PONE-D-24-01243Quality of Basic Emergency Obstetric and Newborn Care Services from Patients’ Perspective in Selected Public Health Centers in Addis Ababa, Ethiopia, 2022: A Cross-Sectional StudyPLOS ONE

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Academic Editor

PLOS ONE

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Additional Editor Comments:

Reviewers 1

1) Summary of the research and your overall impression

This was a research conducted to assess the quality of Basic Emergency Obstetric and New-born Care services from patients' perspective in 11 public Health Facilities in Addis Ababa Ethiopia. The paper sought to establish the contribution of mothers' perspective on the care they received at the health facility in relation to their health outcomes. It provided evidence that factors such as patient purchasing power ,the patient being accompanied to the hospital and the mothers' age influenced their rating of the services received from the health facility. This study is relevant to the current literature because it allows policy makers to understand challenges which when addressed can increase the quality of care an overall reduce maternal and new-born mortality. Also, the study provides a unique opportunity to understand behavioural challenges that negatively impact on the experience of mothers while at the health facility such as administration of medication without informing them or not being courteous toward the mothers. Furthermore the study was well researched with current and relevant literature.

However, I feel the information on the quality of BEmONC based on the BEmONC signal functions is lacking which will be insightful, particularly in their appreciation of whether the dispensation of all signal functions from the mother's perspective aligns with what is expected as per the national guidelines. Also, in line 4 of page 6 the author states that the health facilities were selected through a simple random sampling method and does not clarify whether all eleven health facilities provided BEmONC services. Overall this was a well researched subject that has the potential to influence policies in the domain of preventing and managing obstetrical complications.

2)Major Issues

• It is not clear from the write up how many of the chosen facilities actually practiced BEmONC. I suggest the author states in the form of a table the facilities and categorize them as performing BEmONC or not, in addition the catchment populations of the facilities should be included to allow readers have an idea of the patient influx ,finally the number of patient captured per facility should be stated as this allows readers to better understand the conclusions drawn from the study.

• The author demonstrated a good mastery of the subject in the discussion section by pointing out discrepancies and using other studies to support their claims ,however the discussion was not well structured alternatively, the author should use the STROBE guideline linked here:https://www.strobe-statement.org/ to improve the structure of the discussion section.

• The authors clearly put in efforts to ensure their study was conformed to ethical considerations. However in paragraph 2 of page 9 entitled "Ethical Consideration" ,the author states in line 7 that verbal consent was obtained from participants ,however we note on table 1 the age group includes minors of 15 years ,could the author state if consent was obtained from their guardians for the purpose of this study.

• Under methods and materials of page 5, the author failed to indicate who was included or excluded from the study even though they belonged to the study population, to avoid confusion the author should boldly outline and inclusion and exclusion criteria for the study.

• In the discussion section the author aimed to demonstrate that discrepancies observed between the studies compared could be due to element such as a difference in culture , difference in national guideline.... however this approach undermines the efforts of the team by not comparing valuable information such as the difference in study design, study population, or the methodology used in both studies. In case the author wishes to attribute the differences to the culture, or the national guideline or other element as they may see fit , this should be substantiated by stating exactly what the difference is.

3) Minor Issues

• In paragraph 3 of the discussion entitled study limitation the author states element that reduce the validity of the study and failed to demonstrate the strengths of the study that that minimized the study limitations. Alternatively, the author should state the study limitations and how it was minimized.

• On page 7 line 15 ,the definition of signal function, "Consequences" should be replaced by "Complications"

• On Page 7 line 17 "is" should be removed.

Reviewer 2

Comments to the Author

Manuscript Number: PONE-D-24-01243

The manuscript titled " Quality of Basic Emergency Obstetric and Newborn Care Services from Patients’ Perspective in Selected Public Health Centers in Addis Ababa, Ethiopia, 2022: A Cross-Sectional Study " is important research that adds to present knowledge on obstetric violence. The study was generally well conducted but the authors need to address pertinent issues.

My comments are as follows:

Abstract:

Line 24: The gap in this study has not been adequately addressed, highlighting a significant oversight in the research process. Without a thorough exploration of this gap, the study may lack depth and fail to contribute meaningfully to the existing body of knowledge. So, addressing this issue will enhance the overall rigor and relevance of the research.

Next to line 27: Please ensure that the aim/objective of the study are included into the abstract section. This addition will provide clarity and context for readers.

Line 34: The final model identified several significant variables: age, income, companion, and payment. However, the results section only addressed two of these variables—companion and payment. For clarity and consistency, all significant variables should be discussed.

Line 42: Add your recommendation

Background

The discussion is well-presented, but addressing the gaps will strengthen it and make it more convincing.

Methods and material

Study setting and period

I recommend that you include the number of health facilities, the number of healthcare providers—particularly obstetric healthcare providers—and the number of women who utilized BEmONC services.

Population

How did you determine whether the women received at least one Basic Emergency Obstetric and Newborn Care (BEmONC) signal function service in order to include them in your study?

Line 121-123: Please provide the average number of one-month postnatal mothers to clarify the calculation of the k-th interval for selecting the study population.

Operational definition

The author should provide clear definitions for all components of the Donabedian model(input, process and output) to offer a more detailed understanding.

Results

Socio demographic features

Line 229: Since the table includes economic variables, it would be more appropriate to refer to it as sociodemographic/economic features.

Line 231: What were the reasons for the 6% of your sample size that did not participate in the study?

Table 1: You have three participants whose ages are under 18, classifying them as minors. This population typically requires support from their guardians or partners to participate in the study. Did you obtain assent from these minors before conducting the interviews? Additionally, how did you address the ethical considerations related to including children in your research activities?

Table 1: While the study thoroughly examined all variables related to women's sociodemographic, it notably overlooked the variables associated with husbands or partners. This omission is significant, as the role of a husband can greatly influence various aspects of women's health and well-being.

Table 1: ` What was the rationale behind classifying income in this manner? The classification of women's income is unclear. Could you please provide a detailed explanation of how it was operationalized?

Obstetric characteristics of participants

Line 272: I recommend creating a table to present the obstetric characteristics, as this will help readers easily grasp the overall context of maternal-related issues.

Line 2273-274: While it is acceptable to report whether the mothers had antenatal care (ANC) visits, what is crucial is the total number of contacts these women had with healthcare providers. This aspect has not been addressed in the study.

Line 274: “339 (96%) of them wanted pregnancy for this current one” …. This not clear. Please make it clary and understandable by the readers

Line 278-280: Do you think women can determine properly the amount of time they spend before receiving the services. Have you cross checked their responses with other mechanisms

Line 280: Companionship is an important intervention that enhances maternal healthcare services, and it is also a fundamental right for women to have during the utilization of maternal health services. In the study, “Twenty (5.7%) of the women had no companion (attendant) 281 during their stay “…this is too general. So, it should be specified where (service units) women utilize the companionship.

Line 285-286: The study revealed “Two-thirds (75.6%) of the 286 women did not pay for any of the services in the health centers during their stay.” This indicates that approximately 25% of women have covered their medical expenses. However, the Ethiopian government has exempted nearly all maternal healthcare services from charges for women. What accounts for this discrepancy in your findings?

Line 289- 290: in the methods section you operationalized good quality as the quality of BEmONC services from the mothers’ perspective when the mothers 161 scored greater than or equal to the mean of 104 (70%) of all the quality questions. However; in the result section good quality defined as those who scored greater than or equal to the mean of 15 (60%) or rated as good quality, was 174 291 (49.3%). This is contradicted with each other. Look at also the quality measures for process and output. Please see it carefully.

Line 377: In addition to the percentage, please include the frequency for the variables. For example, you could present it as frequency (56.9%).

Table 5: Avoid relying solely on statistical hypothesis testing, such as P values, which fail to convey important information about effect size and precision of estimates. thus, focusing on confidence interval can clearly explain the significance of the variables. Better if you delete the p-value.

Table 5: I have observed wide confidence interval in the final model. A wide confidence interval (CI) indicates a high level of uncertainty regarding the estimated parameter, suggesting that the sample does not provide a precise representation of the population. It suggests that there is insufficient evidence to make definitive conclusions about the parameter being estimated. This can occur due to smaller sample size, high variability or dispersion within the sample data and others. check it.

Discussion

Line 435- 437: the way you justify somehow it is not convincing. Please discuss how your findings relate to existing literature, highlighting both similarities and differences with previous studies.

The study compares and contrasts only a limited number of variables and lacks evidence-based justifications for the discrepancies and similarities between the studies. Therefore, the author should provide strong scientific reasoning for any inline studies and those that align with the findings.

Limitation

While it is important to acknowledge the limitations of your study, it is equally essential to discuss its strengths. Why was this aspect overlooked in your explanation?

Conclusion

Line 473 says the total quality of BEmONC services from the viewpoint of mothers was suboptimal. What was your criteria to declare as it is suboptimal? What was your comparator?

[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: Yes

**********

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: 1) Summary of the research and your overall impression

This was a research conducted to assess the quality of Basic Emergency Obstetric and New-born Care services from patients' perspective in 11 public Health Facilities in Addis Ababa Ethiopia. The paper sought to establish the contribution of mothers' perspective on the care they received at the health facility in relation to their health outcomes. It provided evidence that factors such as patient purchasing power ,the patient being accompanied to the hospital and the mothers' age influenced their rating of the services received from the health facility. This study is relevant to the current literature because it allows policy makers to understand challenges which when addressed can increase the quality of care an overall reduce maternal and new-born mortality. Also, the study provides a unique opportunity to understand behavioural challenges that negatively impact on the experience of mothers while at the health facility such as administration of medication without informing them or not being courteous toward the mothers. Furthermore the study was well researched with current and relevant literature.

However, I feel the information on the quality of BEmONC based on the BEmONC signal functions is lacking which will be insightful, particularly in their appreciation of whether the dispensation of all signal functions from the mother's perspective aligns with what is expected as per the national guidelines. Also, in line 4 of page 6 the author states that the health facilities were selected through a simple random sampling method and does not clarify whether all eleven health facilities provided BEmONC services. Overall this was a well researched subject that has the potential to influence policies in the domain of preventing and managing obstetrical complications.

2)Major Issues

• It is not clear from the write up how many of the chosen facilities actually practiced BEmONC. I suggest the author states in the form of a table the facilities and categorize them as performing BEmONC or not, in addition the catchment populations of the facilities should be included to allow readers have an idea of the patient influx ,finally the number of patient captured per facility should be stated as this allows readers to better understand the conclusions drawn from the study.

• The author demonstrated a good mastery of the subject in the discussion section by pointing out discrepancies and using other studies to support their claims ,however the discussion was not well structured alternatively, the author should use the STROBE guideline linked here:https://www.strobe-statement.org/ to improve the structure of the discussion section.

• The authors clearly put in efforts to ensure their study was conformed to ethical considerations. However in paragraph 2 of page 9 entitled "Ethical Consideration" ,the author states in line 7 that verbal consent was obtained from participants ,however we note on table 1 the age group includes minors of 15 years ,could the author state if consent was obtained from their guardians for the purpose of this study.

• Under methods and materials of page 5, the author failed to indicate who was included or excluded from the study even though they belonged to the study population, to avoid confusion the author should boldly outline and inclusion and exclusion criteria for the study.

• In the discussion section the author aimed to demonstrate that discrepancies observed between the studies compared could be due to element such as a difference in culture , difference in national guideline.... however this approach undermines the efforts of the team by not comparing valuable information such as the difference in study design, study population, or the methodology used in both studies. In case the author wishes to attribute the differences to the culture, or the national guideline or other element as they may see fit , this should be substantiated by stating exactly what the difference is.

3) Minor Issues

• In paragraph 3 of the discussion entitled study limitation the author states element that reduce the validity of the study and failed to demonstrate the strengths of the study that that minimized the study limitations. Alternatively, the author should state the study limitations and how it was minimized.

• On page 7 line 15 ,the definition of signal function, "Consequences" should be replaced by "Complications"

• On Page 7 line 17 "is" should be removed.

Reviewer #2: Comments to the Author

Manuscript Number: PONE-D-24-01243

The manuscript titled " Quality of Basic Emergency Obstetric and Newborn Care Services from Patients’ Perspective in Selected Public Health Centers in Addis Ababa, Ethiopia, 2022: A Cross-Sectional Study " is important research that adds to present knowledge on obstetric violence. The study was generally well conducted but the authors need to address pertinent issues.

My comments are as follows:

Abstract:

Line 24: The gap in this study has not been adequately addressed, highlighting a significant oversight in the research process. Without a thorough exploration of this gap, the study may lack depth and fail to contribute meaningfully to the existing body of knowledge. So, addressing this issue will enhance the overall rigor and relevance of the research.

Next to line 27: Please ensure that the aim/objective of the study are included into the abstract section. This addition will provide clarity and context for readers.

Line 34: The final model identified several significant variables: age, income, companion, and payment. However, the results section only addressed two of these variables—companion and payment. For clarity and consistency, all significant variables should be discussed.

Line 42: Add your recommendation

Background

The discussion is well-presented, but addressing the gaps will strengthen it and make it more convincing.

Methods and material

Study setting and period

I recommend that you include the number of health facilities, the number of healthcare providers—particularly obstetric healthcare providers—and the number of women who utilized BEmONC services.

Population

How did you determine whether the women received at least one Basic Emergency Obstetric and Newborn Care (BEmONC) signal function service in order to include them in your study?

Line 121-123: Please provide the average number of one-month postnatal mothers to clarify the calculation of the k-th interval for selecting the study population.

Operational definition

The author should provide clear definitions for all components of the Donabedian model(input, process and output) to offer a more detailed understanding.

Results

Socio demographic features

Line 229: Since the table includes economic variables, it would be more appropriate to refer to it as sociodemographic/economic features.

Line 231: What were the reasons for the 6% of your sample size that did not participate in the study?

Table 1: You have three participants whose ages are under 18, classifying them as minors. This population typically requires support from their guardians or partners to participate in the study. Did you obtain assent from these minors before conducting the interviews? Additionally, how did you address the ethical considerations related to including children in your research activities?

Table 1: While the study thoroughly examined all variables related to women's sociodemographic, it notably overlooked the variables associated with husbands or partners. This omission is significant, as the role of a husband can greatly influence various aspects of women's health and well-being.

Table 1: ` What was the rationale behind classifying income in this manner? The classification of women's income is unclear. Could you please provide a detailed explanation of how it was operationalized?

Obstetric characteristics of participants

Line 272: I recommend creating a table to present the obstetric characteristics, as this will help readers easily grasp the overall context of maternal-related issues.

Line 2273-274: While it is acceptable to report whether the mothers had antenatal care (ANC) visits, what is crucial is the total number of contacts these women had with healthcare providers. This aspect has not been addressed in the study.

Line 274: “339 (96%) of them wanted pregnancy for this current one” …. This not clear. Please make it clary and understandable by the readers

Line 278-280: Do you think women can determine properly the amount of time they spend before receiving the services. Have you cross checked their responses with other mechanisms

Line 280: Companionship is an important intervention that enhances maternal healthcare services, and it is also a fundamental right for women to have during the utilization of maternal health services. In the study, “Twenty (5.7%) of the women had no companion (attendant) 281 during their stay “…this is too general. So, it should be specified where (service units) women utilize the companionship.

Line 285-286: The study revealed “Two-thirds (75.6%) of the 286 women did not pay for any of the services in the health centers during their stay.” This indicates that approximately 25% of women have covered their medical expenses. However, the Ethiopian government has exempted nearly all maternal healthcare services from charges for women. What accounts for this discrepancy in your findings?

Line 289- 290: in the methods section you operationalized good quality as the quality of BEmONC services from the mothers’ perspective when the mothers 161 scored greater than or equal to the mean of 104 (70%) of all the quality questions. However; in the result section good quality defined as those who scored greater than or equal to the mean of 15 (60%) or rated as good quality, was 174 291 (49.3%). This is contradicted with each other. Look at also the quality measures for process and output. Please see it carefully.

Line 377: In addition to the percentage, please include the frequency for the variables. For example, you could present it as frequency (56.9%).

Table 5: Avoid relying solely on statistical hypothesis testing, such as P values, which fail to convey important information about effect size and precision of estimates. thus, focusing on confidence interval can clearly explain the significance of the variables. Better if you delete the p-value.

Table 5: I have observed wide confidence interval in the final model. A wide confidence interval (CI) indicates a high level of uncertainty regarding the estimated parameter, suggesting that the sample does not provide a precise representation of the population. It suggests that there is insufficient evidence to make definitive conclusions about the parameter being estimated. This can occur due to smaller sample size, high variability or dispersion within the sample data and others. check it.

Discussion

Line 435- 437: the way you justify somehow it is not convincing. Please discuss how your findings relate to existing literature, highlighting both similarities and differences with previous studies.

The study compares and contrasts only a limited number of variables and lacks evidence-based justifications for the discrepancies and similarities between the studies. Therefore, the author should provide strong scientific reasoning for any inline studies and those that align with the findings.

Limitation

While it is important to acknowledge the limitations of your study, it is equally essential to discuss its strengths. Why was this aspect overlooked in your explanation?

Conclusion

Line 473 says the total quality of BEmONC services from the viewpoint of mothers was suboptimal. What was your criteria to declare as it is suboptimal? What was your comparator?

**********

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: No

Reviewer #2: No

**********

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Quality of Basic Emergency Obstetric and Newborn Care Services from Patients’ Perspective in Selected Public Health Centers in Addis Ababa, Ethiopia, 2022: A Cross-Sectional Study

PONE-D-24-01243R1

Dear Dr. Willi_Bahre,

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,

 Asaye, PhD 

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #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: (No Response)

Reviewer #2: The author has addressed all comments and suggestions related to the introduction, methodology, data analysis, discussion, and conclusion of the study.

**********

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

**********