PONE-D-22-28650Maternal death surveillance and response system evaluation in Makonde District, Zimbabwe, 2021PLOS ONE

Dear Dr. Chadambuka,

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.Thank you for considering PLoS ONE for your manuscript " Maternal death surveillance and response system evaluation in Makonde district, Zimbabwe, 2021". Peer review of your manuscript is now complete and, based on the reports, a major decision has been made. 

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We look forward to receiving your revised manuscript.

Kind regards,

Richard Kalisa, MD, PhD

Academic Editor

PLOS ONE

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Additional Editor Comments:

John Azaare, Ph.D. (Reviewer 1)

Major decision

Abstract

Introduction

1. Your introductory statement “…with 810 women dying every day from preventable causes related to pregnancy” refers to figure as of 2017, five years behind. This (2017) should be refenced in the statement. Alternatively, the authors should revise the statement to report the current figures of maternal mortality globally and in sub-Saharan Africa and then in Zimbabwe.

2. The statement “Globally the maternal mortality ratio is declining however the average rate of decline is not fast enough to achieve SDG target of 70 maternal deaths per 100000 live births” is similar to the statement “The United Nations Sustainable Development Goal target 3.1 aims at reducing global maternal mortality ratio to less than 70 per 100 000 live births by 2030…” and conveys the same meaning. I suggest you consider merging the two.

3. The authors referenced “the Centre for Disease Control” which collaborated with the World Health Organization. Could you be specific about the particular Centre for Disease Control? We have so many Centres for Disease Control who could partner WHO to implement programmes in LMIC.

4. The authors explained that the “Maternal Death Surveillance and Response System (MDSR)” is what is partially being evaluated in Makonde District. Perhaps, the authors could be much clearer on the motivation for choosing the Makonde District. Although the authors explained that 62% of maternal death were notified and audited which presumably is low for them, this figure is left standing alone could rather be an impressive figure if compared contextually. Perhaps, it could be compared with the figures of other districts who implemented the “MDSR” to show a compelling reason for wanting to know the situation in the Makonde District in particular.

5. Also, note that “MDSR” used as an abbreviation in the manuscript does not exactly represent the “Maternal Death Surveillance and Response System (MDSR). Probably MDSRS. Please check and revise appropriately.

6. General Comment - The introductory aspects is generally scanty and does not address the topic area in literature, rational for the choice of study area and purpose of study, adequately.

Study setting

1. The authors gave statistics of antenatal care attendance in the district of study to include one visit etc. Again, we are not told what percentage made 8+ visits and if none, indicate so to put the reference data into proper perspective, especially as the WHO was part of the implementation of the MDSR.

2. The authors also left out health facility delivery percentages from the Makonde District, although they attempted to explain that health facilities existed widely with capabilities and with one referral centre – the Chinhoyi Provincial Hospital. Please add facility delivery figures of the district. It will be useful in your discussion.

Maternal Death Surveillance and Response System in Zimbabwe

1. The statement “…. health facilities and communities should include zero reporting in their routine reports” is not clear. Perhaps, you could explain what you mean by zero reporting.

2. Fig 1: Flow of information in a Maternal Death Surveillance and Response System in Zimbabwe is a good representation of information flow relative to the surveillance system. However, Mission Hospital/ Local Authorities is left standing alone with no link to source of information as though it is the final generator of information. It is not clear if the diagram is adopted or adapted or the original creation of the authors. Perhaps the authors could consider creating a link of information from the community to the mission hospital/local authority, since the community is the original and last source of maternal data.

3. Also, I don’t find an in-text reference to figure 1. which makes the figure appear not useful in the manuscript, but that is not the case. Please reference the figure in the write up appropriately.

Study design

1. “The updated CDC guidelines for 163 Surveillance System Evaluation” … was the updated version utilized in the Makonde District surveillance, otherwise, the authors may have to explain why they chose the updated version of CDC guidelines.

2. What is “T5” registers?

Sample size and data collection

1. “A minimum sample size of 61 was calculated”. This does not marry well with “we interviewed five doctors and forty nurses from the provincial hospital, two doctors and six nurses from the rural hospital, one nurse and one doctor from the private maternity clinic, ten nurses from the urban clinics and fourteen nurses from the rural clinics”. Clarity is necessary. Your sample calculation of the mortality record for desk top review must stand out clear from your choice of health care professionals for interviews.

2. Could the authors share the data collection tools?

Ethical consideration

1. Perhaps the authors could quote the approval code or number from the Mashonaland West Provincial Ethics Committee.

Results

1. Only 41% were midwives, although a large portion of the health professionals interviewed were nurses. The expectation is that midwives should be the main target group for interview in matters of maternal deaths and audit. The authors need to explain further why this was not the case. Perhaps numbers and availability and willingness, to add meaning to the results.

2. The writing of the results should be re-organised to give a good flow. For example, “Overall, 61 (77.2%) of the 248 healthcare workers displayed good knowledge of the MDSR system. Table 3 shows the results” should be the opening paragraph of that section and followed by other relevant portions of the results which the authors intend to communicate rather than make this statement in the ending paragraphs.

3. “Assuming a nurse’s salary of $400 USD and a distance of 120 km of the furthest health facility to the district hospital” what is the need for introducing a nurse’s salary in the cost component of the results write up? It appears tangential to the study discourse. In any case, the entire idea of cost does not add value to the study objective. It can be removed without a significant damage to the study results.

Discussion

1. Generally good-

2. The authors made a statement that “Healthcare workers in Makonde District presumed the MDSR system to be useful as they utilised the information generated from audits to improve maternal health service delivery and monitor maternal mortality” yet, the district doesn’t seem to achieve what is expected. Could there be some conflicting reasons??? This needs to come out clearly in the discussion.

Limitation of study

1. Although the study is useful, it is limited in many ways. For example, not targeting midwives more in the study, given they are the professional grouping mandated to handle pregnant women limits the validity of information obtained from the health workers. This has to be stated in the manuscript.

Conclusion and Recommendations

1. Your results show 87.3% know the importance of the tool, 91% know the timeliness importance, 97% thinks the system is useful, 88.6% are willing to continue with the surveillance system yet “lack of motivation” and “training gap” appeared in your conclusion? Readers will not understand this. The authors need to revise their conclusion based on the study results.

2. The authors rather gave general recommendation including training requirement of staff and also recommended the need for ambulance services to be effectively provided. I don’t find these as borne out of the study results/discussion, especially as the surveillance process did not involve ambulance system and the results suggest the staff had good knowledge of the surveillance system.

3. The author’s recommendations ought to be specific to the gaps identified in their evaluation or emanating from the discussion of the results. Specific and targeted.

Saumya Nanda, MD in OBGYN, FICOG (Reviewer 2)

The manuscript is technically sound descriptive cross-sectional study.

A 1-5 Likert scale was used to measure level of knowledge among health care workers. Data was captured using Epi Info 7.2.4 statistical package. This software was used to conduct 221 univariate analysis to generate frequencies, means and proportions which is appropriate for the study. Data underlying the findings are available.

The manuscript is written in standard English without ambiguity. No typographical or grammatical errors were detected. Few lines of the Introduction are similar to the introduction of the following publication and needs to be addressed.

Millimouno TM, Sidibé S, Delamou A, Bello KOA, Keugoung B, Dossou JP, Beavogui AH, Meessen B. Evaluation of the maternal deaths surveillance and response system at the health district level in Guinea in 2017 through digital communication tools. Reprod Health. 2019 Jan 18;16(1):5. doi: 10.1186/s12978-019-0671-3. PMID: 30658674; PMCID: PMC6339333.

The manuscript is loosely inspired by the following publication:

Maphosa, M., Juru, T. P., Masuka, N., Mungati, M., Gombe, N., Nsubuga, P., & Tshimanga, M. (2019). Evaluation of the Maternal Death Surveillance and response system in Hwange District, Zimbabwe, 2017. BMC Pregnancy and Childbirth, 19(1). https://doi.org/10.1186/s12884-019-2255-1.

There is profound similarity in the aim, study design and methodology of the submitted manuscript with the above publication.

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)

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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: 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: The authors attempted to evaluate a very important surveillance programme on marternal mortality. Their attempt is largely descriptive and less of analysis of association or impact evalaution. It is also imperitive to note that the authors relied much on data from nurses and doctors and less from midwives, which raises questions of data validity, given midwives are the first point of call on matters of maternal mortality.

Reviewer #2: The manuscript is technically sound descriptive cross-sectional study. A 1-5 Likert scale was used to measure level of knowledge among health care workers. Data was captured using Epi Info 7.2.4 statistical package. This software was used to conduct 221 univariate analysis to generate frequencies, means and proportions which is appropriate for the study. Data underlying the findings are available. The manuscript is written in standard English without ambiguity. No typographical or grammatical errors were detected. Few lines of the Introduction are similar to the introduction of the following publication and needs to be addressed.

Millimouno TM, Sidibé S, Delamou A, Bello KOA, Keugoung B, Dossou JP, Beavogui AH, Meessen B. Evaluation of the maternal deaths surveillance and response system at the health district level in Guinea in 2017 through digital communication tools. Reprod Health. 2019 Jan 18;16(1):5. doi: 10.1186/s12978-019-0671-3. PMID: 30658674; PMCID: PMC6339333.

The manuscript is loosely inspired by the following publication:

Maphosa, M., Juru, T. P., Masuka, N., Mungati, M., Gombe, N., Nsubuga, P., & Tshimanga, M. (2019). Evaluation of the Maternal Death Surveillance and response system in Hwange District, Zimbabwe, 2017. BMC Pregnancy and Childbirth, 19(1). https://doi.org/10.1186/s12884-019-2255-1.

There is profound similarity in the aim, study design and methodology of the submitted manuscript with the above publication.

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Reviewer #1: Yes: John Azaare, PhD

Reviewer #2: No

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Attachments

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Submitted filename: Reviewers Comments.docx

PONE-D-22-28650R1Maternal death surveillance and response system evaluation in Makonde District, Zimbabwe, 2021PLOS ONE

Dear Dr. Chadambuka,

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 Sep 02 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.

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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,

Richard Kalisa, MD, PhD

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.

Additional Editor Comments:

Thanks for addressing the reviewers comments. However, there are still minor revisions prior acceptance of your manuscript are listed below:

1.This manuscript should be proofread by a native English speaker

2. I noted the cost of notifying and investigating a single death was USD$65.18. Please clarify to your readers its relevance as it was ONLY mentioned in the abstract and not elsewhere.

3. The manuscript needs to formatted in accordance journal's manuscript style.

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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-22-28650R2Maternal death surveillance and response system evaluation in Makonde District, Zimbabwe, 2021PLOS ONE

Dear Dr. Chadambuka,

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 22 2024 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,

Johanna Pruller, PhD

Associate Editor

PLOS ONE

on behalf of 

Srinivasa Rao Gadde, Ph.D.

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.

Additional Editor Comments:

Acceptance of the paper for publication is possible. Prior to accepting the submission, the following errors must be fixed by the authors:

Aline all the lines in the entire document.

Table contents and labels should be unbolded.

Examine the style of referring.

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Maternal death surveillance and response system evaluation in Makonde District, Zimbabwe, 2021

PONE-D-22-28650R3

Dear Dr. Chadambuka,

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,

Srinivasa Rao Gadde, Ph.D.

Academic Editor

PLOS ONE