PONE-D-22-28776Validating the indicator “maternal death review coverage” to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record dataPLOS ONE

Dear Dr. Gausman,

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George Kuryan

Academic Editor

PLOS ONE

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Additional Editor Comments:

I concur in large part with the reviewer

METHOD:

Study setting: The readers need more information here. Briefly describe why those countries were selected, whether the study is part of a larger study, location of those districts, either rural and / or urban. How the health system is basically organized in each country from lower to higher level health facility, what type of health workers can be found in each level of health facility (for instance: the requirement can be to have at least one nurse and midwife in each health post), etc.

Data collection and source: Why only public health facilities are included in India and Argentina? What is the data collection period? Tell us more about the expertise data collectors (are they health professionals? How the training was done? Etc.) what tools were used to collect the data, ect…

District/provincial data: Was individual level data or aggregate level data extracted from HMIS?

- If aggregate level, how the linkage was done with facility level data?

- If individual level, what variables were extracted to be used to link with facility data (only date of death is not sufficient in my view). You need to convince why only this information was enough to link facility and district level data.

Please be more precise.

Data analysis: You need to define your indicators (completeness, content, death with evidence, etc.). What criteria was used for each indicator? For instance, what is “death evidenced at facility” what criteria was used to help classify it as Yes or No.

Socio-demographic characteristics of women (age, place of residence and timing of death): Why only those indicators are selected. Is it based on literature review? How are they selected? Ar those only available variables collected in death certificate? Why not include additional variables such as profession, education, marital status, etc… if available.

Lines 208-211: We need more details about the linkage between facility and district level data. Variables used for this linkage. I do not think only date of death is enough to link two datasets. There are linkage procedures that were developed to link two datasets using names, place of death, date of death, etc. Be more specific about technic you have used here.

RESULTS:

There are too many tables and figures. Many of them can be combined or summarized. Readers may be lost here with too many repeated results. For instance the last table (table 6), almost all information were found in table 1.

While this has some merit the poor quality of the write up and analysis detract from The findings

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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

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

Reviewer #1: 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: 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

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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: VALIDATING THE INDICATOR “MATERNAL DEATH REVIEW COVERAGE” TO IMPROVE MATERNAL MORTALITY DATA: A RETROSPECTIVE ANALYSIS OF DISTRICT, FACILITY, AND INDIVIDUAL MEDICAL RECORD DATA

Maternal mortality in LMIC remains is an important topic to explore due to high persistence of MMR even at a health facility level. The authors used an interesting approach to assess the maternal death review coverage. The results of the paper should guide policymarkers on the improvement of maternal mortality data and maternal health programs.

The Introduction is well written. But it is too long. Recommend to shorten it.

METHOD:

Study setting: Even if the authors asked to review the study protocol for more detail, the readers need more information here. For instance, I would suggest to briefly describe why those countries were selected, whether the study is part of a larger study, location of those districts, either rural and / or urban. How the health system is basically organized in each country from lower to higher level health facility, what type of health workers can be found in each level of health facility (for instance: the requirement can be to have at least one nurse and midwife in each health post), etc.

Data collection and source: Why only public health facilities are included in India and Argentina? What is the data collection period? Tell us more about the expertise data collectors (are they health professionals? How the training was done? Etc.) what tools were used to collect the data, ect…

District/provincial data: Was individual level data or aggregate level data extracted from HMIS?

- If aggregate level, how the linkage was done with facility level data?

- If individual level, what variables were extracted to be used to link with facility data (only date of death is not sufficient in my view). You need to convince why only this information was enough to link facility and district level data.

Please be more precise.

Data analysis: You need to define your indicators (completeness, content, death with evidence, etc.). What criteria was used for each indicator? For instance, what is “death evidenced at facility” what criteria was used to help classify it as Yes or No.

What is completeness of death review, what is the criteria? You may have mentioned it in the Box 1 (Introduction), but we still need it here.

Socio-demographic characteristics of women (age, place of residence and timing of death): Why only those indicators are selected. Is it based on literature review? How are they selected? Ar those only available variables collected in death certificate? Why not include additional variables such as profession, education, marital status, etc… if available.

Lines 208-211: We need more details about the linkage between facility and district level data. Variables used for this linkage. I do not think only date of death is enough to link two datasets. There are linkage procedures that were developed to link two datasets using names, place of death, date of death, etc. Be more specific about technic you have used here.

RESULTS:

There are too many tables and figures. Many of them can be combined or summarized. Readers may be lost here with too many repeated results. For instance the last table (table 6), almost all information were found in table 1.

I suggest reorganizing the results’ section to summarize your main findings in 3-4 tables and 1-2 graphs. Numbers from one table to another are different and confusing.

Lines 241-258: This section is difficult to read. You start with age group then residence area and talk again about age group. I suggest to reorganize it taking into account one characteristic at a time.

Minors

Line 49: correct “indictor” to “indicator”

Line 113-5: something is missing in this sentence, not clear

Lines 139-9: Not clear, do you say that death that occurred outside the health facility may be counted in the denominator. I thought this indicator only considers intra-facility (hospital) death.

Table 3. Ghana (Yes, column 6), correct n should be 14 instead of 13

Table 4. Review the total number for India.

Line 278: Review the sentence. I think it should be “higher than” instead of “lower than”

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Reviewer #1: Yes: Almamy Malick Kante

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PONE-D-22-28776R1Validating the indicator “maternal death review coverage” to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record dataPLOS ONE

Dear Dr. Gausman,

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 09 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,

George Kuryan

Academic Editor

PLOS ONE

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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 #2: (No Response)

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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 #2: Yes

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

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 #2: 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

**********

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 #2: This study addressed an important area od validity and quality of maternal death statistics based on MDR. The study has clear approach relating to the indicators used globally and issues addressing both the numerator and denominator.

However, there are some concerns which need to be addressed.

1. While the authors make enormous efforts in six districts over three countries, at the end the number of deaths which from the core of the analyses are small. 17 in Argentina, 14 in Ghana and 58 in India. The numbers are too small to make generalizations even within the country. One cannot escape a sense that there is over-interpretation based on a small set of data.

2. While the introduction makes a good case for the need for the study, methods section is quite confusing. Overall, the paper fails to have an engaging narrative and that subtracts significantly from the importance of the paper. I would recommend a tabular approach to list the key questions /indicators and methodological approach to answering them.

3. The formation of tables, too many, needs rethinking. Since inter-country comparison is neither attempted nor necessary, could the authors consider using country specific tables with each indicator as a row. and provide a clear narrative of a country as a case study before going to next and maybe use summary table for comparison.

4. To fully understand the results and their implications to make the recommendation, it would be useful to add some observations related to the process of reviews and reporting made by the investigators.

5. Lack of inclusion of private facilities in India and Argentina is a serious limitation.

Minor:

• Table 3 shows that both in Argentina and India approx. 17% of maternal deaths, had no evidence that a death review occurred (L 325-26); the denominator for Fig1 is not clear, whether it excludes these.

• Table 4 says India complete death review is 48 whereas it is only 24. 48 deaths had any review and not complete review. Needs correction.

• Table 5 can be simplified by deleting all NO as it is a binary and except complicating the table, add no value to the paper.

• L204 – six weeks of abortion and 42 days of delivery ).. Aren’t these same then why use different time units.

• Table 1 can go as supplementary table.

• Quality of figures are very poor. Fig1 need to have numbers, a horizontal bar could be considered for ease in interpretation. Figure 2 summary is a good idea but was difficult to interpret.

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Reviewer #2: Yes: Anand Krishnan

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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-22-28776R2Validating the indicator “maternal death review coverage” to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record dataPLOS ONE

Dear Dr. Gausman,

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 23 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,

Jianhong Zhou

Staff Editor

PLOS ONE

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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.

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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 #2: (No Response)

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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 #2: Yes

**********

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

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 #2: (No Response)

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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

**********

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 #2: Overall the paper covers an important area and uses a sound approach.

Abstract:

• Use the term assessed rather than explore the validity of the indicator.

• Add the actual number of deaths covered in the study.

• Conclusions: First line can be deleted. It says we found incompleteness in deaths recorded. Is this result shown in the abstract?

Main Paper:

They selected on high performing and one low performing districts – are they reporting the results by this?

What proportion of the maternal deaths are expected to happen in the private sector needs to be told, even if this is approximate and is from the district level reporting.

I still think that there are too many tables and it is best to organize all indicators of one country in a table to give a composite idea of that country to make a meaningful interpretation. Repeated comparisons between countries (which is meaningless) in all tables hinders and is boring beyond a point. The common issues can then be taken up in discussion. The authors feel otherwise. I leave it for the editors to decide.

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Reviewer #2: Yes: Anand Krishnan

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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.

Validating the indicator “maternal death review coverage” to improve maternal mortality data: A retrospective analysis of district, facility, and individual medical record data

PONE-D-22-28776R3

Dear Dr. Gausman,

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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Jianhong Zhou

Staff Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: