Exposure to trauma in pregnant women and its association with previous perinatal complications, IPV and antenatal service satisfaction in rural Ethiopia: a cross-sectional facility-based study

Raquel Catalao; Lelina Kebede; Adiyam Mulushoa; Tigist Eshetu; Girmay Medhin; Ahmed Abdella; Atalay Alem; Roxanne C. Keynejad; Jane Sandall; Louise M. Howard; Martin Prince; Charlotte Hanlon

doi:10.1371/journal.pone.0319362

Peer Review History

Original SubmissionFebruary 2, 2025
12 May 2025 Decision Letter - Muhammad Stanikzai, Editor PONE-D-25-05649Exposure to trauma in pregnant women and its association with previous perinatal complications, IPV and antenatal service satisfaction in rural Ethiopia: a cross-sectional facility-based studyPLOS ONE Dear Dr. Hanlon, 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. Two review reports have been obtained. Please revise them accordingly. Please submit your revised manuscript by Jun 26 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 . 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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 ****** 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, the Editorial Team, for inviting me to review this manuscript on an important and timely topic. The manuscript is well written and present in rigours, impactful study that advances understanding of perinatal PSTD in LMICs. After a careful review, I offer the following comments and questions to help strengthen the clarity, contextual relevance, and implications of findings. Introduction 1. Could the authors elaborate on why Ethiopia’s specific context makes this study particularly urgent? How might cultural stigma surrounding mental health and interpersonal violence affect women’s willingness to disclosure trauma in this setting? 2. Were trauma-informed care interventions considered in the study design. Particularly given the sensitive nature of PSTD and IPV?? 3. Although the Study conducted in Ethiopia, and framed with in the broader LMIC context, only one LMIC (Nigeria) is cited. The authors could expand their discussion of gaps in perinatal PSTD research across LMICs to better contextualize the study’s contribution. Methods 4. Please provide more details on how the PTSD Checklist for DSM-5 (PLC-5) and life event Checklist (LEC) were culturally adapted or validated for use in rural Ethiopia settings. 5. The study defines probable PTSD using a PCL-5 cut-off score of 31. While this ia a commonly used threshold, further justification or local validation data would strengthen its application to this population 6. Only 0.01 % participants were reported to have obstetric complications. Could extremely low figure reflect a limitation in data collection or recording? 7. How were lay data collectors trained to handle disclosures of trauma or IPV? Were any safeguards or referral mechanisms in place? Results 8. The findings that PTSD positive women reported higher satisfaction with privacy and referral, yet lower overall satisfaction, is intriguing. Could the authors explore whether response bias or differing expectations influenced these responses? 9. How were potential comorbidities such as depression or anxiety accounted for in the analysis? Were these controlled for as confounding variables? Discussion 10. Could the relatively low prevalence of PSTD observed reflect cultural coping mechanism or alternative expression of distress that may not be captured by PLC-5? 11. Given the facility-based study design, how might the exclusion of women who avoid ANC possible due to trauma or stigma have biased the finings? These high-risk groups might be underrepresented/ Conclusion 12. How do the findings inform the broader goals of the ASSET project in strengthening health systems? Are there specific programmatic or policy recommendations that emerged from this work? Reviewer #2: The topic is of high public health significance, particularly in LMICs where perinatal mental health is often neglected despite its profound intergenerational effects. The study highlights a gap in literature on perinatal PTSD in African settings, moving beyond the common focus on depression and anxiety. However, there are some suggestions which can strength the manuscript. In my view, cross sectional design limits the ability to draw causal inferences between trauma exposure, PTSD, and ANC satisfaction. Longitudinal data would be better suited to assess the trajectory and impacts of PTSD over time. Potential reporting bias were not properly addressed s sensitive topics such as IPV and mental health symptoms were self-reported and may be underreported due to stigma or fear, especially in patriarchal rural settings. While the PCL-5 was used, the absence of clinical diagnostic interviews may have led to misclassification. The cut-off of 31, though standard, may need local validation. The satisfaction scale was originally designed for mental health services. Its adaptation to ANC settings is not fully described—how well it captured maternity-specific concerns is unclear. The categorization of IPV based on just three items may miss subtler or more severe forms of abuse. The scale might underestimate IPV prevalence. There is no mention of how missing data were handled, which could influence the validity of the results. The study presents valuable, methodologically sound findings that advance understanding of trauma and PTSD among pregnant women in a resource-limited context. There is no mention of theoretical models (e.g., trauma-informed care frameworks, health-seeking behavior models) that could strengthen the interpretation of complex findings. This weakens the scholarly rigor of the discussion even it should be part of methodology. The discussion briefly notes that PTSD prevalence was low, but it misses a deeper exploration of whether this reflects methodological limitations (e.g., time window of trauma, cultural variation in symptom reporting, or cutoff scores). The conclusion would benefit from a more nuanced interpretation of this discrepancy. The observation that women with probable PTSD scored some aspects of ANC more positively is raised but not critically interrogated. Is this a reflection of lowered expectations, social desirability bias, or misinterpretation of the scale? These ambiguities weaken the interpretation. The authors rightly emphasize person-centred maternity care, but the discussion lacks depth about how this can be implemented effectively in the Ethiopian context. There is also limited integration of study findings to support this advocacy—what specific elements of care were deficient? Finally, conclusion appropriately emphasizes the need for better recognition of trauma and integration of psychosocial care into ANC, but falls short in providing actionable insight or priorities for intervention or future research ****** 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: Temesgen Anjulo Ageru 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". 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Revision 1
9 Jun 2025 Author Response Response to reviewers 1. The topic is of high public health significance, particularly in LMICs where perinatal mental health is often neglected despite its profound intergenerational effects. The study highlights a gap in literature on perinatal PTSD in African settings, moving beyond the common focus on depression and anxiety. However, there are some suggestions which can strength the manuscript. RESPONSE: Thank you for your comments to improve our manuscript. 2. In my view, cross sectional design limits the ability to draw causal inferences between trauma exposure, PTSD, and ANC satisfaction. Longitudinal data would be better suited to assess the trajectory and impacts of PTSD over time. RESPONSE: We recognize the limitation of our cross-sectional analysis. In the section “Strengths and Limitations” we have now added the following sentence: “Due to the cross-sectional design of our study, we are also unable to draw casual inferences; studies with a longitudinal design would be helpful to further identify the trajectory of trauma symptoms and their impact on psychological wellbeing and ANC satisfaction over time in this setting.” (page 35). 3. Potential reporting bias were not properly addressed s sensitive topics such as IPV and mental health symptoms were self-reported and may be underreported due to stigma or fear, especially in patriarchal rural settings. While the PCL-5 was used, the absence of clinical diagnostic interviews may have led to misclassification. The cut-off of 31, though standard, may need local validation. RESPONSE: We recognize the sensitivity of the topic and challenges with accurate measurement and have amended the “Strengths and Limitations” section on page 34 as follows: “Rural populations in Ethiopia face multiple barriers to care including low awareness of, and high stigma, related to mental health symptoms(46,47). Previous studies have shown that females and those with lower level of education have higher internalised self-stigma regarding mental illness in the country(48). Therefore, fear and stigma of sensitive topics such as IPV, trauma and mental health symptoms may have contributed to significant underreporting in our study. This is the first study in Ethiopia and one of few from LMICs, to investigate the relationships between trauma symptoms, IPV, obstetric complications and ANC satisfaction using contextually validated (for satisfaction) and adapted (trauma, IPV) measures in a large sample. Limitations include potential under detection of traumatic events, PTSD and IPV. There is a need for further studies to examine how trauma symptoms may manifest differently in this setting, the validity of cut-off points used by our measuring tools and to develop targeted interventions to elicit sensitive disclosure. “ We acknowledge the limitation that cut-off of 31 in the PCL-5 was not validated in this setting. In recognition of that, we used the term “probable PTSD” throughout the paper. In addition, we have now conducted further analyses using the PCL-5 total score as continuous measure which corroborate the direction of the associations found using the cut off score of 31 (supplementary table 1). To reflect the extra analyses, we added “We also conducted linear mixed-effects regression tests of association between PCL-5 total scores and co-morbid depression, anxiety, probable IPV and total ANC satisfaction score.” in Analysis Plan on page 10 and reported results on pages 17 and 18. 4. The satisfaction scale was originally designed for mental health services. Its adaptation to ANC settings is not fully described—how well it captured maternity-specific concerns is unclear. RESPONSE: We have now included the following statement in the “Strengths and Limitations” section on page 34: “The satisfaction scale used was initially developed to capture satisfaction with mental health services and although it includes several of the relevant concepts for person-center care including dignity, respect and collaboration, it may be missing other important aspects of maternity-specific care.” 5. The categorization of IPV based on just three items may miss subtler or more severe forms of abuse. The scale might underestimate IPV prevalence. RESPONSE: We thank the reviewer for raising this point. However, work by Zink et al showed that less direct ways of indicating IPV may be more accurate, and that the three-question combination including the domains of argument, safety, and manner of treating the responder had the best results (Zink T, Levin L, Putnam F, Beckstrom A. Accuracy of Five Domestic Violence Screening Questions With Nongraphic Language. Clinical Pediatrics. 2007;46(2):127-134. doi:10.1177/0009922806290029). 6. There is no mention of how missing data were handled, which could influence the validity of the results. RESPONSE: We thank reviewer for raising this point. We now added the sentence “Complete case analyses were performed.” to the analysis plan section on page 10. 7. The study presents valuable, methodologically sound findings that advance understanding of trauma and PTSD among pregnant women in a resource-limited context. RESPONSE: We thank the reviewer for the positive feedback and opportunity to address their comments. 8. There is no mention of theoretical models (e.g., trauma-informed care frameworks, health-seeking behavior models) that could strengthen the interpretation of complex findings. This weakens the scholarly rigor of the discussion even it should be part of methodology. RESPONSE: In order to strengthen our interpretation and highlight commonalities between the endorsed model of person-centered care and trauma informed care we added the following sentence: “In higher income settings, trauma-informed approaches have been increasingly cited in policy and adopted in practice as a means for reducing the negative impact of trauma experiences and supporting mental and physical health outcomes and prevent re-traumatisation (48). Whereas several of the principles of person-centered care overlap with principles of trauma-informed care (such as trustworthiness, safety, collaboration and choice), further studies are required to understand how local policies, protocols and processes can be responsive to the needs of individuals served and how they can be empowered in their interactions with the health system.“ (pages 34 and 35). 9. The discussion briefly notes that PTSD prevalence was low, but it misses a deeper exploration of whether this reflects methodological limitations (e.g., time window of trauma, cultural variation in symptom reporting, or cutoff scores). The conclusion would benefit from a more nuanced interpretation of this discrepancy. RESPONSE: In response to these important comments raised by the author we have modified the “Strengths and Limitations” section of our manuscript on page 34 as follows: “Rural populations in Ethiopia face multiple barriers to care including low awareness of, and high stigma, related to mental health symptoms(46,47). Previous studies have shown that females and those with lower level of education have higher internalised self-stigma regarding mental illness in the country(48). Therefore, fear and stigma of sensitive topics such as IPV, trauma and mental health symptoms may have contributed to significant underreporting in our study. This is the first study in Ethiopia and one of few from LMICs, to investigate the relationships between trauma symptoms, IPV, obstetric complications and ANC satisfaction using contextually validated (for satisfaction) and adapted (trauma, IPV) measures in a large sample. Limitations include potential under detection of traumatic events, PTSD and IPV. There is a need for further studies to examine how trauma symptoms may manifest differently in this setting, the validity of cut-off points used by our measuring tools and to develop targeted interventions to elicit sensitive disclosure. “ and “Due to the cross-sectional design of our study, we are also unable to draw casual inferences; studies with a longitudinal design would be helpful to further identify the trajectory of trauma symptoms and their impact on psychological wellbeing and ANC satisfaction over time in this setting.” on page 35. We also acknowledge the limitation that cut-off of 31 in the PCL-5 was not validated in this setting. In recognition of that, we used the term “probable PTSD” throughout the paper. In addition, we have now conducted further analyses using the PCL-5 total score as continuous measure which corroborate the direction of the associations found using the cut off score of 31 (supplementary table 1). To reflect the extra analyses, we added “We also conducted linear mixed-effects regression tests of association between PCL-5 total scores and co-morbid depression, anxiety, probable IPV and total ANC satisfaction score.” in Analysis Plan on page 10 and reported results on pages 17 and 18. 10. The observation that women with probable PTSD scored some aspects of ANC more positively is raised but not critically interrogated. Is this a reflection of lowered expectations, social desirability bias, or misinterpretation of the scale? These ambiguities weaken the interpretation. RESPONSE: The reviewer made an important point regarding the need to further interrogate these findings. We amended the paragraph in “Discussion” in page 32 as following to provide a more nuanced interpretation: “Women with antenatal PTSD showed a lower overall satisfaction with ANC compared to women without antenatal PTSD but paradoxically scored certain aspects of care higher than women without PTSD. Indeed, they endorsed more items regarding respect for their privacy and confidentiality. This finding should be interpreted with caution due to potential for response bias if women believe their answers may influence further care. In addition, previous studies in lower income countries have shown that lower expectations can lead to higher levels of satisfaction with care(38). A study from Ethiopia also reported higher satisfaction with ANC care to be associated with lower levels of education(39) and women in our sample with antenatal PTSD were more likely to have lower levels of education than those without, highlighting the complex interplay between education, expectations and potential social desirability bias (the tendency to underreport socially undesirable attitudes and behaviors and to over report more desirable attributes). “ 11. The authors rightly emphasize person-centred maternity care, but the discussion lacks depth about how this can be implemented effectively in the Ethiopian context. There is also limited integration of study findings to support this advocacy—what specific elements of care were deficient? Finally, conclusion appropriately emphasizes the need for better recognition of trauma and integration of psychosocial care into ANC, but falls short in providing actionable insight or priorities for intervention or future research. RESPONSE: Thank you for highlighting the need to identify priorities for intervention. We have added the following paragraph to “Strengths and Limitations on page 35: ” Future research should explore women’s, maternal health care workers’ and other relevant stakeholders’, including intimate partners’, perspectives on high quality ANC and person-centred care and specifically how services can be adapted to ensure the necessary space is provided to facilitate sensitive disclosure of trauma, validate feelings and concerns of staff and patients, support people to make decisions and take action and involve family members in a constructive and culturally-acceptable manner. Recently, there has been close working between the Ethiopian Federal Ministry of Health and the ASSET research team to integrate the Practical Approach to Care Kit (PACK) programme, which comprises the provision of carefully designed comprehensive and integrated clinical decision support into primary health care (50)and develop training on person-centered maternal care(51). In addition, there is ongoing research to support the development of brief psychological interventions for perinatal women with exposure to IPV that can be feasibly delivered by primary care workers(52,53).” We hope the current revision addresses all the raised points by reviewers and we remain committed to improve the manuscript to the highest standard by addressing the constructive feedback given. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0319362.r002
26 Jun 2025 Decision Letter - Muhammad Stanikzai, Editor PONE-D-25-05649R1Exposure to trauma in pregnant women and its association with previous perinatal complications, IPV and antenatal service satisfaction in rural Ethiopia: a cross-sectional facility-based studyPLOS ONE Dear Dr. Hanlon, 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 for addressing reviewers' comments. Before this manuscript can be accepted for publication, I request some minor correction mentioned at additional editor comments section. ============================== Please submit your revised manuscript by Aug 10 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. 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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 ****** 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 ****** 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: (No Response) ****** 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: Temesgen Anjulo Ageru ******** [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". 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Revision 2
1 Jul 2025 Author Response Muhammad Haroon Stanikzai Academic Editor PLOS ONE 1st July 2025 Dear Dr Stanikzai, Re: PONE-D-25-05649 Exposure to trauma in pregnant women and its association with previous perinatal complications, IPV and antenatal service satisfaction in rural Ethiopia: a cross-sectional facility-based study Thank you for the opportunity to further review and improve our manuscript. We addressed the raised points as below: 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. RESPONSE: We have now reviewed the full reference list to ensure references are complete and correct. The following changes have been implemented: • Reference 14 which was published as pre-print at time of submission of our manuscript but has since been accepted and published has been added as full reference as follows: 14. Eshetu T, Fekadu E, Abdella A, Mulushoa A, Medhin G, Belina M, et al. Towards person-centred maternal and newborn care in Ethiopia: a mixed method study of satisfaction and experiences of care. BMC Pregnancy and Childbirth. 2025; 25(1):1–13. doi: 10.1186/s12884-024-07116-4. • Reference 21 was updated to a more relevant paper of the validation of GAD-7 as measuring tool for anxiety symptoms. 21. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7. Arch Intern Med. 2006; 166(10):1092–7. doi:10.1001/archinte.166.10.1092 • Similarly. reference 24 was amended to a more relevant paper describing the use of our intimate partner violence measuring tool in the local setting: 24. Bitew T, Keynejad R, Honikman S, Sorsdahl K, Myers B, Fekadu A, et al. Stakeholder perspectives on antenatal depression and the potential for psychological intervention in rural Ethiopia: A qualitative study. BMC Pregnancy Childbirth. 2020; 20(1):1–11. doi:10.1186/s12884-020-03069-6. Additional Editor Comments: - Please look at previous publications at PLOS ONE and use in-text citations as per journal style. RESPONSE: We have added in-text citations as per journal style including use of square brackets for references. - Please use capital letter for the word of heading and subheadings Please review the whole manuscript and table headings). RESPONSE: We have now reviewed the whole manuscript and implemented 3 levels of Headings with font size and bold formatting as specified. We have also added Fig 1 caption in the manuscript as well as specified supplementary information at end of manuscript. - Line 214: Please make it statistical analysis. RESPONSE: Changed as requested. - The manuscript would be benefit from careful reading by authors (particularly capitalization and punctuation). RESPONSE: Reviewed as requested. Minor changes were tracked in manuscript. We hope this version meets the required criteria for publication in your journal. Kind regards, Professor Charlotte Hanlon Attachments Attachment Submitted filename: Response to Reviewers_2025_07_01.docx https://doi.org/10.1371/journal.pone.0319362.r004
4 Jul 2025 Decision Letter - Muhammad Stanikzai, Editor Exposure to trauma in pregnant women and its association with previous perinatal complications, IPV and antenatal service satisfaction in rural Ethiopia: a cross-sectional facility-based study PONE-D-25-05649R2 Dear Dr. Hanlon, 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): Thank you for addressing reviewers' comments. Reviewers' comments: https://doi.org/10.1371/journal.pone.0319362.r005
Formally Accepted
Acceptance Letter - Muhammad Stanikzai, Editor PONE-D-25-05649R2 PLOS ONE Dear Dr. Hanlon, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Muhammad Haroon Stanikzai Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0319362.r006

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