various paragraphs could be clubbed

Analysis of the response

• The percentile part has to be removed

• The threshold has to be defined to label as acceptable.

References

• Please correct ref no 4 and 5

the annexes can also be formatted so that they are easier to fill.

Reviewer 4

The study topic is interesting especially in resource poor settings. The study protocol needs language editing and along sentence reframing as mentioned by fellow reviewers.

Please resubmit with revisions.

Reviewer 5

The current study will be a major milestone in determining the prevalence of pre-eclampsia in Zanziber, because the last study done was in the year 2011 (as per the reference given) in just one clinic. Since this study includes many PHCs and referral hospitals, it can give more accurate picture of prevalence of pre-eclampsia as well as the readiness of health facilities in early diagnosis and management. Ensuring dispersal of guidelines for management of pre-eclampsia pregnant women identified within the sample size will be appreciated. That can help in framing better management protocols which will include measures to curtail existing loopholes.

There are grammatical corrections required, cited some:

Abstract (bottom up fifth line) simple grammatical correction: Data will be ‘analyzed’ using SPSS software.

Line 105: may ‘contribute’ to

Line 110: Reframe grammatically if possible

Line 351: the results obtained will portray

Best regards,

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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 #2: No

Reviewer #3: No

Reviewer #4: Yes

Reviewer #5: 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 #2: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

​6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: PLease see the enclosed file for comments( track changes). TITLE NEEDS REVISION.

SYNTAX / TECHNICAL PROBLEM.

The objective is NOT OK,

Reviewer #3: I must congratulate the authors for planning a very apt study. I have attached my comments as annotation in the attached pdf.

Few of the comments are as follows:

Abstract

• Future tense has to be used at some places.

Introduction

• Minor grammatical corrections required

• The more recent data from Zanzibar should be quoted

Methods

• The bullets could be replaced by plain text

• Sample size estimation

• The various paragraphs could be clubbed

Analysis of the response

• The percentile part has to be removed

• The threshold has to be defined to label as acceptable.

References

• Please correct ref no 4 and 5

the annexes can also be formatted so that they are easier to fill.

Reviewer #4: The study topic is interesting especially in resource poor settings. The study protocol needs language editing and along sentence reframing as mentioned by fellow reviewers.

Please resubmit with revisions.

Reviewer #5: The current study will be a major milestone in determining the prevalence of pre-eclampsia in Zanziber, because the last study done was in the year 2011 (as per the reference given) in just one clinic. Since this study includes many PHCs and referral hospitals, it can give more accurate picture of prevalence of pre-eclampsia as well as the readiness of health facilities in early diagnosis and management. Ensuring dispersal of guidelines for management of pre-eclampsia pregnant women identified within the sample size will be appreciated. That can help in framing better management protocols which will include measures to curtail existing loopholes.

There are grammatical corrections required, cited some:

Abstract (bottom up fifth line) simple grammatical correction: Data will be ‘analyzed’ using SPSS software.

Line 105: may ‘contribute’ to

Line 110: Reframe grammatically if possible

Line 351: the results obtained will portray

**********

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 #2: Yes: AMARJEET SINGH

Reviewer #3: No

Reviewer #4: No

Reviewer #5: 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.

Attachments

Attachment

Submitted filename: protocol clean third.docx

Attachment

Submitted filename: PONE-D-21-13246_R2_reviewer_ Aug 31.pdf

Auditing the Readiness of Healthcare Facilities for  Referral and Management of Pre-eclampsia Cases in Zanzibar- A Protocol Study

PONE-D-21-13246R3

Dear Dr. Rashid,

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,

Jasbir Singh, M.D.

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #5: Yes

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3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #2: Yes

Reviewer #3: No

Reviewer #5: Yes

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4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. 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 #2: Yes

Reviewer #3: Yes

Reviewer #5: 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 #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Readiness of Healthcare Facilities – not defined – A COMPOSITE SCORE could have been contemplated?

LINE 77 Introduction T Risk factors like obesity- pl check TYPO / proof reading error.

"Whether management of pre-eclampsia was conducted as per the established guidelines, which includes provision of correct medications, monitoring of blood pressure and fetal heart rate, checking protein in urine and conducting liver and kidney function tests..." –

Will there be an observation of the process? If yes- ETHICAL dilemma!? BIAS…What if NOT ADHERED to? Will it NOT be corrected? ("Process measure will be adherence to the guideline")..

IT CAN NOT BE A descriptive cross-sectional design, e.g., the text states-"When a healthcare facility meets all required referral standards to refer a woman with signs of pre-eclampsia or eclampsia based on the recommended guidelines it is considered a successful referral in this study."

Jhpiego ?, JHPIEGO

Reviewer #3: Thank you for responding to majority of comments.

the threshold of adequate knowledge still needs to be addressed in the Compliance of referral guideline, Knowledge of pre-eclampsia, Skills for management of pre-eclampsia still needs to be addressed.

Reviewer #5: The authors have made necessary changes to their manuscript, remarkably in standard English and grammar. The protocol can be accepted for publication.

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Reviewer #2: No

Reviewer #3: No

Reviewer #5: Yes: Dr. Madhuri Devaraju

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