PONE-D-24-07591Magnitude and Associated Factors of Postpartum Anemia After Caesarean Delivery in Public Hospitals of Awi Zone, North West Ethiopia, 2023; A Cross-Sectional Study.PLOS ONE

Dear Dr. Belay,

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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ACADEMIC EDITOR: Please respond to all reviewers comments point by point 

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We look forward to receiving your revised manuscript.

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Ahmed Mohamed Maged, MD

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: Yes

Reviewer #2: No

Reviewer #3: Partly

Reviewer #4: Partly

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

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: I Don't Know

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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

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: 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: No

Reviewer #3: No

Reviewer #4: No

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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: 1. Do you have full confidence to say this study, a cross sectional?

2. What was the basic gap for this study? What if there is no study in study area and little is known about it? you are well expected to show the impact of little knowledge about PPA after CD?

3. Why do you say this study is cross-sectional? Since, it used The card numbers of all mothers who gave birth through cesarean section at Awi Zone public hospital for the last two years before the study (January 1, 2021 to December 31, 2022) were traced from the hospital’s delivery log book registry and were listed down. A two-year report of birth through cesarean section is collected from each hospital health management information system and sum up to calculate proportion?

4. Have you ever tried the reverse of these relations to explore positive association? If, yes why not presented in result section?

5. Sections from study design to eligiblity criteria could be deduced in a single paragraph/sentence.

6.Double population proportion should be used for two independent populations and used for study designs compare two different populations. So, why you compute DPPF for this cross-sectional study?

7. please, be consistent with your study objective/title and/operational definition (for surgical site infection 17 (24.6%)). Or again operationally define this phrase.

8. Indication for current CS was not significant in bivariate. So, why you used in multivariate analysis?

9. revise the conclusion section because, a conclusion of a manuscript should be very precise, short and comprehensive.

10. limitation lacks not only treatment outcome, which is not the concern of this study. It lack variables that can help to generalize the findings.

11. in General, the manuscript needs critical revision including grammatical correction and keeping the standard based on instruction for authors

Reviewer #2: 1- Title can be simplified as prevalence of post partum anemia :An observational study

2- Abstract contains unknown abbreviation eg AOR?

3- The major defect in this cross sectional is lacking control group? As it must be compared with non anemic patients so you must compare anemic patients versus non anemic patients as regard age ,parity, previous morbidity and so on

4- So this is not cross sectional study please compare your data to control group otherwise it lacks credibility or significance

Reviewer #3: Conclusion:

The findings of the study show that the magnitude of postpartum anemia after cesarean delivery is a mild public health problem. Therefore, promoting the benefits of early detection and management of pregnancy complications such as predelivery anemia and medical complications is crucial.

Comment : the conclusion does not refer to or clarify to the paper title i.e. no comment about associated factors

Sampling procedure :

Comment : concerning cases who had postpartum hemorrhage or blood transfusion , when was the HB sample collected ? before or after the hemorrhage or before or after transfusion ?

Obstetrics related characteristics of mother:

The most common type of CS was emergency 318 (82.2%)

Comment : very high percentage of emergency Cs , what is the reason behind that ? and as mentioned in table 3 : 30 % was due to fetal distress which is also a very high percentage

Table 3 :

Comment : Type of pregnancy : should be renamed to number of gestations : singleton or multiple

Weight of newborn

Comment : change normal to average

Comment : change Gravida to Gravidity

Study Area and Period

Comment ; you should mention the number of deliveries annually in the area

Table 4

Comment : why include severe abdominal pain as a complication ? and what was the cause of the pain ?

CONCLUSION AND RECOMMENDATION

Comment :You should mention that you should reduce the emergency Cs rates as it is related to anemia and elaborate a bit about how you can do that in your setting

English

Comment : the English should be revised before publishing

Reviewer #4: Dear Editor, thank you much for inviting me to review this manuscript. I forwarded the following comments and recommendations to the authors.

Title: Replace the term “Magnitude” with prevalence.

Introduction:

Line 40-42: “It can be defined as Hgb < 10 g/dl, Hgb < 11g/dl, and Hgb < 12g/dl cut off values within the first 48 h of delivery, at 1 week and 6 weeks of postpartum duration, respectively(2, 3). Since you put different three cut-off value, you would cite all the sources. Again write ‘hour’ in full.

Line 72: “Additionally, … “ Avoid this conjunction because the earlier paragraph states about attributes of postpartum anemia.

“Despite positive progress being made in many countries to reduce maternal mortality, there is still evidence of a persistent increase in the rate of indirect causes” cite the sources.

“Several studies have been conducted 78 on anemia during pregnancy” cite the sources

Materials and Methods:

The authors would gave more detail the study settings (hospitals), including the types of maternal services, estimated number of population being served, number skilled personnel… etc.

How the authors could include all two years cesarean deliveries the settings? Was it census study?

The authors excluded postpartum women who had pre-operative severe anaemia. But they did not define severe anemia either in introduction or methods sections.

Line 123 All the public hospitals in the Zone were included.

Line 13: “The extent of postpartum anemia after caesarean delivery as a dependent variable, defined by World Health Organization (WHO) criteria as a postpartum Hgb level of less than 11 g/dL, measured closest to the day of hospital discharge (27).” That means you have missed possible causes of anemia that could occur after discharge

Line 144: Postpartum anemia after Caesarean delivery what; incidence, prevalence, or what? Please, make it clear and understandable for readers.

Each independent variable would be depicted.

Line 176 & 177: “The final model fitness was checked using the Hosmer-Lemeshow Goodness of Fit test 177 and multicollinearity test were done to check the relationship between independent variables.” Revise this sentence.

Results:

Line 188 &189: “There were 1995 deliveries in 2021 and 2688 deliveries in 2022, were delivered by CS in five public hospitals of Awi zone.” a confusing statement.

The study missed important sociodemographic and dietary or nutritional-related attributes of anemia .

I suggest he authors to include “Medical conditions related characteristics” in the “Obstetrics related characteristics of mother” because they did not mention any non-medical condition under this section. Two mentioned conditions (anemia during pregnancy and PIH) are obstetric related characteristics.

The authors would distinguish the degrees of anemia (depending on the severity) in their study that is very important management options and prioritizations.

The authors would include the p-values of variables associated in bivariable analysis.

The authors did not described “medical related conditions in the last pregnancy” as a variable in the descriptive statistics but they analysed it as independent variable predictor of postpartum anemia.

Discussion:

You would not compare your finding with the findings from California and Uganda those used Hgb level <8 g/dl and <7g/dl, respectively, a cut-off value.

The authors compared and contracted their proportions with incidence rates. For instance reference number 33 states about incidence rate postpartum anemia.

The authors would not compare their finding with the proportion of anemia among lactating mothers in subsistence farming households. Different population characteristics and diffirent settings. Reference number 35.

Line 275-277: Would be included in first paragraph or omitted.

General comments:

This manuscript has major tense, grammar, punctuation, and sentence errors. So the authors must get help from professional language editors.

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Reviewer #1: No

Reviewer #2: Yes: Adel Mohamed Nada

Reviewer #3: Yes: Hassan Gaafar

Reviewer #4: No

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PONE-D-24-07591R1Prevalence and Associated Factors of Postpartum Anemia After Caesarean Delivery in Public Hospitals of Awi Zone, North West Ethiopia, 2023; A Cross-Sectional Study.PLOS ONE

Dear Dr. Belay,

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: Please respond to all reviewers comments

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

Please submit your revised manuscript by Sep 12 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,

Ahmed Mohamed Maged, MD

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 #1: (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 #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: No

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 #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: mOST OF THE COMMENTS I FORWADED HAVE NOT BEEN COMPLETE. tHUS, THE AOUTHORS ARE EXPECTED TO DO SO BEFORE PUBLICATION OF THE MANUSCRIPT.

Reviewer #3: thank you for replying to all my comments

i think the paper is now ready to be published

next time try to use better English and address all points of the title of the paper in the discussion

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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.

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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: No

Reviewer #3: Yes: Hassan Gaafar

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[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: Manuscript on PPA 1.docx

Attachment

Submitted filename: PONE-D-24-07591.pdf

Prevalence and Associated Factors of Postpartum Anemia After Caesarean Delivery in Public Hospitals of Awi Zone, North West Ethiopia, 2023; A Cross-Sectional Study.

PONE-D-24-07591R2

Dear Dr. Belay,

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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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,

Ahmed Mohamed Maged, MD

Academic Editor

PLOS ONE

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