PONE-D-24-30395Assessment of antenatal care quality in Ethiopia: Facility based study using service provision assessment dataPLOS ONE

Dear Dr. Alemu,

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.

==============================Overall, this manuscript presents an important topic and employs appropriate methods for its analysis. However, major revisions are required before being acceptable for publication. In your revision, please consider my suggestions as well as the suggestions provided by Reviewer s for further consideration. 

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Please submit your revised manuscript by Oct 11 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Muhammad Haroon Stanikzai

Academic Editor

PLOS ONE

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Additional Editor Comments:

Overall, this manuscript presents an important topic and employs appropriate methods for its analysis. However, major revisions are required before being acceptable for publication. In your revision, please consider my suggestions as well as the suggestions provided by Reviewer s for further consideration.

1- Please proofread the whole article for language correction (Last line in abstract does not have a punctuation).

2- It has been suggested that 99% of maternal deaths in LMICs, including Sub-Saharan Africa, can be prevented with quality ANC [10, 11]. Please check your citations. I could not find this claim it the mentioned citations. Please use appropriate citations or remove this sentence.

3- Discussion: Recommendations for each of the key observations they have made.

4- I propose the authors use, consult, and add the following reference in the manuscript that assess ANC quality in another LMIC.

Stanikzai, M.H., Tawfiq, E., Jafari, M. et al. Contents of antenatal care services in Afghanistan: findings from the national health survey 2018. BMC Public Health 23, 2469(2023). https://doi.org/10.1186/s12889-023-17411-y

5- Please revise your tables according tho the journal style.

6- Please add line numbers in the revised manuscript.

[Note: HTML markup is below. Please do not edit.]

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: Partly

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

Reviewer #1: Yes

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: Yes

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: Yes

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: Dear Editors and Authors,

Thank you for giving me the opportunity to review the manuscript, titled “Assessment of antenatal care quality in Ethiopia: Facility based study using service provision assessment data”

The authors of the study chose a very important topic related to maternal and child health.

The study aimed to assess the quality of ANC and its associated factors in Ethiopia. The authors used data the 2021/2022 Ethiopian Service Provision Assessment survey and used data from pregnant women during their first ANC consultation. The authors assessed and summed 24 components of ANC components (ranged 0-24), with higher score indicating a better ANC quality. They employed and fitted a poisson regression model to examine predictors of ANC quality.

The authors found that the mean ANC quality was 11 (SD 3.8), with blood pressure measurement the most commonly performed ANC service, and breast examination for cancer screening the least performed component of ANC. They found that when ANC was provided by female health workers the ANC quality was higher, and that the ANC quality was lower in rural health facilities, and for women with increased gestational age, and for women who received care from non-nearby health facility.

My assessment of the manuscript is that it is well written and is well organized. The findings from this study have the potential to impact health interventions and policy to improve neonatal, children, and women’s health. However, the authors need to address the following two issues before the paper can be considered for publication.

1. In table 3, the column showing regression coefficients (SEs) is not necessary. The authors may opt to revise table 3 which should present IRR (95%CI) and p-values for unadjusted IRRs, and adjusted IRRs (which are the current IRRs in table 3).

2. The flow chart shows that out of 4355 women, data from 2042 women were analysed and 2313 women were excluded. In the discussion section as part of the limitations of the study, the authors may opt to discuss the extent of the possible selection bias because of the exclusion of 2313 women. It would be useful to provide some descriptive statistics similar to the one in table 1, as supplementary material, on the 2313 women who were excluded from this study.

Reviewer #2: First and foremost, thank you for the opportunity to review your manuscript. This study has significant potential to impact antenatal care quality improvement on a large scale in Ethiopia. I trust that the review process will contribute to further enhancing the manuscript and increasing its likelihood of reader understanding in this context.

The paper is well-constructed and presents a comprehensive study with several notable strengths, including a well-crafted title and clear organization. However, it would benefit from the inclusion of a conceptual framework to more effectively link the variables. Additionally, the claims should be more clearly positioned within the context of existing literature, supported by relevant citations. The feedback provided aims to assist in refining your work and enhancing its impact within the field.

To follow the comments go to file attached.

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Reviewer #1: Yes: Dr Essa Tawfiq

Reviewer #2: No

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Attachments

Attachment

Submitted filename: reviewers comments.pdf

Attachment

Submitted filename: Comment to the authorPLOS ONE1.pdf

PONE-D-24-30395R1Assessment of antenatal care quality in Ethiopia: Facility based study using service provision assessment dataPLOS ONE

Dear Dr. Alemu,

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.

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

Thank you for addressing the initial comments provided by the reviewers. Based on the revised manuscript, the reviewers have requested that some minor comments still need to be addressed.

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

Please submit your revised manuscript by Nov 21 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,

Muhammad Haroon Stanikzai

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.

Additional Editor Comments:

Please make sure your tables align with PLOS ONE requirements.

[Note: HTML markup is below. Please do not edit.]

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 #2: 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 #2: Yes

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

Reviewer #1: Yes

Reviewer #2: 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 #1: Yes

Reviewer #2: Yes

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

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

Reviewer #1: Yes

Reviewer #2: 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: Dear Authors,

I thank you for addressing the comments I made in my previous review of your paper. Please also adhere to all requirements of PLOS ONE.

Reviewer #2: Thank you to the authors and editors for the opportunity to review the manuscript titled, “Assessment of antenatal care quality in Ethiopia: Facility-based study using service provision assessment data.” This is an important study on a critical topic related to maternal and child health, especially considering its large-scale scope.

Most of the previous comments have been addressed, and the manuscript has significantly improved. However, there are a few areas that still require refinement:

Abstract:

In the conclusion, the phrase “Thus, efforts are needed to ensure that quality ANC is provided for every pregnant woman in Ethiopia” could be further improved by providing more specific guidance for policymakers and authorities. It would be helpful to include concise recommendations based on the study's findings, focusing on how to improve ANC quality in the Ethiopian context in line with the study’s aim of assessing healthcare facility capacity.

Introduction:

This section has improved compared to the previous version. However, the authors should refine the conceptual framework of the ESPA to better align with ANC quality assessment as informed by DHS survey data. This would help readers better understand the scope of the study.

Methods:

The constructs in this section have been improved significantly.

Results:

No additional comments.

Discussion:

The discussion needs to better connect and justify the study’s findings. For instance, in line 272, the statement “suboptimal facility readiness, primarily caused by shortages of trained staff and equipment” should be revisited to ensure clarity and better integration with the overall discussion. Additionally, the subsequent sentences regarding WHO recommendations (lines 273-277) do not clearly link to the prior argument. These points should be reworded or modified to create a smoother flow and ensure coherence in presenting the study's implications.

In lines 278-287, the discussion on the frequency and quality of the first ANC visit needs further refinement. The authors should better articulate why and how to increase the number of pregnant women receiving their first ANC check-up before three months of gestation, using insights from the observed results in Table 1 (Characteristics of the study participants).

For example, factors such as "Partner’s involvement" could be highlighted as a potential strategy to encourage earlier ANC visits. Additionally, Table 2 presents critical data, such as:

Discussed healthy pregnancy: 39.0%

Discussed healthy diet: 47.4%

Discussed importance of at least 4 ANC visits: 19.0%

The relatively low percentages across these indicators underscore the need for improved ANC quality. The discussion should address these gaps and suggest specific interventions, such as better communication during consultations or enhanced health education, to promote early and frequent ANC attendance.

Strengthening this section will improve the manuscript’s clarity on how to address the barriers to early ANC and ensure alignment with the study's findings.

In line 307, the authors mention that "there is evidence that availability of resources does not guarantee provision of quality ANC [59]." However, this statement seems disconnected from the previous assertion in line 272, where it is suggested that "The low ANC content observed in our study could be due to suboptimal facility readiness, primarily caused by shortages of trained staff and equipment [45]."

To improve coherence, the authors should clarify the relationship between resource availability and ANC quality. If resource availability alone is not sufficient for ensuring quality care, the conclusion should focus more on other factors—such as the provider's gender or the proper use of resources—that contribute to the low quality of ANC. The authors should also provide clearer evidence or examples from their findings to support this argument, ensuring alignment between both statements. This refinement will strengthen the discussion and offer a more nuanced understanding of the factors influencing ANC quality.

Additionally, the conclusion seem so long , it should be more concise and clear.

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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 #2: 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.

Attachments

Attachment

Submitted filename: Reviewer Recommendation .pdf

Assessment of antenatal care quality in Ethiopia: Facility based study using service provision assessment data

PONE-D-24-30395R2

Dear Dr. Alemu,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Muhammad Haroon Stanikzai

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 #2: 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

**********

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

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

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

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

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

Reviewer #2: Thank you to the authors and editors for the opportunity to review the manuscript titled, “Assessment of antenatal care quality in Ethiopia: Facility-based study using service provision assessment data.” This is a valuable and timely study on a critical topic within maternal and child health, particularly given the large-scale scope of the data analyzed. The authors have comprehensively addressed all previously suggested revisions, resulting in an improved and well-structured manuscript to meet The journal criteria that

The study provides original research findings.

The results are novel and have not been published elsewhere.

The methodologies, including experiments and statistical analyses, are technically sound and thoroughly explained.

The conclusions are clearly stated and well-supported by the data.

The manuscript is well-written and easy to understand, meeting standard English language requirements.

The research maintains ethical standards and integrity throughout.

The study follows appropriate reporting guidelines, and data availability meets community standards.

So, I have no further comment.

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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

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