Suboptimal factors in maternal and newborn care for refugees: Lessons learned from perinatal audits in the Netherlands

A. E. H. Verschuuren; J. B. Tankink; I. R. Postma; K. A. Bergman; B. Goodarzi; E. I. Feijen-de Jong; J. J. H. M. Erwich

doi:10.1371/journal.pone.0305764

Peer Review History

Original SubmissionOctober 16, 2023
4 Dec 2023 Decision Letter - Omid Dadras, Editor PONE-D-23-31690Suboptimal factors in maternal and newborn care for refugees: lessons learned from perinatal audits in the Netherlands.PLOS ONE Dear Dr. Verschuuren, 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. ============================== Major revisions required============================== Please submit your revised manuscript by Jan 18 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. 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Reviewer #1: No Reviewer #2: Partly Reviewer #3: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: N/A Reviewer #3: Yes ****** 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 Reviewer #2: Yes Reviewer #3: No ****** 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: No Reviewer #2: Yes Reviewer #3: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Dear Author, I found your paper interesting; however, I have a few comments and suggestions for improvement Clarity and Flow: Work on simplifying language and ensure a smooth flow. Collaborate with team members for input before finalizing. Table Presentation: Enhance the visual appeal of the table for clarity. Ensure that the data selected is both relevant and effective. Visualization: Consider presenting findings in diagrammatic form for a more engaging presentation. Literature Review: Expand the literature review to include more suboptimal factors in the discussio. Avoid singular focus and explore a comprehensive range of factors such as education, financial costs, health insurance, wait times, age, and gender in the context of access to healthcare. Ensure clarity and conciseness in presenting the expanded list of factors for a more comprehensive understanding. Conciseness: Make the paper more clear and concise, avoiding unnecessary details. List and present factors explicitly to enhance readability. By addressing these points, the paper can become more accessible, visually appealing, and comprehensive. Reviewer #2: The author has written the overall manuscript well. However, the sample size and conclusion are dubious. Line 209. Pakistan and Afghanistan are not Middle Eastern countries. I suggest the authors revise the tables and findings. Line 260. Table 3. Postnatal maternity care should incorporate dietary considerations, including religious restrictions, for refugees. It is pertinent to evaluate why dietary factors are not addressed in the table 3 during institutional or non-institutional-based care, particularly given the focus of the study on refugees. The lack of attention to this aspect may lead to suboptimal care and outcomes for refugee women, who may have unique dietary needs due to religious restrictions or other factors. Line 408-409 The overall conclusion appears to be too general in nature. Specifically, the authors should direct their attention towards addressing the unique needs of refugee women in the Netherlands. A more targeted approach would be more effective in delivering the intended message. A more targeted approach would be more effective in delivering the intended message. Reviewer #3: In the throes of the world's current multiple wars, within and between many countries, the authors' research is a timely and significant contribution towards global best practice for managing the welfare of refugees, in particular, pregnancy and perinatal care. Their data analysis appears appropriate for a reviewer with limited statistical expertise that I am. However, their findings do not support the generalizability reflected in their results and conclusions, and their "Strengths and Limitations" section partly reveals this point. There are methodological limitations including retrospective design, using a national audit whose cases are incomplete, with an unknown denominator, subjective criteria for case inclusion/rejection by the research team, absence of non-refugee population data for background and comparison. In my opinion, 'minor revision' is warranted such that the manuscript would meet acceptance for publication. Its conclusions and recommended policy adjustments ought to be limited to the scope of the audit, namely, the findings that need future corroboration to drive policy change. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Rita Adhikari Reviewer #2: Yes: Ishtiaq Ahmad Reviewer #3: 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: Verschuuren et al. manuscript.docx https://doi.org/10.1371/journal.pone.0305764.r001
Revision 1
28 Apr 2024 Author Response Author’s response: Reviewer #1 Dear reviewer, Thank you for your constructive, relevant, and helpful comments to improve the manuscript. We used the track changes tool to indicate the edits we made. Comment 1: Dear Author, I found your paper interesting; however, I have a few comments and suggestions for improvement Response 1: Thank you for your comments and suggestions. We hope to have answered them to your satisfaction. Comment 2: Clarity and Flow: Work on simplifying language and ensure a smooth flow. Collaborate with team members for input before finalizing. Response 2: After we changed the manuscript according to all reviewer’s comments, all authors thoroughly reviewed the manuscript to improve language and readability. All changes made based on reviewers’ comments were approved by the entire research team before re-submission. Comment 3: Table Presentation: Enhance the visual appeal of the table for clarity. Ensure that the data selected is both relevant and effective. Response 3: We decided to remove Table 2 entirely as we agree with the reviewer that it was difficult to interpret and added relevant information to the text. We adjusted the text accordingly. In addition, to improve clarity and readability we removed the number of minor suboptimal factors from table 3. The visual appeal of the table will be further amplified by the journal before publication. Comment 4: Visualization: Consider presenting findings in diagrammatic form for a more engaging presentation. Response 4: We presented the Three Delays Model in a diagrammatic format as suggested in the comments in the manuscript, to clarify the factors in the different phases of delay. Comment 5: Literature Review: Expand the literature review to include more suboptimal factors in the discussion. Avoid singular focus and explore a comprehensive range of factors such as education, financial costs, health insurance, wait times, age, and gender in the context of access to healthcare. Ensure clarity and conciseness in presenting the expanded list of factors for a more comprehensive understanding. Response 5: We understand your concern. We agree that the above-mentioned factors may play a role in access to health care. We decided to mostly focus our discussion on factors identified within the Perinatal Audit registry. Because of the way the registry is constructed and the retrospective nature of the study, we were unable to assess the influence of factors such as education, financial costs, health insurance, wait times, age, and gender on care. Considering your comment, we added women’s educational attainment as a phase 1 and 2 barrier to the discussion. We did not discuss the financial costs of pregnancy care because in the Netherlands these are covered by healthcare insurance (also for refugees and undocumented migrants). Financial costs are therefore considered less of a barrier to accessing care in our country. In addition, there are negligible wait times for accessing antenatal care. As pregnant women are generally around the same age and of the same gender, we did not consider these factors relevant in light of the population we are studying. Comment 6: Conciseness: Make the paper more clear and concise, avoiding unnecessary details. List and present factors explicitly to enhance readability. By addressing these points, the paper can become more accessible, visually appealing, and comprehensive. Response 6: We tried to remove unnecessary details by removing table 2, removing unnecessary information from table 3 and by partially rewriting the text. We hope this makes the results more accessible and clearer. We kindly thank you again for your input and hope that you consider the revised version more accessible, visually appealing and comprehensive. Reviewer #2 Dear reviewer, Thank you for your thorough review of our manuscript and your constructive feedback. We used the track changes tool to indicate the edits we made. Comment 1: The author has written the overall manuscript well. However, the sample size and conclusion are dubious. Response 1: We understand the reviewer’s concerns considering the sample size. However, since we used the national registry of the perinatal audit and included all cases of refugees, this is the maximum sample size we had access to. We are confident our sample holds sufficient data to provide important qualitative insights regarding care in this specific population. We adjusted the conclusion to better fit the results and the design of the study. Comment 2: Line 209. Pakistan and Afghanistan are not Middle Eastern countries. I suggest the authors revise the tables and findings. Response 2: Thank you for this important comment. We changed the name of the country group from 'Middle East’ to ‘Asia’. Comment 3: Line 260. Table 3. Postnatal maternity care should incorporate dietary considerations, including religious restrictions, for refugees. It is pertinent to evaluate why dietary factors are not addressed in table 3 during institutional or non-institutional-based care, particularly given the focus of the study on refugees. The lack of attention to this aspect may lead to suboptimal care and outcomes for refugee women, who may have unique dietary needs due to religious restrictions or other factors. Response 3: We agree that diet may affect maternal and perinatal outcomes. We were only able to focus on factors identified within the Perinatal Audit registry in this study. Because of the way the registry is constructed and the retrospective nature of the study, we were unable to assess the influence of dietary restrictions. This would make for interesting further research. In general, dietary options in the Netherlands will fulfill people’s needs. Fasting due to Ramadan is usually partially done during pregnancy. Possible effects on fetal growth are indicated by the known birth weights. Comment 4: Line 408-409 The overall conclusion appears to be too general in nature. Specifically, the authors should direct their attention towards addressing the unique needs of refugee women in the Netherlands. A more targeted approach would be more effective in delivering the intended message. Response 4: We adjusted the conclusion to better fit the results and the design of the study. Reviewer #3 Dear reviewer, Thank you for your thorough review of our manuscript and your constructive feedback. We used the track changes tool to indicate the edits we made. Comment 1: In the throes of the world's current multiple wars, within and between many countries, the authors' research is a timely and significant contribution towards global best practice for managing the welfare of refugees, in particular, pregnancy and perinatal care. Their data analysis appears appropriate for a reviewer with limited statistical expertise that I am. Response 1: Thank you for your kind words. Comment 2: However, their findings do not support the generalizability reflected in their results and conclusions, and their "Strengths and Limitations" section partly reveals this point. There are methodological limitations including retrospective design, using a national audit whose cases are incomplete, with an unknown denominator, subjective criteria for case inclusion/rejection by the research team, absence of non-refugee population data for background and comparison. In my opinion, 'minor revision' is warranted such that the manuscript would meet acceptance for publication. Its conclusions and recommended policy adjustments ought to be limited to the scope of the audit, namely, the findings that need future corroboration to drive policy change. Response 2: We agree with the reviewer and acknowledge the limitations of this study. However, we think our results provide valuable data to identify important factors to improve maternal and newborn care for refugees which is partially independent of the data’s completeness. We adjusted the conclusion to better fit the results and the design of the study. Response to reviewers’ comments in text: Abstract: Reviewer’s comment: Clarify your study by explicitly mentioning the retrospective audit design and study period, and briefly noting the sample size (53 cases) for transparency. The audit involves a review of past records and performance itself. How important is it to mention the retrospective audit over here? Additionally, succinctly categorize the severity and types of adverse outcomes to offer readers a clearer understanding of your research context and findings. Author's response: We clarified the abstract according to the reviewer’s comment. Keywords: Reviewer’s comment: Choose specific and broad keywords, with synonyms, for clarity and broaden the audience. Limit the list to 5-6 words. Consult the latest PLOS ONE guidelines for keyword count and word limits for the single keyword and consider adding "maternal and newborn health. Author's response: We’ve adjusted keywords according to the reviewer’s comment and hope this will broaden the paper’s audience. Introduction: Reviewer’s comment : Improve the flow with transitions, state more about how your study address the challenges and its contribution to resolving the challenges, and incorporate a clear research question to offer the readers clear directions Author's response: We strived to improve the flow, clarified the research question, and stated additional information about the goal of the study and how it contributes to improving birth care for asylum seekers and refugees. Methods: Reviewer’s comment: Please rewrite it as the reader could not get sense from it. Author's response: We revised both the aforementioned sentence and its precursor. Reviewer’s comment: Better to present this model in the framework in the diagrammatic form . Framework is usually looks good in frame. Author's response: We added the model in diagrammatic form. Reviewer’s comment: How do you determine the factor’s likelihood of contributing to the problem is major or minor? Author's response: We clarified that this was based on expert opinion Reviewer’s comment: I think its crucial to provide the detailed information regarding the research documentations to ensure the transparency and compliance with the ethical standards within the research. Author's response: We added additional information on this topic. Results: Reviewer’s comment: Rewrite it : please never starts with number in the beginning of the paragraph. Author's response: We rewrote the paragraph Reviewer’s comment: Please make it concise and clear. Author's response: We rewrote the paragraph to try to make it more concise and clear. Reviewer’s comment: Why the dublicate title in same paper? I suggest you to change the title. Author's response: We changed the title. Reviewer’s comment: Would you please clear about the what is 12/1 or 13/2. I didn’t get the idea. Rearrange the table in standard format with clear view. Author's response: After discussion with all authors, we decided to remove the table entirely as we agree with the reviewer that it was difficult to interpret and added little to no extra information to the article. We adjusted the text accordingly. Discussion: Reviewer’s comment: List more literature review to make your discussion more strong and effective. Author's response: We added additional references (which are not marked with track changes as they were added through Mendeley Reference Manager). Reviewer’s comment: You have talk about the language barrier and the policy of migrant as a factor. But is it the only factors that is associated for access of services? What about education level, age and gender, health literacy, financial barriers,?? Why you are just focusing these two factors only among a lot?? Author's response: We understand your concern. We agree that the above-mentioned factors may play a role in access to health care. We decided to mostly focus our discussion on factors identified within the Perinatal Audit registry. Because of the way the registry is constructed and the retrospective nature of the study, we were unable to assess the influence of factors such as education, financial costs, health insurance, wait times, age, and gender on care. Considering your comment, we added women’s educational attainment as a phase 1 and 2 barrier to the discussion. We did not discuss the financial costs of pregnancy care because in the Netherlands these are covered by healthcare insurance (also for refugees and undocumented migrants). Financial costs are therefore considered less of a barrier to accessing care in our country. In addition, there are negligible wait times for accessing antenatal care. As pregnant women are generally around the same age and of the same gender, we did not consider these factors relevant in light of the population we are studying. Reviewer’s comment: You yourself are saying its underrepresentation of the study population so how it gonna represent the other refugees? Author's response: What we mean here is that there are probably more factors that play a role in prenatal care for refugees than we were able to identify in this study (due to the design of the National Preinatal Audit and retrospective nature of the study). This makes the high number of suboptimal factors identified even more alarming. Conclusion: Reviewer’s comment: I did not find any new and innovative things over here. These are already published similar result in other publication. Author's response: We adjusted the conclusion to better fit the results and the design of the study. Reviewer’s comment: I think it is better not to keep in the conclusion part. You can Author's response: We moved the further research recommendations to the last paragraph of the discussion. As we considered it important to maintain these recommendations. Attachments Attachment Submitted filename: Response to reviewers comments Plos one.docx https://doi.org/10.1371/journal.pone.0305764.r002
5 Jun 2024 Decision Letter - Omid Dadras, Editor Suboptimal factors in maternal and newborn care for refugees: lessons learned from perinatal audits in the Netherlands. PONE-D-23-31690R1 Dear Dr. Anouk Verschuuren, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Omid Dadras, MD, PhD Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0305764.r003
Formally Accepted
18 Jun 2024 Acceptance Letter - Omid Dadras, Editor PONE-D-23-31690R1 PLOS ONE Dear Dr. Verschuuren, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr Omid Dadras Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0305764.r004

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