PONE-D-24-10835Trend of Home Delivery and Its Associated Factors in Ethiopia during COVID 19 and Social Crisis (2019-2023)PLOS ONE

Dear Dr. Bayou,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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ACADEMIC EDITOR:

• The manuscript has very valuable contributions but it requires solving some flaws: editing tables and figures, references and some writing errors.
• I suggest that the authors strengthen consistency between the different sections: for example the role of personnel who attend home births versus hospital births.
• The reviewers agree on the need to unify the way of referring to home birth: birth or delivery
• I considered that the major revision is the relevant decision to improve the manuscript due to inconsistencies that I point out below.

Please submit your revised manuscript by Sep 15 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,

Doris Verónica Ortega-Altamirano, PhD

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 noticed you have some minor occurrence of overlapping text with the following previous publication(s), which needs to be addressed:

file:///home/administrator/Downloads/Phase%202_3%20Protocol_Final_02_07_EN.pdf

https://pubmed.ncbi.nlm.nih.gov/34913391/

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

3. In the online submission form you indicate that your data is not available for proprietary reasons and have provided a contact point for accessing this data. Please note that your current contact point is a co-author on this manuscript. According to our Data Policy, the contact point must not be an author on the manuscript and must be an institutional contact, ideally not an individual. Please revise your data statement to a non-author institutional point of contact, such as a data access or ethics committee, and send this to us via return email. Please also include contact information for the third party organization, and please include the full citation of where the data can be found.

Additional Editor Comments:

Abstract: the surveys analysed correspond to the period 2021-2023. However, the study period was from 2019 to 2023. Clarify this inconsistency.

Line 70-71”… substantial prevalence of home birth preference in Ethiopia…” The ratio of births at home to hospital is missing. How much substantial?

Line 74. Improve drafting. Clarify: Prevalence of which country Ethiopia or other African countries? The baseline should be reviewed to determine where the prevalence of 94.20% is from.

Lack information about the association, if there is between home-assisted delivery and the prevalence of maternal morbidity and mortality due to bleeding, infection and high blood pressure. Also clarify the fraction attributable to attention to birth given by attendee without sufficient training.

Line 81-86. The authors list different causes of preference for home births attributable to pregnant women and their family members and access to health services. Please clarify the idea and put separately the causes attributable to pregnant women and home birth, as well as the causes attributable to the health system, And human resources with insufficient training for childbirth care.

Line 92: Check if the idea is correct. If the number of home births was not measured, why are you planning to expand services from 50% to 76%?

Study Design and Data Source. Line 106-107: “We obtained the data for this study from four recent rounds of the Performance Monitoring for Action (PMA) surveys conducted from 2021-2023." The date of the data source 2021-2023 does not coincide with the study period mentioned in the manuscript title: 2019-2023. Where the data for the years 2019 and 2020 come from.

Line 109-112. Authors should specify in detail the agency responsible for PMA surveys.

Line 121-122. Reference of the sample frame missing: “Enumeration areas (EAs) were selected from the master sample frame of the Central Statistical Agency”.

Line 128-129: It is not clear how household surveys are included in the PMA.

Review text organization, for example:

Line 100-104. Information to include in the introduction.

Line 137-138: Information to be in the data source section.

Line 147. “Four years trend in home delivery was analyzed from PMA data”. Information that should be in the data section and not in the results.

Line 139: authors must justify the use of two statistical packages and what contribution to the study makes the analysis in two different software: STATA 17 and SPSS 25.

Line 141: it is redundant to point out that the logistic regression is binary. If applicable, mention whether the response variable had more than two categories so it was chosen to transform it into a binary.

Line 148-150. “For two regions (namely Tigray and Afar, two years (2022 and 2023 were missed.” Explain in limitations of the study, at the end of discussion, how did the loss of data affect the study?

The topics of discussion should come from the results of the study. The following is from the literature review and the authors did not raise it in the introduction: Line 178-184. The authors argue that births should be attended by personnel trained to detect and manage complications that may arise during childbirth. Do the authors assume that the personnel attending to deliveries at the women’s home are not sufficiently trained to detect and manage complications? Missing references. Explain in Introduction that home delivery care can become complicated if the attending midwife or obstetrician is insufficiently trained.

Line 188- 192. In 2019, a study reported the prevalence of home birth care at 28% vs. 37.80% found by the authors. To delve into the reasons for this difference of 9% between its finding and that reported by other authors previously.

Line 230. To name the regions. How does the underestimation of prevalence in these regions affect or not the trend identified in the country from 2019 to 2023?

Typo:

Line 178. “world health organization” is not correct. Most use capital letters.

Edit references with the style requested by PLOSOne.

Tables and figures contain insufficient information to understand the data they display.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

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

Reviewer #1: No

Reviewer #2: Yes

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

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

Reviewer #1: Yes

Reviewer #2: No

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

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

Reviewer #1: No

Reviewer #2: No

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5. Review Comments to the Author

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

Reviewer #1: Thank you for inviting me to review the manuscript “Trend of Home Delivery and Its Associated Factors in Ethiopia during COVID 19 and Social Crisis (2019-2023)”. This paper needs English editing before having the potential to be published. In addition, a number of issues have to be addressed.

1) Abstract: method should be revised by detailing the study design, sample, sample size, data collection, etc.

2) Method: The instrument for outcome measure (Home Delivery/ Health facility delivery) should be clearly described.

3) Introduction and methods: The selection of “factors” and their measurement tools should be clearly stated. There are many factors influencing “place of delivery” potentially. The authors should explained why they selected the ones in this paper but not others. The instruments for measuring the factors should also be detailed.

4) Method: Did the authors combine four years data and then conduct the regression analyses?. Information on how the regression analyses were performed should be expanded.

5) Result: Standard deviation should be illustrated in figure 1.

6) Discussion: Strength of the study should be discussed

Reviewer #2: Thank you for giving me the opportunity to review this interesting manuscript. Measure against high mortality rates in Ethiopia and birth attendance of skilled health professional are very important topics. However, the manuscript needs thorough revision before publication could be considered. Especially the language needs to be improved. There are many sentences which are difficult to understand. Additionally, it would be good to replace the word “delivery” with “birth” which is a more active term and seems more appropriate. I would also suggest taking a more differentiated view on the problems around giving birth in Ethiopia and making a clearer distinction between the problem of home births, the circumstances in which they take place and the problem of births without skilled attendants.

Abstract

- Background, first sentences: mortality rates are not high in every part of the world, this first sentence seems to be too general.

- Background: I already wondered at this point if home births are the only problem or if their circumstances and that they take place without skilled health professionals is just as important.

- Objectives: I do not understand the “2024” in the end. In the title it was 2019-2023…

- Methods: were the data sets appended or merged?

- Results: “…showed a significant decline decreased from…” seems not to be correct. Additionally, “didn’t” is not academic writing.

Introduction

The introduction is logically structured and justifies the study well.

- The first sentence needs a reference.

- Line 51: is the information within the brackets correct?

- Lines 57-60: references are needed.

- Line 64: Reference 4 is not a reference by the World Health Organisation but from the NHS in the UK. Additionally, this reference takes a very differentiated view of the problem of place of birth. Under certain circumstances, home births can be recommended. However, the problem in Ethiopia is that women with high-risk pregnancies also give birth at home and are inadequately supported there.

- Line 67: Ethiopia is a member of what?

- Lines 69-72: this sentence is not correct and can not be understood.

- Line 74: the abbreviation DHS needs to be introduced correctly. This is true for all abbreviations, e.g. also ANC on line 82.

- Lines 87 and following: there is a confusion with the verb tenses in this paragraph.

Methods

- At the beginning of the chapter, the study design is missing, and it was also not mentioned at the beginning of the chapter Study Design and Data Source.

- Line 98: it needs to be explained, why the study was conducted in predominantly agrarian regions and this needs to be considered in the interpretation of the results.

Results

- Line 149: it should be “were missing” and in the next sentence “ranged” instead of “were ranged”. Please consider careful proofreading for this manuscript.

- Line 154 and other parts of the manuscript: inconsistencies in the number of decimals should be harmonized.

- Lines 155-156 as well as Table 2: the subdivision into the groups with overlapping years is very confusing and need explanations and justifications.

- Lines 169 und 172: I wonder if “counter parts” and “counterparts” are correct terms.

Discussion

The discussion needs some work. The first paragraph in the current version is not study related, misses references and would rather belong to the introduction. The first sentence of the discussion should include what was special for this study (if applicable) and/or what the authors intended to do. It should be followed by a very short, to the point summary.

- In my opinion, it should also be discussed and differentiated whether the problem is about home birth as such or about the circumstances in which home births take place (no risk assessment, probably no skilled health professionals, …).

- Lines 188-189: there is an inconsistency in the number of decimals.

- Lines 193-194: no new paragraph would be necessary as it continues with the same topic.

- Line 202: “avail” might not be the correct term.

- Lines 207-208 and line 221: the current study can support results from previous ones but not vis versa, because other study already existed before.

- Line 232: is it for sure an underestimation or is also an overestimation possible?

- Line 232: it probably should be “encouraging”.

Tables

- Table 1: Amhara 2019: a bracket is missing. Addis Ababa 2023: the space between the number and the bracket is missing.

- Table 2: as said above, the subdivision into these groups seem unclear with the overlapping years.

- Table 3: spaces between numbers and brackets are missing and there are inconsistencies with the number of decimals.

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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: Yes:  Susanne Grylka-Baeschlin

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PONE-D-24-10835R1Trend of Home Birth and Its Associated Factors in Ethiopia during COVID-19 and Social Crisis (2019-2023)PLOS ONE

Dear Dr. Bayou,

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: The manuscript must be edited, particularly the tables lack of title and source.

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

Please submit your revised manuscript by Nov 15 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,

Doris Verónica Ortega-Altamirano, PhD

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 :

The manuscript is suitable for publication in the journal.

Tables lack of titles and sources.

Table 1. Discriptions of the study participants by region and survey years in Ethiopia, 2024 (the study is from 2019 to 2023. The year in the table´s title is wrong.

Table 2. Percent change in prevalence of home delivery from 2019-2023, Ethiopia, 2024. The same that above.

Table 3 Multivariable logistic regression analysis of the factors associated with home birth in Ethiopia, 2024. The same comment in table 1 and 2.

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

Reviewers' comments:

[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.

PONE-D-24-10835R2Trend of Home Birth and Its Associated Factors in Ethiopia during COVID-19 and Social Crisis (2019-2023)PLOS ONE

Dear Dr. Bayou,

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. The manuscript addresses a topic of interest but does not explain it sufficiently and clearly.It presents multiple areas for improvement and requires authors to respond to reviewers' comments. Please submit your revised manuscript by Jan 04 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,

Doris Verónica Ortega-Altamirano, PhD

Academic Editor

PLOS ONE

Additional Editor Comments:

The manuscript addresses a topic of interest but does not explain it sufficiently and clearly. Presents multiple areas for improvement and requires authors to respond to reviewers' comments.

[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 #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #2: Yes

Reviewer #3: Yes

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

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

Reviewer #2: Yes

Reviewer #3: Yes

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

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

Reviewer #2: Yes

Reviewer #3: Yes

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6. Review Comments to the Author

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

Reviewer #2: Thank you for thoroughly revising the manuscript. I evaluated R1 and R2 together and the manuscript improved considerably. There are still a few minor comments:

- Thank you for harmonising the decimals. While this is necessary and makes sense in the result section, it is not adequate in the introduction in formulations such as “nearly 95%” and “around 70%”. Please remove the decimals there.

- Lines 108-110: word repetition of “population”, which should be avoided.

- Title “Limitation of the study” should now be “Strength and limitation of the study”

- Line 264: I do not understand the numbers in the bracket (2022 and 149 2023)

- Line 265: The term “probably” does not make sense in this context. You could write: “… might have under- or overestimated the proportion…”

Reviewer #3: I am very grateful to be part of this peer review; it is a pleasure to read about such an important topic for women’s health and well-being as the trend of home births in Ethiopia and its associated factors. Below, I will outline some key points to strengthen the rigor and clarity of the manuscript.

In the introduction section, specifically in line 91, the influence of cultural beliefs and social norms on the preference for home births is not addressed. Incorporating these factors, could provide a more comprehensive understanding of the cultural and social factors influencing the choice of birth location.

In line 118, it is mentioned that the sampling was conducted only in certain regions of Ethiopia, which is inconsistent with the conclusions that state the results are representative of the entire country.

In line 141, the two-stage cluster sampling technique is described. I suggest providing a more detailed description of the sampling process at each stage, including the criteria for selecting clusters and study units.

Finally, in line 154, variables such as awareness, perception, knowledge, and use of contraceptive methods, components of health service delivery, perceived quality, and side effects among current users, birth history, fertility intentions, and empowerment domains are mentioned. However, the absence of variables such as educational level, family income, and geographical location is significant, as they are essential for controlling potential confounding factors, which could enrich the study’s conclusions.

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

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

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

Reviewer #2: Yes:  Susanne Grylka-Baeschlin

Reviewer #3: Yes:  PhDc Gustavo Alejandro Román-Brito

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

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

Trend of Home Birth and Its Associated Factors in Ethiopia during COVID-19 and Social Crisis (2019-2023)

PONE-D-24-10835R3

Dear Dr. Bayou,

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,

Tegene Atamenta Kitaw (MSc, MPH), Woldia University

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

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

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

Reviewer #2: Yes

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

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

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

Reviewer #2: (No Response)

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

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

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

Reviewer #2: Yes:  Susanne Grylka-Baeschlin

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