PONE-D-24-08940Determinants of Maternal Health Service Utilization and Continuum of Care in Nepal: An Analysis from Demographic and Health Survey 2022PLOS ONE

Dear Dr. Pandey,

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 Sep 20 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,

Devendra Raj Singh, MSc Public Health, MA

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.

The American Journal Experts (AJE) (https://www.aje.com/) is one such service that has extensive experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. Please note that having the manuscript copyedited by AJE or any other editing services does not guarantee selection for peer review or acceptance for publication.

Upon resubmission, please provide the following:

The name of the colleague or the details of the professional service that edited your manuscript

A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

A clean copy of the edited manuscript (uploaded as the new *manuscript* file)

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 the suggestions provided by Reviewers for further consideration.

[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: Partly

Reviewer #2: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

**********

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: Thank you for providing the opportunity to review the manuscript. The authors have conducted an analysis addressing critical issues, and addressing the gap in the continuum of care is essential for policymakers and program implementers. Once the below comments are addressed, I would recommend this manuscript for publication. However, I suggest reviewing the introduction and discussion sections with experts who have extensive knowledge about the current policies and programs related to maternal and neonatal health.

1. The authors mentioned logistic regression in the abstract, yet Poisson regression is detailed in the methodology section. Additionally, the findings present logistic regression output. Please review the report carefully to ensure coherence.

2. Be consistent in the use of decimal places, either using one or two after the decimal point throughout the document.

3. Regarding the statement, "Madhesh residents had lower odds (AOR: 0.47, 95% CI: 0.23 - 0.99), Sudurpaschim had 27 higher odds (AOR: 2.37, 95% CI: 1.17 - 4.82) for ≥4 ANC visits and health facility delivery than Koshi," I question the significance of the upper limit of 0.99. If rounded to a single decimal place, it may not appear significant. Furthermore, please confirm if the associated p-value is less than 0.05.

It seems like the authors are trying to forcefully emphasize significance.

4. I suggest adding 95% confidence intervals (CI) in the last sentence of the methods section in the abstract. The authors overlooked mentioning CI.

5. In the introduction section of the main body, the authors discuss the SDG target for neonatal mortality. I suggest including a similar discussion for maternal mortality ratio.

6. Consider including information about the policy scenario concerning maternal and neonatal health in Nepal in the introduction section. For example, mention initiatives like the Nepal Safe Motherhood and Newborn Health Road Map 2030 and elaborate on its focus on the continuum of care.

7. It seems unnecessary for authors to use the abbreviation "MCVs" in parentheses (line # 73) since it's not used later in the text.

8. Please ensure the survey year is mentioned in the opening sentence of the methods section.

9. Simplify the discussion of sampling procedures in the methods section. Instead of detailed procedures, provide a brief overview and mention the total number of strata, refer readers to the main report for further details with citations. Additionally, consider including a flowchart illustrating the process leading to the selection of 1933 participants, indicating any missing cases.

10. Clearly define the continuum of care, stating that 'Women who received all three stages of care (Full ANC, ID, and PNC) were considered to have undergone complete Continuum of Care.' Additionally, define Full ANC, ID, and PNC, and clarify how they were calculated, specifying whether women or live births or live births and still births were used as the denominator. Provide rationale for not including stillbirths, if applicable. Alternatively, consider mentioning this information in the sample size flow chart as suggested.

11. Why did not authors include essential variables for the current topic, such as "parity/ or birth order" and "distance to health facility," as covariates.

12. In the independent variables, "age" is mentioned, but in the table, it's labeled as "age at delivery." I suggest maintaining consistency. Additionally, the independent variables do not specify how media exposure, occupation, and health insurance were categorized.

13. Please review and confirm lines 141-143, and cross-check with the results output.

14. Given the smaller sample sizes for rural residence in Table 1, it's important to note that these smaller numbers should be interpreted cautiously to avoid misinterpretation of the results. Consider referencing how the DHS main report addresses and handles smaller sample sizes.

15. Check the spelling of "richer" in Table 2 and ensure that similar minor mistakes are corrected in other tables and categories as well.

16. Consider including "place of residence" in Table 2 and ensure its consistency throughout the table.

17. Consider visualizing the continuum of care for ANC, ANC+ID, and ANC+ID+PNC to enhance understanding.

18. Instead of simply writing "Wealth index combined (Table 2)," suggest using the term "wealth quintile" and providing a brief explanation in the methodology section, referring to the DHS wealth index calculation process.

19. Note that "Internet use" is included in Table 4 but not in Tables 1-3 and is also missing from the list of independent variables.

20. The first paragraph of the discussion should ideally be integrated into the introduction to provide background information for readers.

21. Include a discussion of maternal health inequalities in the introduction and link it to the disparities in continuum of care (CoC) discussed in the findings.

22. Maintain consistency in referring to NMICS or MICS.

23. Improve the discussion by linking evidence of maternal health service inequalities at both national and provincial levels. Consider examining supply-side data to provide further evidence of CoC disparities.

24. Ensure that when short forms like NMICS/MICS are used, they are explained or mentioned in parentheses upon first use to avoid confusion.

25. Overall comment: Check for grammatical errors and consider having the document proofread by native speakers for further refinement.

Reviewer #2: Reviewer Report: Version 1

Date: 4th Aug 2024

Determinants of Maternal Health Service Utilization and Continuum of Care in Nepal:

An Analysis from Demographic and Health Survey 2022

Overall Impression:

Although there are proven evidences of increasing coverage of Antenatal care (ANC), institutional delivery and postnatal care (PNC) could improve the maternal and neonatal health outcomes, little importance has been given to continuum of care (CoC) in Nepal. There are different determinants that drives women for not continuing the services. This manuscript examines the determinants of four or more ANC, institutional delivery, PNC within 2 days of delivery, and also the combined coverage of these variables to assess the determinants of service utilization for CoC in Nepal. Using the recent nationally representative Nepal Demographic and Health Survey 2022, the authors have performed univariate and multivariable regression analyses, the authors have tried to assess the status of continuum of care and explore the factors associated with it for maternal healthcare services. The findings can be important evidence for those who are involved in improving the maternal healthcare service utilization in Nepal. However, the authors lack adequate discussion of policy implication of their findings.

Abstract:

The AOR value for the wealthiest quintile seems unusually high (AOR: 11.96, 95% CI: 14.36 - 32.79). The reported AOR should fall within the range of the confidence interval resulting CI not aligning with AOR. Furthermore, AOR of ~12 indicates that individuals in the wealthiest/richest quintile have almost 12 times higher odds of receiving the combined maternal health services compared to the reference group. Although this is possible, it is unusually high and warrants further scrutiny considering the non-alignment of AOR and CI as mentioned above.

Stating the reference group is missing in some context.

The conclusion is concise and straight forward. It could be further expanded slightly by linking with the policy implications or recommendations based on the findings which are more important for the readers. However, the authors have not discussed the policy implication in their discussion and obviously in the conclusion as well.

Introduction:

The introduction presents the magnitude of the problem of maternal health in global and Nepalese context (para 1). The statistics related to leading cause of maternal mortality and its relation with the quality of healthcare (para 2) and the trend of service utilization (para 3) justifies the motivation of the authors to conduct this study.

Although the authors have mentioned a little about the importance of continuum of care, it would be useful to elaborate. This will allow readers the importance of such intervention that the authors are interested to explore further. Due to the lack of such information, the introduction section has limited theoretical underpinning for conducting this research. Why exploring the determinants of continuum of care is important?

The authors used the term Maternal Care Visits (MCVs) taking the reference #17. Is this term same with ‘Continuum of Care’ that the authors have used throughout this manuscript? What are the similarities and what are the differences of these terms?

Additionally, providing definitions for the variables of interest and explaining how the DHS formulated the survey questions (possibly in a separate table) would enhance the manuscript's clarity. This would ensure that readers understand, for example, that "PNC" refers specifically to "PNC visit for the mother within 2 days of delivery," as used throughout the manuscript.

Method:

The methodology section provides a thorough description of the sampling frame, data collection process, and statistical analysis.

In data collection tools, the authors state that “DHS Program's model questionnaires were modified to address Nepal's unique demographics and health problems in consultation with various stakeholders, including government departments agencies, non-governmental organizations, and funders.” What were the unique demographics and health problems for Nepal identified after such consultation? What were such unique health problems that are relevant for this study? Were the respondents themselves also consulted before modifying the tools? How?

Clarify why only those women who had live births within two years preceding the survey were included in the analysis, and why this specific timeframe was chosen?

This manuscript does not mention how data cleaning was done. Since the authors used the DHS data source, DHS might have explained the data cleaning process elsewhere. A description of how DHS used any methods for cleaning the data would improve the robustness of the methodology.

The independent variables are listed but lack detailed definitions and categories in some places. Providing precise definitions (e.g. basic/secondary/higher education, urban/rural settings) and clarifying the dichotomization of religion variable (into Hindu and others, only in a religiously diverse society which could impact in health service utilization) would enhance further understanding.

Results:

This section requires thorough consistency checks to avoid any similar discrepancies which have occurred in the abstract section earlier.

The overall number does not match with sum of urban and rural. Please check it.

I am not clear why the authors have done subgroup analysis in table 1. The rationale for conducting subgroup analysis might be required.

I would suggest highlighting only key differences or changes the results to avoid repeating the same figures (line 154-157) in

Although the authors have numbered their table, this has not been mentioned in the text. I would suggest for citing table 1, 2, 3 ..... while writing the result section.

Discussion:

The discussion section is well-structured and aligns with the findings. The authors have tried to make a broader interpretation of findings with comparing and contrasting with the previous similar studies or with the previous studies conducted in other countries. The authors have tried to explain why their findings are different if their results conflicts with such compared studies.

The authors argue that federal structure after the political change of 2015 and the transfer of authority to local level governments after the election of 2017 may have led to relatively better planning and effective implementation of interventions which increased the coverage in rural areas at a faster pace than urban areas in 2022 compared to 2016. Again, the authors have discussed the role of FCHVs in encouraging the utilization of MNCH services to increase the utilization in rural areas. Such arguments should be used cautiously. Does this mean, the FCHVs in urban areas (as per the definition of rural areas in DHS survey) have less contribution? To what extent this argument is valid? Is there any possibility that massive increase in number of municipalities/Urban areas after the political changes of 2017 could have resulted this variation? Is the definition of urban areas in 2016 comparable with the definition used in 2022?

The authors stated that they found provincial variations in continuum of care for maternal health services utilization. The authors argue that management approaches and strategies adopted in expanding coverage within the provinces could be responsible for differences. What is the basis under this assumption? What does these management approaches mean here? How these approaches are different by provinces? Can this be clearly stated through the critical review of provincial health plans and policies (if exists)? Is the health plans and policies of Sudhurpaschim province has something different than other provinces which has resulted these findings? Are there specific policies or initiatives in Sudurpaschim that could serve as models for other provinces?

Discussing about the results in discussion section, the manuscript lacks discussion on implications of wide confidence intervals in some cases. Wide CI in some instances suggest there might be significant variability within those subgroups analysis. The discussion of reasons behind such variability example [11.96 (4.36, 32.79) or even 21.15 (8.80, 50.86) in case of richest quintile] and their implication can enhance the manuscript quality.

One of the major drawbacks of this manuscript is it lacks the discussion on policy implication of their findings. For instance,

Age at delivery: I was interested to see the age at delivery for those who were below 20 years. Since the data was collected in 2022 and the survey asked for those who had live births within two years preceding the survey, what does it indicated with the existing laws of National Criminal Codes 2017 that criminalizes the acts of early marriage? How the health programs should be tailored to address this issue among the young population to prevent early marriage?

The use of internet services and health service utilization is interesting. What can be its policy implication? How can the IEC/BCC interventions be revamped considering the increased access to internet services over the period of time?

Government of Nepal has endorsed ANC to PNC Continnum of care Guideline https://fwd.gov.np/wp-content/uploads/2023/06/ANC-to-PNC-continuum-of-care-guideline-4.pdf. How can this findings be linked with the existing guidelines? What need to be added? These kinds of discussion might be required.

These are only some examples. The discussion on separate subheading for policy implication is essential to make the manuscript better.

Conclusion:

As discussed in the abstract section, this conclusion is straight forward which needs further expansion by linking with the policy implications or recommendations based on the findings which are more important for the readers.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: Yes:  Kiran Acharya

Reviewer #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: Review_.docx

PONE-D-24-08940R1Continuum of Care for Maternal and Newborn Health Services in Nepal: An Analysis from Demographic and Health Survey 2022PLOS ONE

Dear Dr. Pandey,

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:

Thank you for addressing the previous comments. However, there are some minor revisions that need to be addressed before the manuscript can be accepted for publication. Please carefully review and incorporate the additional feedback provided by reviewers. 

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

Please submit your revised manuscript by Jan 09 2025 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,

Devendra Raj Singh, MSc Public Health, MA

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:

Thank you for addressing the previous comments. However, there are some minor revisions that need to be addressed before the manuscript can be accepted for publication. Please carefully review and incorporate the additional feedback provided by reviewers.

[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

**********

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: No

**********

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

Reviewer #1: Yes

Reviewer #2: No

**********

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

**********

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: 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 #1: Dear Editor,

Thank you for sending the review of the revision. The authors have revised the manuscript, and I am satisfied with the changes. However, there are a few minor comments worth mentioning:

1. Rather than only including the analysis description in the methods section of the abstract, I suggest adding a sentence about the study design and sample size before discussing the analysis.

2. In the list of independent variables, I recommend clarifying media exposure by specifying examples like newspapers, TV, and radio. This will enhance readers' understanding.

3. Since the authors have three outcomes, I suggest replacing 'multivariable' with 'multivariate analysis' throughout the manuscript, where applicable.

4. I recommend not mentioning R Studio as an analysis tool, as it is an environment rather than a statistical tool. If you wish to include it, please also specify its version.

5. I hope the authors checked for multicollinearity before conducting the regression analysis. I suggest mentioning this explicitly, as variables such as age at delivery and birth order could be correlated.

Reviewer #2: Reviewer Report: Version 2

Date: 23rd Nov 2024

Continuum of Care for Maternal and Newborn Health Services in Nepal: An Analysis from 2 Demographic and Health Survey 2022

Overall Impression:

The authors have done excellent work and have addressed most of the concerns raised by the reviewers. However, the manuscript requires a thorough review of data consistency and comprehensive editing especially in findings and discussion to ensure it is ready for publication.

Introduction:

The first paragraph presents the magnitude of problem in global context. It would be beneficial if the authors update this with recent data to ensure that that they are discussing the current situation more accurately.

Para 3: In this para, the authors have presented the leading causes of maternal mortality. For more comprehensive view, it would be better if they present the leading causes for neonatal mortality as well.

Results:

This section requires a thorough consistency check, as there are several issues with data consistency throughout the first paragraph and table-1. The figures reported in Table 1, (the point estimates and their respective confidence intervals), do not align in many cases for both urban and rural groups. For example, the point estimate of 15.68 (95%CI: 18.12 to 23.30) for the urban group and 20.59 (95%CI: 13.28 to 18.42) for the rural group suggest that the reported point estimate does not fall within the given confidence interval. This inconsistency should be addressed. I recommend that Table 1 undergo a thorough review and verification to make sure that all reported values are consistent and correct. Although the authors have stated that they checked the consistency of the findings, my random check shows further discrepancies now that needs to be corrected.

Discussion:

There appears to be some redundancy in the background section. Please review and address this. Additionally, lines 325–328 could be consolidated to avoid repetition.

Both the results and the discussion section need to be revised/edited to improve clarity. This will help the readers understand easily what the authors mean to say.

Line 282-289: I recommend comparing the coverage over time using similar data sources, if available. Moreover, it would be beneficial to compare the findings with more recent data if available. For example, instead of comparing with the 2017-18 DHS data, the authors could consider referencing the Bangladesh Survey 2022 for a more recent statistic.

**********

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: Yes:  Geha Nath Khanal

**********

[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.

Continuum of Care for Maternal and Newborn Health Services in Nepal: An Analysis from Demographic and Health Survey 2022

PONE-D-24-08940R2

Dear Dr. Pandey,

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,

Devendra Raj Singh, MSc Public Health, MA

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 #1: All comments have been addressed

Reviewer #2: 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 #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

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 #1: Yes

Reviewer #2: 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 #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 #1: All comments have been addressed. I would like to congratulate the authors; the paper is now in very good shape.

Reviewer #2: Dear Editor,

There are some very minor comments and some typo that need to be addressed before accepting for publication.

**********

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: Yes:  Kiran Acharya

Reviewer #2: Yes:  Geha Nath Khanal

**********