PONE-D-23-10565Ranked Severe Maternal Morbidity Index for Population-Level Surveillance at Delivery HospitalizationPLOS ONE

Dear Dr. Womack,

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Additional Editor Comments:

Dear Authors,

thanks for the submission of the manuscript to PLOS ONE. Please find attached some minor revisions suggested by revieweres.

Reviewer #1

This is an important and well-written study that I believe adds substantial information to the study of severe maternal morbidity.

I have just a few observations and suggestions that require only minor revisions.

1. The study design/source should be presented in the title.

2. The number of hospitalizations should be presented in the abstract.

3. I suggest that the total number of deaths, in addition to the rate, be presented in the results section.

That is all. Congratulations on your work.

Reviewer #2

This manuscript uses data from the NIS to estimate the relative contribution of SMM indicators to in-hospital mortality. The approach expands the findings from a Canadian study cited by the authors. The inclusion of the signal-to-noise ratio is novel and useful for interpreting the PAF for factors with high prevalence but low mortality. The text is well written and the conclusions are supported by the results with appropriate acknowledgement of the limitations of the study.

1. Introduction. Suggest reporting the range of sensitivity for the 3 indicators reported to have low sensitivity - DIC, transfusion, eclampsia

2. Is there evidence that coding for HELLP and severe preeclampsia is any more valid than eclampsia coding? This seems relevant given that this combined group of hypertensive conditions had the highest prevalence but a low contribution to mortality. Did the authors consider a sensitivity analysis using eclampsia alone?

3. It might be helpful to include a sentence helping readers interpret the SNR - are high or low values better?

4. The methods should include the information reported in footnote 'c' for Table 2 - that hPAFs controlled for year, payer, race, region, hospital teaching status. How were these covariates selected? It also seems that there should be a descriptive table reporting the distribution of these characteristics for the study population. Race is often missing in administrative data. Was this also the case for this study and if so, how was it addressed? Also, consistent with recommended best practices (https://jamanetwork.com/journals/jama/article-abstract/196632), please note how race data are collected in NIS and why race was included in the analysis.

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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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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: Yes

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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: This is an important and well-written study that I believe adds substantial information to the study of severe maternal morbidity.

I have just a few observations and suggestions that require only minor revisions.

1. The study design/source should be presented in the title.

2. The number of hospitalizations should be presented in the abstract.

3. I suggest that the total number of deaths, in addition to the rate, be presented in the results section.

That is all. Congratulations on your work.

Reviewer #2: This manuscript uses data from the NIS to estimate the relative contribution of SMM indicators to in-hospital mortality. The approach expands the findings from a Canadian study cited by the authors. The inclusion of the signal-to-noise ratio is novel and useful for interpreting the PAF for factors with high prevalence but low mortality. The text is well written and the conclusions are supported by the results with appropriate acknowledgement of the limitations of the study.

1. Introduction. Suggest reporting the range of sensitivity for the 3 indicators reported to have low sensitivity - DIC, transfusion, eclampsia

2. Is there evidence that coding for HELLP and severe preeclampsia is any more valid than eclampsia coding? This seems relevant given that this combined group of hypertensive conditions had the highest prevalence but a low contribution to mortality. Did the authors consider a sensitivity analysis using eclampsia alone?

3. It might be helpful to include a sentence helping readers interpret the SNR - are high or low values better?

4. The methods should include the information reported in footnote 'c' for Table 2 - that hPAFs controlled for year, payer, race, region, hospital teaching status. How were these covariates selected? It also seems that there should be a descriptive table reporting the distribution of these characteristics for the study population. Race is often missing in administrative data. Was this also the case for this study and if so, how was it addressed? Also, consistent with recommended best practices (https://jamanetwork.com/journals/jama/article-abstract/196632), please note how race data are collected in NIS and why race was included in the analysis.

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Reviewer #1: No

Reviewer #2: No

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Ranked severe maternal morbidity index for population-level surveillance at delivery hospitalization based on hospital discharge data

PONE-D-23-10565R1

Dear Dr. Womack,

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.

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Kind regards,

Simone Garzon

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

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

**********

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

**********

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: Dear authors:

I read and greatly appreciated the responses to my comments as a reviewer of your interesting article and I was pleased to see that all my suggestions were incorporated into the text. As I previously highlighted, it is an important article that makes a substantial contribution to the study of severe maternal morbidity. Therefore, I recommend its approval in this version.

Reviewer #2: (No Response)

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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: Melania Maria Ramos de Amorim

Reviewer #2: No

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