PONE-D-23-12582A mixed-method analysis of provider adherence to integrated antenatal care guideline in primary health centre: An Indonesian casePLOS ONE

Dear Dr. Yuliyanti,

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.

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Phyllis Lau, PhD

Academic Editor

PLOS ONE

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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: No

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: No

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: Abstract.

Please describe where and when the study was conducted. How do you assess the adherence?

Introduction.

Please provide the full name of CEmNOC before put the acronym.

This sentence should be place in the methods: "Health providers in BEmNOC PHC administer parenteral drugs (i.e., antibiotics, uterotonic, oxytocin, and magnesium sulfate for preeclampsia and eclampsia). They also manually remove the placenta and retained products (e.g. manual vacuum extraction, dilation, and curettage), assisted vaginal delivery, and basic neonatal resuscitation."

Methods.

The 1st and 2nd paragraph of study setting should be part of the introduction as the rationale of the study.

Table 1 should be part of the result.

There some redundancy of information between the study design section and the quantitative and qualitative section. Please select the information that you put there carefully, without repetition.

Why do you choose medical records of ANC visits from November 2018 and August 2019 and not a 1-year period instead?

You stated that you select the PHC that collaborates with the hospital where the principal researcher works. Isn't that cause selection bias? How do you managed it?

You stated that "The provider adherence to integrated ANC guidelines was determined using the Indonesian Ministry of Health indicators enacted in 2012." However, in the result you also mentioned that you also analyzed whether it adhere to the local policy. Please also stated it in the methods.

Please give more detail about the type of socio-demographic data collected.

In the results, besides Kruskal Wallis, you also use Chi-square and Fisher. Please stated it in the methods, and explain which data use which type of analysis. Also you must stated here that you analyzed the average for the continuous data, and conduct statistical analysis to identify the difference. Have you conducted normality test for numerical data?

Please give more description regarding the SPSS, the company that produce it and the city where the company is located.

Please also give more detail information regarding the "observation". Who conducted it? What is the instrument utilized?

What is the qualification of the interviewer on the qualitative part? Since you stated that the PHCs were conveniently selected, how do you ensure that there is no interviewer bias?

Results.

The sentence, "These results showed that a compulsory education program and the minimum age of marriage law had been implemented well in this city22,33,34. It is belong to the discussion, not results.

Table 1. The term "study participants" is not appropriate, as you only analyzed the medical records which is not requiring participation of the women. Please also use complete full name for PHC and BEMNOC (not the acronym) and where is it located. Although it is already narrated previously. A table should be self explained.

The statement, "However, more pregnant women received an integrated ANC procedure in BeMNOC (average score of 42.26) than non-BEmNOC (average score 39.8)." This statement here reflect a proportion comparison, while you actually comparing the score, please rephrase.

The statement, "The medical record review showed excellent documentation of interdisciplinary examination and

education except for the first visits." This is actually an interpretation, which should be part of discussion. The result should only present fact.

Table 3. You use "general state" while in the methods you use term "general condition". Please be consistent.

Please use complete word for "and" not symbol "&". It appears in several parts of the manuscript.

For the p-value, please write "<0.001" for "0.00". The value is actually not zero, but the SPSS shortened it.

The sentence, "Still, the interdisciplinary education was excellent in all PHC except for the dentist visit in the first visits." This is also discussion.

You mentioned "reagent" several times. Please explain "reagent" for what.

In the quote line 277, what is "general checking" refers to? Is it the same meaning with "general condition" or "general status"? Please be consistent in the terminology.

You mentioned about policy document review. Please give more description in the methods.

Is BPJS-K the same with BPJS? Please be consistent.

Discussion.

The statement (line 317), The different findings were related to the difference in assessment methods and content of the integrated ANC procedure. Explain more about the difference in the assessment methods.

Line 327: LMIC (Low Middle Income Country), should be the complete name first and the acronym in the bracket.

Line 333: Ministry of Health Regulation No. 97 of 2014, did you mean the Ministry of Health of Indonesia?

Line 343: general perception assessment. what is "general perception assessment"? Please use same terminology through-out. Or provide explanation for each in the methods section.

You should acknowledge the biases in your study methods as the limitations.

How is the generalizability of this study?

Conclusion.

For the first statement please make clear that it is in Indonesia.

The statement, "The average score of provider adherence to the integrated ANC guideline in non-BEmNOC PHC (66,66) was higher than BEmNOC (33,3). However, there was no statistical difference (p = 0.000)." It seems to not appear in the result previously. Conclusion should be based on the result. Where is the statement appear in the result? Please don't add new result in the discussion or conclusion.

Acknowledgement.

Is The Indonesia Endowment Fund for Education funding the study? If so, please mention in the funding section.

General comment.

The manuscript need to be proof-read by an English language editor. Also the author mentioned about reporting guidelines, but it is not attached.

Reviewer #2: Dear Editor,

Thank you very much for the opportunity to review this manuscript, that the topic is close to my research interest and geographic expertise.

The authors have provide quite comprehensive study about the adherence of antenatal care in Semarang Indonesia.

From me, there are couple of minor revisions that the authors need to address before the publication of this paper:

1. The author mentions BemNOC many times, which is I understand, However, I would suggest to use a more widely used Basic Emergency Obstetric and Newborn Care (BEmONC)-See UNFPA publication, to represent Puskesmas with PONED-an Indonesian term for it.

2. Couple of abbreviations are not mentioned earlier but at the later part of the manuscript, for example LMIC-should be expand for the first time it is mentioned and BPJS-BPJSK.

3. Details for data analysis, data collection, trustworthiness, demographic of qual participants for the qualitative interviews/FGs are missing.

4. I would comment more also for the discussion and limitations, including implications for further research. This research would imply many, such as the need of training for non BEmONC, authority within primary care staff, and also perhaps further training for pregnancy complication screening-This was discussed superficially and authors discussed more on the numbers only.

5. Implication for further research and limitation of the study, including limited number of women and health providers involved in the study have not been clearly acknowledged. While Semarang is one of the big cities in Indonesia that usually the availability at least one doctor in the daily PHC practice is usually warranted. It raised concerns on the quality of care rather than numbers.

Thank you very much.

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Reviewer #1: No

Reviewer #2: No

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PONE-D-23-12582R1A mixed-method analysis of provider adherence to integrated antenatal care guideline in primary health centre: An Indonesian casePLOS ONE

Dear Dr. Yuliyanti,

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.

==============================

ACADEMIC EDITOR: - If the aim of the study is to compare BeMONC and non-BeMONC centers, please indicate so in the title- The authors mentioned that this is a larger study with PHCs caring for women with heart diseases. Does this mean this study includes only women with heart diseases? Please elaborate- "Adherence to guidelines was assessed based on the fulfillment of items in the modified national integrated ANC guideline checklist" --> What is the specific criteria? Does the failure of not checking one item is already considered non-adherence?- What is the estimated sample size for the qualitative phase? Why were only five women included?- What is the MMR in Semarang over time compared to the national level?- In Line 464, the conclusion mentions no statistical difference despite the p value being less than 0.000 (which cannot be true anyway). Please explain- In Line 242, the authors mentioned there were no differences, when it is more accurate to state that there is no statistically significant differences, as there are actually differences in the percentages.- I suggest the authors to use a proofreading service as there are careless typos all over the manuscript. The most egregious one is in line 123 with "agshsus", which I could not make neither heads nor tails what that mean.

==============================

Please submit your revised manuscript by Jan 05 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,

Gilbert Sterling Octavius

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)

Reviewer #3: 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 #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: 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

Reviewer #3: 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: No

**********

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: Unfortunately, it is still unclear to me in this version, as only one highlight in the manuscript so I don't really know which one has been edited. Could the author provide the tracked changes all of the edits? or highlight it?

At the response to the reviewers also do not specifically answering the reviewers comment.

Reviewer #3: The study reaches its aim to compare the provider’s adherence to the integrated antenatal care between two types of health care units. The structure is interesting but not innovative. Yet, maternal mortality reflects the quality of a health care system and therefore I have a positive opinion on this study.

Positive points:

Study design and methods are accurately described. The Statistical analysis used was adequate. Tables are clear and readable, table captions are complete and accurate.

Negative points:

The literature statistics should be in provided in table for easier studying.

I suggest a more detailed description of the local health care system. The structure of the health care system in developing countries and a brief description of the way it functions should be addressed.

In study design, lines 111-115 should be addressed in the results.

Language editing is recommended.

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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 #2: No

Reviewer #3: No

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Attachments

Attachment

Submitted filename: PONE.docx

PONE-D-23-12582R2A mixed-method analysis of provider adherence to integrated antenatal care guideline in BEmONC and Non BEmONC primary health center: An Indonesian casePLOS ONE

Dear Dr. Yuliyanti,

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 Aug 08 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,

Gilbert Sterling Octavius

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.

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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 #3: All comments have been addressed

Reviewer #4: 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 #3: Yes

Reviewer #4: Partly

**********

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

Reviewer #3: N/A

Reviewer #4: 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 #3: Yes

Reviewer #4: 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 #3: Yes

Reviewer #4: 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 #3: My overall impression is positive about this study. The article is well structured. The data provided can be easily studied as well as the results. The Minor points of this part of the healthcare system are accurately described and they are reflected through the results.

Reviewer #4: The authors have adopted most of the comments and suggestions. If possible, it is suggested to complement with the following recommendations:

Clarity and depth of quantitative analysis:

- It is recommended to explain in greater detail why specific statistical methods, such as the Mann-Whitney and Chi-square tests, were chosen. Additionally, a deeper discussion on the assumptions and limitations of these methods would strengthen the analysis.

- Providing a more detailed description of the coding process and thematic analysis, including examples of coded quotes and how they were grouped into themes, would improve the transparency and replicability of the qualitative analysis.

- Detailing the standard procedures used for training healthcare professionals in the implementation of ANC guidelines would offer a clearer view of how to improve adherence in other contexts.

- Proposing a specific system for the continuous evaluation of adherence to the guidelines, including key performance indicators and feedback methods for healthcare providers, would be beneficial.

- Including more concrete and practical suggestions to overcome the identified barriers, based on the study's findings, would enrich the discussion.

- Expanding the review of existing literature on adherence to ANC guidelines in other middle- and low-income countries would provide a broader context for the study's results.

- Discussing the study's limitations in more depth, especially regarding sample size and the generalizability of the findings, would provide a more balanced and critical view of the study.

- Identifying specific areas for future research, such as longitudinal studies that evaluate changes in adherence over time or research on the implementation of specific interventions to improve adherence, would be beneficial.

**********

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 #3: No

Reviewer #4: 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.

A mixed-method analysis of provider adherence to integrated antenatal care guideline in BEmONC and Non BEmONC primary health center: An Indonesian case

PONE-D-23-12582R3

Dear Dr. Yuliyanti,

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,

Gilbert Sterling Octavius

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: