Determinants of maternity services utilisation among women of reproductive age across sub-Saharan Africa

Julia Marie Hajjar; Obasanjo Bolarinwa; Oluwatobi Abel Alawode; Adeolu Anthony Olagunju; Lawrence Jones-Esan; Sanni Yaya

doi:10.1371/journal.pone.0321521

Peer Review History

Original SubmissionJuly 3, 2024
29 Aug 2024 Decision Letter - Amanuel Yoseph, Editor Dear Dr. Afolabi Bolarinwa, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Oct 13 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. 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'. 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Decision: Major revision [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? Reviewer #1: Yes Reviewer #2: No ******** 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 Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: No Reviewer #2: Yes ****** Reviewer #1: Thank you for your valuable work on this important topic. Your research addresses a prevalent and systematic issue, and your efforts are much appreciated. Here are my comments and suggestions for improving the manuscript: Abstract Section - Lines 29 and 30: "In 2020, approximately 800 women died daily as a result of largely preventable complications of pregnancy and delivery" – Please specify the location of these deaths. Is this a global statistic? - Lines 55 and 56: "whilst women who were gainfully employed were more likely to utilize postnatal care within 48 hours of delivery" – The term "gainfully employed" is broad and should be clearly defined in the methods section. Background Section - Lines 63 and 64: This should be modified in line with the first comment in the abstract section. - Lines 94 to 97: It would be more appropriate to include this information in the methodology section, specifically under outcome variables and explanatory variables. - Overall, try to summarize and shorten the background section. Avoid repetitive ideas and combine related sentences for better clarity. Results Section - Lines 234 and 235: "For the household wealth index, 20% of the women reported being from poorer, middle, richer, and richest households" – This sentence needs restructuring to convey a clearer message. - When reporting the results of the multilevel regression analysis, mention both comparison groups. For example, on page 17, lines 278 to 280: “it can be reported that the older a woman, the more likely she was to deliver at a health facility with women aged 25-34 and 35-49 being 19% (aOR=1.18; 95% CI:1.10 -1.26) and 39% (aOR=1.39; 95% CI: 1.28 – 1.51) significantly more likely to deliver at a health facility respectively” – More likely to deliver compared to which group? Ensure the comparison group is mentioned in all relevant instances. Discussion Section - The discussion should be rewritten, refined, and shortened. It should not merely repeat the results section. Instead, discuss possible reasons for the study's major findings and variations compared to other studies. Compare and contrast your results with the existing literature. - For the result mentioned in lines 308 to 312, where women with primary and secondary education are more likely to have PNC compared to those with no education, discuss possible reasons for this finding. - Discuss why women in polygamous marriages were less likely to have ANC visits but more likely to have PNC visits compared to those in monogamous relationships. Additionally, explore reasons why women with social media exposure, from households with higher wealth indices, and those in high literacy communities are less likely to have PNC visits. Conclusion Section - The conclusion should be rewritten and shortened. Focus on answering the objective of the study and providing clear, concise conclusions. Your attention to these details will greatly enhance the clarity and impact of your manuscript. Thank you for considering these suggestions. Reviewer #2: 1. Title:is better to be stated as Determinants of maternity services utilisation Across SubSaharan Africa 2. From line number 127 and 128, you stated as you considered 58648 reproductive women from 27 countries but not state how you pooled different country data. 3. Your propsed model for out come variable is good. but mony research that have been conducted on your research area using multilevel model. So is it apropriate model for your research problem? Why not using count models? ( needs your clear justification on it) 4. From line number 182; you you state “you have done model comparasion but you did not state for what purepose you do model comparasion. 5. From line number 251 you state “model 4” but from line number 182 you stated”model IV” , so the numberig method is better to be the same and the same is true for onthres. 6. “You stated as model comparasion have been done” but I did not get model compasion results for three models using AIC, BIC and other you stated method. ****** 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 ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. Attachments Attachment Submitted filename: Comment plos.docx https://doi.org/10.1371/journal.pone.0321521.r001
Revision 1
2 Oct 2024 Author Response Reviewers’ comments and replies Reviewer #1: Thank you for your valuable work on this important topic. Your research addresses a prevalent and systematic issue, and your efforts are much appreciated. Here are my comments and suggestions for improving the manuscript: Reply Thank you for taking the time to review our manuscript and we thank you for your review and comments that have improved our work. Abstract Section - Lines 29 and 30: "In 2020, approximately 800 women died daily as a result of largely preventable complications of pregnancy and delivery" – Please specify the location of these deaths. Is this a global statistic? Reply Yes, it’s a global statistic, and this has been added. Line 30 and 63. - Lines 55 and 56: "whilst women who were gainfully employed were more likely to utilise postnatal care within 48 hours of delivery" – The term "gainfully employed" is broad and should be clearly defined in the methods section. Reply The word “gainfully employed” has been changed to “employed” throughout the manuscript; information about employment was explained under the methods section in line 150. Background Section - Lines 63 and 64: This should be modified in line with the first comment in the abstract section. Reply Yes, it’s a global statistic, and this has been added. Line 30 and 63. - Lines 94 to 97: It would be more appropriate to include this information in the methodology section, specifically under outcome variables and explanatory variables. Reply Yes, we included it. Lines 135 to 142. - Overall, try to summarise and shorten the background section. Avoid repetitive ideas and combine related sentences for better clarity. Reply The background section has been restructured to avoid repetitions of ideas. Results Section - Lines 234 and 235: "For the household wealth index, 20% of the women reported being from poorer, middle, richer, and richest households" – This sentence needs restructuring to convey a clearer message. Reply The paragraph has been rewritten to convey a clear message. Page 10, lines 234 to 237. - When reporting the results of the multilevel regression analysis, mention both comparison groups. For example, on page 17, lines 278 to 280: “it can be reported that the older a woman, the more likely she was to deliver at a health facility with women aged 25-34 and 35-49 being 19% (aOR=1.18; 95% CI:1.10 -1.26) and 39% (aOR=1.39; 95% CI: 1.28 – 1.51) significantly more likely to deliver at a health facility respectively” – More likely to deliver compared to which group? Ensure the comparison group is mentioned in all relevant instances. Reply Thank you for the observation. This has been corrected throughout the manuscript. Discussion Section - The discussion should be rewritten, refined, and shortened. It should not merely repeat the results section. Instead, discuss possible reasons for the study's major findings and variations compared to other studies. Compare and contrast your results with the existing literature. Reply This section has been rewritten and reduced. - For the result mentioned in lines 308 to 312, where women with primary and secondary education are more likely to have PNC compared to those with no education, discuss possible reasons for this finding. Reply More information about this has been provided in the discussion section in line with the study results. - Discuss why women in polygamous marriages were less likely to have ANC visits but more likely to have PNC visits compared to those in monogamous relationships. Additionally, explore reasons why women with social media exposure, from households with higher wealth indices, and those in high literacy communities are less likely to have PNC visits. Reply More information about this has been provided in the discussion section in line with the study results. Conclusion Section - The conclusion should be rewritten and shortened. Focus on answering the objective of the study and providing clear, concise conclusions. Reply This section has been rewritten and reduced. Your attention to these details will greatly enhance the clarity and impact of your manuscript. Thank you for considering these suggestions. Reply We have checked through the manuscript again and have made substantial changes to improve the manuscript. Reviewer #2: Comment General comments: --writeup in introduction is well - Writeup in method is a litle bit good. -result write up have good floow and detail -the overall result will have significant impact Reply Thank you for taking the time to review our manuscript and we thank you for your review and comments that have improved our work. 1. Title:is better to be stated as Determinants of maternity services utilisation Across SubSaharan Africa Reply The title has been changed to reflect this. 2. From line number 127 and 128, you stated as you considered 58648 reproductive women from 27 countries but not state how you pooled different country data. Reply Information about this has been added to page 6, lines 173 to 175, under statistical analyses. 3. Your propsed model for out come variable is good. but mony research that have been conducted on your research area using multilevel model. So is it apropriate model for your research problem? Why not using count models? ( needs your clear justification on it) Reply Thank you for calling our attention to this. Yes, we believed this is the appropriate model because of the nature of the dataset, and because we considered three outcome variables in this study, we believed it’s appropriate to consider using the same model for the three outcomes given the fact that “facility delivery” is dichotomous. 4. From line number 182; you you state “you have done model comparasion but you did not state for what purepose you do model comparasion. Reply This information has been added to ensure better understanding “to show which model significantly improves over others whilst ensuring the appropriate model with goodness of fit is selected.” 5. From line number 251 you state “model 4” but from line number 182 you stated”model IV” , so the numberig method is better to be the same and the same is true for onthres. Reply This has been changed to “model I to model IV” in the same format. 6. “You stated as model comparasion have been done” but I did not get model compasion results for three models using AIC, BIC and other you stated method. Reply The results were stated in the tables except for BIC. All other results have been reported in the results section, and the BIC claim has been deleted. Attachments Attachment Submitted filename: Reviewers replies_R1.docx https://doi.org/10.1371/journal.pone.0321521.r002
9 Apr 2025 Decision Letter - Steve Zimmerman, Editor Dear Dr. Bolarinwa, 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 has been evaluated by two reviewers, and their comments are available below. Although reviewer 1 is satisfied with the revised manuscript, reviewer 3 has raised a concern that needs attention. -->?> Please submit your revised manuscript by May 24 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. 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 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, Steve Zimmerman, PhD Senior 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. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed Reviewer #3: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #3: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #3: (No Response) ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #3: (No Response) ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #3: (No Response) ****** Reviewer #1: (No Response) Reviewer #3: This retrospective cross-sectional study employed Demographic Health Surveys (DHS) conducted in 27 countries in SSA. The outcome and explanatory variables were adequately defined. On Line 164 the authors state , “…. three-level multi-level logistic regression….” Do they actually mean, “three-level multiple logistic regression…”? Tables 3,4 and 5 are well constructed as one would expect a hierarchical presentation. Since this was a multilevel look, the authors did put a descriptive paragraph at the end of the Tables 3,4, and 5 presentation stating the relative merits of the three constructs in some way. However, this could have been a bit more sophisticated beyond the model fit statistics with a Factor analysis type structure if individual, household and community separate out to three meaningful constructs to determine which grouping is the most statistically significant contributor to the three endpoints being investigated. Why , no attempt for a Data reduction strategy in view of the many variables being examined separately? There is no explanation in the discussion section as to the statistical overall comparison of the three levels (constructs) as to their relative importance individually or why that was not considered. This could possibly be a study limitation from the analytical perspective. ****** 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 #3: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org https://doi.org/10.1371/journal.pone.0321521.r003
Revision 2
25 Aug 2025 Author Response Reviewers comments and replies Reviewer #1: (No Response) Reply Thank you for taking the time to review our manuscript. We greatly appreciate your feedback and constructive comments. Reviewer #3: This retrospective cross-sectional study employed Demographic Health Surveys (DHS) conducted in 27 countries in SSA. The outcome and explanatory variables were adequately defined. Reply Thank you for taking the time to review our manuscript. We greatly appreciate your feedback and constructive comments. On Line 164 the authors state , “…. three-level multi-level logistic regression….” Do they actually mean, “three-level multiple logistic regression…”? Reply This study employed a three-level multilevel logistic regression analysis rather than a multiple regression approach, as it accounted for unexplained variations across all levels. Models 0 to IV were assessed using log-likelihood ratio and Akaike Information Criterion (AIC), as presented in Tables 3 to 5. Tables 3,4 and 5 are well constructed as one would expect a hierarchical presentation. Since this was a multilevel look, the authors did put a descriptive paragraph at the end of the Tables 3,4, and 5 presentation stating the relative merits of the three constructs in some way. However, this could have been a bit more sophisticated beyond the model fit statistics with a Factor analysis type structure if individual, household and community separate out to three meaningful constructs to determine which grouping is the most statistically significant contributor to the three endpoints being investigated. Why , no attempt for a Data reduction strategy in view of the many variables being examined separately? There is no explanation in the discussion section as to the statistical overall comparison of the three levels (constructs) as to their relative importance individually or why that was not considered. This could possibly be a study limitation from the analytical perspective. Reply Thank you for raising this important observation. We have addressed it in the limitations section of the revised manuscript. The updated Strengths and Limitations section now reads as follows: “This study analysed pooled DHS datasets from 27 sub-Saharan African countries involving 58,648 women of reproductive age. Using nationally representative data provided a robust and comparative picture of the facilitators and barriers to maternity service utilisation across the region. The inclusion of a decade-long dataset enhances the reliability and generalisability of the findings, making an important contribution to advancing knowledge on maternal and newborn health coverage in SSA. However, the exclusion of 19 countries due to unavailable data limits full regional representation. Reliance on self-reported data introduces the possibility of recall bias, while the cross-sectional design prevents determination of causality. In addition, the absence of a data reduction strategy, such as factor analysis, restricts the ability to assess the relative contributions of individual, household, and community-level factors. Finally, given the study’s scope and eligible respondents, findings may not fully align with patterns reported in other literature.” Attachments Attachment Submitted filename: Reviewers replies_R2.pdf https://doi.org/10.1371/journal.pone.0321521.r004
8 Jan 2026 Decision Letter - Mubarick Asumah, Editor Determinants of maternity services utilisation among women of reproductive age across sub-Saharan Africa PONE-D-24-26208R2 Dear Dr. Bolarinwa, 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. For questions related to billing, please contact billing support . 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, Mubarick Nungbaso Asumah Academic Editor PLOS One Additional Editor Comments (optional): Reviewer #3: Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #3: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #3: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #3: (No Response) ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #3: (No Response) ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #3: (No Response) ****** Reviewer #3: (No Response) ****** 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 #3: No ******** https://doi.org/10.1371/journal.pone.0321521.r005
Formally Accepted
Acceptance Letter - Mubarick Asumah, Editor PONE-D-24-26208R2 PLOS One Dear Dr. Bolarinwa, 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 Mr. Mubarick Nungbaso Asumah Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0321521.r006

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