PONE-D-23-10669Effectiveness of community-based intervention package in maternal health service utilizations: A cross-sectional quasi-experimental study in rural GhanaPLOS ONE

Dear Dr. Aiga,

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Academic Editor

PLOS ONE

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[Authors’ acronyms] Hirotsugu Aiga (HA); Yoshito Kawakatsu (YK); Nobuhiro Kadoi (NK); Emmanuel Obeng (EO); Frank Tabi Addai (FTA); Frederick Ofosu (FO);

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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: Partly

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

Reviewer #1: No

Reviewer #2: 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: No

Reviewer #2: No

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

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Reviewer #1: No

Reviewer #2: 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: I am thankful for this opportunity of reading a very interesting research. I must emphasize that the manuscript will benefit immensely from a thorough editing to eliminate language-related and grammatical mistakes.

Abstract

Background

The main objective is not clearly written.

I would request the authors to consider writing something like this: “We examined the effectiveness of a community-based intervention package for pregnant women in increasing utilization of maternal health services. The package consisted of: (i)..., (ii)..., (iii)... and (iv) ...

Methods

I recommend the authors clarify how both baseline and follow-up data were collected simultaneously “after the implementation of the intervention package” (lines 102–104). How could baseline data be collected “after the implementation of the intervention package”? I found out the answer in lines 228–229, but readers should not be kept wondering about this. Thus, it needs to be clarified in the Abstract that by the word “simultaneously” the authors meant simultaneously in intervention and control sites.

The authors need to specify when the intervention was implemented (from X month to Y month of the year Z) in this section of the Abstract.

The authors need to mention the P-value that they considered for the level of statistical significance: P < 0.05 or a different one? I know that they have provided two reasons in lines 345–350, but here in the Abstract they need to mention that they considered P < 0.10 to indicate statistically significant associations.

Results

This section of the Abstract must be re-written. The authors need to present the answer to their main research question; i.e., the adjusted estimates for the three outcome variables.

I also recommend deleting lines 112–115 for the following two reasons:

i. whether the effectiveness of the intervention varied by categories of household wealth (assuming this to be a proxy for socio-economic status) was not the primary research question. In simpler words, whether household wealth or socio-economic status modifies the “effect” of the intervention on the outcome was not the primary research question as per the explanations provided by the authors in lines 439–445;

ii. the authors kept comparing the stratum-specific odds ratio for women from the “poorer” households with the overall odds ratio for wealth level. Instead, the stratum specific odds ratio for women from the “poorer” households should be compared against stratum-specific odds ratios for the other two wealth categories; i.e., odds ratios for women from the “middle-income” and “richer” households. Moreover, it was not clear whether the authors tested the interaction term incorporating “group” and “wealth level” in the mixed-effects logistic regression model (the legend below Table 3, line 433 does not indicate so). Without the interaction term “group × level” being tested and its P-value being statistically significant, it would be erroneous to infer that household wealth or socio-economic status modifies the “effect” of the intervention on the outcome.

Conclusion

Lines 118–120 read, “Peer health education activities and training existing health workers are likely to have synchronously contributed to an increase in antenatal care coverage. This is largely because peer educators are friendlier to the women from poor households”. I strongly recommend the authors consider deleting these two sentences as they have done no analysis to support these inferences. These inferences regarding how or through which mechanism(s) did the intervention work were not examined by the authors in the study. Besides, I wonder how the authors would know: i. whether “peer health education” and training of “existing health workers” acted synchronously, and ii. peer educators were “friendlier to the women from poor households”?

I would recommend the authors reiterate the main result and comment on the public health relevance of the extent of increase in maternal health care utilization brought on by the intervention in the Conclusion. It would be insightful if the authors comment on whether they think the intervention should be scaled up based on their findings. I would assume the overall impact to be smaller than anticipated after an intervention that ran for more than 16 months (as per lines 238–243).

Main text

Background

Lines 158–161, please provide the reference for these interventions being effective at the end of the sentence.

Lines 161–165, please re-frame this long sentence containing 45 words.

Line 167, please omit the word “physical”.

The authors argued that home visits carried out by “formal health workers” do not lead to “expected effectiveness” as “formal health workers” are “not necessarily interactive and friendly enough to local women” (lines 174–177). I briefly looked into the paper that they cites as a reference for this argument (reference number 11, a study from Ghana by Konlan et al.), and could not find the part of the paper that supports the authors’ arguments. I would request the authors to help me find the part of the paper on which the authors based their argument. Otherwise, the authors need to find a different reference to support their argument.

Line 192, please omit the word “in”.

Lines 200–203 read “The Program also strengthened the functions and capacity of the existing community health management committees, to enable them to continuously support both CHVs and facility-based health workers”. The authors need to briefly mention how did the Program strengthen the “functions and capacity” of the committees.

Customarily, a reader would expect to find out the specific objective(s) of the study in the last paragraph of the Background. However, this was lacking in the manuscript. I would recommend the authors do this instead of what they wrote in lines 213–215.

Methods

I would strongly recommend the authors shed light on any theoretical framework or model and empirical evidence from the same or similar settings that they used to inform and design the intervention. Otherwise, the approach would appear to be “top down” and shaped by the funder’s agenda, not by the local community’s needs.

Under the subsection “Interventions and outcome variables”, the authors need to provide information regarding the educational status of the Maternal and Child Health Promoters and Peer Educators.

In lines 302–305, the authors need to describe how the “capacity of community health management committees was strengthened” for carrying out “evidence-based planning, implementation, monitoring and evaluation”. The authors avoided describing what was actually done “under the third pillar”. This leaves readers open to speculation.

Line 354, please provide a reference that outlines how principal component analysis is used for computing wealth index or asset scores.

In lines 356–358, the authors wrote that “Then, all the households were categorized into five groups (i.e. wealth quintiles) according to the values of wealth index”. However, in the Results section, in Figure 3 captioned “Economic-group-specific crude difference-in-difference for three outcome variables”, they appear to have collapsed the bottom two quintiles into one single category (labelled “Poorer”) and the top two quintiles into another single category (labelled “Richer”). This is a serious discrepancy in my opinion. I strongly recommend the authors either: i. present the DID for all five quintiles, or ii. they convert the values of wealth index into tertiles instead of quintiles and present the DID for all three tertiles.

It would be transparent, if the authors clearly mention which variables were considered random-effect and which were considered fixed-effect in the mixed-effects logistic regression.

I also suggest the authors mention how they assessed the adequacy or fit of the logistic regression models and how they checked for collinearity.

The authors wrote that they had access to attributes that could identify individual participants during and after data collection (lines 368–369). The authors need to mention under Ethical considerations how they have ensured the confidentiality of identifying attributes and personal information as well as what would happen to these in future. The authors need to mention whether participation was voluntary and whether the participants retained their right to withdraw throughout the study.

Results

It is a common practice in writing the Results section that only the findings are presented not any interpretation(s) of the finding(s). Nevertheless, the authors resorted to presenting interpretations and inferences in the Results section (lines 396–400 and 401–405). The authors need to remove these.

As mentioned above, the authors either: i. present the crude DID for all five quintiles, or ii. they convert the values of wealth index into tertiles instead of quintiles and present the DID for all three tertiles in Figure 3. Similarly, Table 4 should demonstrate the estimates for all five or three wealth groups, not just the estimates among “poorer” women. I also think both in Tables 3 and 4, the estimates for “Maternal age”, “Education attainment”, “Marital status”, “Enrolment in health insurance” and “Household size” should not be presented as the main research question does not deal with these variables. Not presenting these estimates would also make the tables less busy.

Discussion

In the first paragraph of this section, the authors need to interpret the difference in difference estimator in a way that would give the readers an impression about how much improvement was brought on by the intervention and what this means from an “effect size” perspective. Please see the comment for the Conclusion

Lines 473–475 read, “This indicates that ANC coverage significantly increased between pre- and post-intervention stages particularly among women from poor households in the intervention group”. I do not agree with how the sentence has been framed. The authors should consider writing something like this: out of the three aspects of maternal health service utilization, the intervention improved only the ANC visit coverage ... A positive impact of the intervention on ... ... ... was not observed.

Furthermore, I think the word “significantly” in line 473 is ambiguous: did the authors mean statistical significance? If so, they should write it clearly. Or, did the authors use “significantly” to indicate a considerably large “effect size”? In that case, the authors need to elaborate further.

I strongly recommend the authors remove what they wrote in lines 565–601. While it is very interesting to explore what might have happened when there were health systems disruptions from COVID-19, this should be reserved for another study. Moreover, the authors used the word “resilience”, and if I am to assume this to be a construct, then the question arises which variable captured this construct. I could not find any variable that systematically and validly captured resilience. In fact, the authors performed no specific analysis to support what they discussed in line 565–601; which makes it akin to speculation. The authors argued that “People’s overall hesitancy to go out should have made pregnant women in the control group refrain from making antenatal care visits. Despite generally increased hesitancy to go out, the proportion of those having made at least four ANC visits slightly increased in the intervention group” (lines 585–589). There could be other confounding factors behind this small increase in proportions (unadjusted, bivariate estimate) of those completing at least four ANC visits among “poorer” women that were not possible to capture because of the study design.

I would prefer a Conclusion section where the authors present the principal finding in plain English and comment on the public health relevance of the extent of increase in maternal health care utilization brought on by the intervention and its scalability.

Reviewer #2: The study is on an important subject with precious information on interventions and women's health.

Regarding the abstract, it could be revised to be more on point and send a clearer message. Also the background and methods need, I would recommend to rewrite those sections and some suggestions are in the document, which can be found as an attachment. Additionally as it is based on an intervention, I would recommend to make a graphical depiction on how the intervention was carried out.

This study might be read, and used also in other contexts and thus it is important to include context specific information on current healthcare services for women of reproductive age.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Comments.pdf

Attachment

Submitted filename: Reviewers comments based on the document.docx

PONE-D-23-10669R1Effectiveness of a community-based intervention package in maternal health service utilizations: A cross-sectional quasi-experimental study in rural GhanaPLOS ONE

Dear Dr. Aiga,

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 May 10 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,

Mohammed Moinuddin, PhD

Academic 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 #1: All comments have been addressed

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: Partly

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

Reviewer #1: Yes

Reviewer #3: No

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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: (No Response)

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 #1: Yes

Reviewer #3: Yes

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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: I thank the authors for their substantial revision. My final, minor suggestions are as follows.

Line 94: please omit the "s" in the word "utilizations".

Line 101: please put a comma after the word "cross-sectional".

Line 109: please consider writing "had already been" instead of "had been already".

Line 113-116: please consider writing "The proportion of women completing at least four ANC visits displayed statistically significant DID in both crude and adjusted analyses. The proportions of women utilizing facility-based delivery services and post-partum care services did not display statistically significant DIDs.".

Line 123-124: please consider writing "... the transition be smooth by increasing the number of ANC visits.".

Reviewer #3: The authors made great efforts to overcome difficulties in conducting the impact evaluation during the pandemic and provide rigorous estimates. The reviewer was invited after the revised manuscript was submitted, i.e., did not participate in the review process at the initial submission. Therefore, the reviewer mainly commented on the points that other reviewers did not address in the first round of the peer review process.

1. Rationales of conducting this study: The authors might want to add explanations in the Background section regarding why this intervention was required in the study site where maternal health coverage was high. The authors added that “Poorer access to health facilities, inadequate quality of health services, and socio-economic/ cultural barriers are the major obstacles in increasing maternal health service utilizations. This prevents reproductive aged women from reaching life-saving services.” (Lines 164-) However, the authors might want to re-examine if this statement is valid to maternal health service provision situations in the study site. Particularly, they would need to explain that the intervention package benefited women who could not receive maternal health services while most women received these services.

2. Design effect: The authors set the design effect at 1.3 (Line 363) for the sample size calculation, seemingly without reference articles. As across-cluster differences may be large in an outcome of receiving health services, compared to a health outcome, this design effect might be too small. Readers may have an impression that a reason for insignificance in DID estimators at a 5% significance level might be because of insufficient sample size, not “the service coverages of the outcome variables had been already too high to have room for an increase 387 at the significance level of 0.05 (e.g., 93.1% of ANC in the intervention group at baseline).” (Lines 386-) The authors might want to justify the design effect level and add a limitation statement if the design effect was smaller than an adequate level. As the authors might have information regarding the high level of maternal health service coverage at the study site as the project funder, the high level of maternal health service coverage at baseline might not be a good reason for loosening the significance level to 10%. Rather than that, logistic or financial constraints in the impact evaluation might justify setting the significance level at 10%, particularly for behavioral studies.

3. Significance testing in socio-demographic and socio-economic characteristics: The authors explained that “Significant differences were unexpectedly detected in the proportions and mean values of 10 of 12 characteristic variables between the four groups (i.e., intervention group at baseline, intervention group at follow-up, control group at baseline, and control group at follow-up).” (Lines 441-) It is unclear why these four groups should have been compared. This approach seems to mix up detecting differences in baseline characteristics between the arms, detecting differences in follow-up characteristics between the arm, and detecting changes in characteristics between baseline and follow-up within the arm. If the authors needed to check the balance of the characteristics between the arms, they might want to present significance testing results at the baseline and at the follow-up separately.

4. Possible contamination: Were Suhum Municipality and Atiwa West District locations close with each other? Is it possible that people in Atiwa West District used maternal health services in Suhum Municipality or received part of the intervention package? The authors might want to expand explanations on the choice of the intervention and control group sites considering contamination possibilities.

5. Terminology: Is the word “difference-in-differences” more common than “difference-in-difference,” which the authors used? Please disregard this comment if the authors had a good reason to call their method difference-in-difference.

6. Estimation of Wealth-group-specific difference-in-differences: The approach used for the analysis of heterogeneity in DID across different wealth groups is so-called difference-in-difference-in-differences, or DDD (for example, Olden and Møen [2022], https://academic.oup.com/ectj/article/25/3/531/6545797). According to Table 5, the authors’ specification may include the variables of group, time, wealth, and DDD (group*time*wealth). Compared to Equation 3.1 in Olden and Møen (2022), the model in Table 5 might miss the interaction terms group*wealth and time*wealth (the interaction term of time*group may be captured as “Adjusted DID estimates among the poor”). Consequently, DDD estimator in Table 5 might cause a bias by capturing two interaction terms (group*wealth and time*wealth), in addition to the appropriate DDD (group*time*wealth). Please check the model in Table 5 to ensure if it was specified appropriately and possibly re-estimate DDD if needed.

7. Percent or percentage point change: In Figures 3 and 4, the authors presented crude DID as a percent form. However, it looks like it should have been “percentage points,” as this is the subtraction of percentages. Please find the following example for details: http://sumn.org/downloads/Percentage_Change.pdf.

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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 #1: No

Reviewer #3: No

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PONE-D-23-10669R2Effectiveness of a community-based intervention package in maternal health service utilizations: A cross-sectional quasi-experimental study in rural GhanaPLOS ONE

Dear Dr. Aiga,

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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Mohammed Moinuddin, PhD

Academic 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 #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: Yes

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

Reviewer #3: Yes

Reviewer #4: Yes

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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: No

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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 #3: Yes

Reviewer #4: Yes

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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: The authors addressed most of the comments made in the previous round of peer review appropriately. Please consider the following remaining comments:

1. Design effect: In the responses-to-reviewers document, the authors explained that the design effect (1.3) used for sample size calculations was based on the Ghana DHS 2022 Report. However, the data collection started on May 2022, before the data collection of the Ghana DHS 2022 (starting on October 2022), the authors might not access to the information in the report when the survey was designed. In addition, it would be noted that 1) design effect is a function of Intraclass Correlation Coefficient (ICC) and cluster size (for example, https://doi.org/10.1016/j.jeph.2024.202198) and 2) cluster size may be different between DHS and this study as it depends on the sampling design of a study. Therefore, it is possible that the design effect expected in this study was larger than the design effect in DHS (if the [average] cluster size of this study is larger than the cluster size of DHS). It is unclear about the cluster size in this study (it should be reported if it is not mentioned in the Methods section), and the cluster size (or the number of samples in the second stage) of Ghana DHS 2022 was 30 according to its report (https://www.dhsprogram.com/pubs/pdf/FR387/FR387.pdf). Thus, if the average cluster size of this study was smaller than Ghana DHS, the authors’ sample size calculation might be sufficient (even if they knew it after the DHS report was issued). Otherwise, the authors might want to add explanations on their initial sample size calculations more in details in the Methods section and a possibility of a smaller sample size than it should have been as a limitation of this study in the Discussion section.

2. Percentage points: In Figures 2 and 3, the authors added the explanation that “Crude DID is expressed in form of percentage difference.” However, the DID may be captured as a difference between the percentages. For example, in the panel (a) of Figure 2, Crude DID was 4.6 percentage points (= [93.4% – 93.1%] – [92.4% – 96.7%] = 0.3% – [-4.3%]). Therefore, in the panel (a), it may be appropriate to present “Crude DID = 4.6 percentage points” instead of “Crude DID = 4.6%.” (If this is correct, the authors might want to revise similar presentations in Figures 2 and 3.

3. Percentage points: In relation to the comment above, the explanation of the Results section might be re-examined. For example, in Lines 487-, the authors explained that “Again, ANC was the only outcome variable that produced significant crude DID (11.5%; P = 0.082 < 0.10).” This percentage presentation (11.5%) might also be 11.5 percentage points. In addition, if it referred to the result presented in Figure 4 [1a] (ANC for women from poor 33%), it would be 11.4 percentage points and p = 0.085, according to the figure. Please check if the explanation in the main text was consistent with what was presented in the figure.

Reviewer #4: Introduction

1. “This is largely because they are not necessarily interactive and friendly enough to local omen” line 178. Who is this sentence referring to?

2. “Peer education has been often employed” – line 180 – grammar??

3. “a study needs to be conducted in Ghana”. Line 216 and 217 – this sentence should be re-stated. The study is done now, apparently.

4. “This is because the implementation of the Program was less affected by the pandemic of SARS-CoV-2 (COVID-19) pandemic in Ghana, compared with other three countries.” Line 218 – why? Unless this can be explained with evidence, the statement is more or less a conjecture and should be revised.

5. at least four ANC visits; (ii) FBD; and (iii) PNC. National Health Insurance Scheme (NHIS) line 218. Why use abbreviation in stating your objectives?

Methods

1. “Ghana was targeted for the study. i.e. Group I1 as the intervention group at baseline, Group I2 as the intervention group at follow-up, Group C1 as the control group at baseline, and Group as the control group at follow-up (Figure 1)”. – line 253. It does not clear to me whether baseline and follow up groups for both intervention and control had same of member for the time difference. Otherwise, how did you manage the difference in characteristics if each group had different participants?

2. “Atiwa West District was appropriate as the control group also because its socio-economic and socio-demographic characteristics, and maternal health service coverages at the baseline were reportedly at the similar level to those of Suhum Municipality.” – line 269, 270 – Atiwa West district is close to Suhum. They share border. How did you manage spillover effect?? If you did not, state it as a limitation.

Design and intervention

1. Ghana and indeed the WHO had abandoned 4 plus visit, even before 2018. What was the motivation for setting your outcome variable at 4+ instead of 8+?

Results

2. Data collection was conducted during the period from 5th to 29th May 2022, the final stage of the five-year Program – line 433. Authors may take this sentence away from results section and move it to methods section.

Discussion

“Of the three types of essential maternal health service utilizations (ANC, FBD and PPC), the intervention package improved only ANC visit coverage. A positive impact of the intervention package on FBD and PPC was not observed” – line 507 to 509 – it appears to me that analysing with 8+ plus in accordance WHO current recommendation even before this intervention was rolled out would have given different results altogether. Authors can re-run with 8+ or offer strong explanation n to support their choice of 4+

Overall, a clean statistical analysis.

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Reviewer #3: No

Reviewer #4: No

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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.

Effectiveness of a community-based intervention package in maternal health service utilizations: A cross-sectional quasi-experimental study in rural Ghana

PONE-D-23-10669R3

Dear Dr. Aiga,

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,

Mohammed Moinuddin, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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

**********

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

**********

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

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 #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 #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 #3: The authors addressed all the comments made in the previous round of peer-review, particularly regarding the design effect issue.

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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 #3: Yes: Akira Shibanuma

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