PONE-D-24-52692

More Than Just Visits: Timing, Frequency, and Determinants of Effective Antenatal Care in Bangladesh - BDHS 2007 to 2017–18

PLOS ONE

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Muhammad Haroon Stanikzai

Academic Editor

PLOS ONE

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Additional Editor Comments:

- Please revise categories for media exposure (yes vs no).

- Please revise categories for mobile ownership (yes vs no).

- It would be desirable for the authors to mention in introduction why it is important for the population of women studied in Bangladesh to analyze access to mobile phones.

- Line 264-266: Suggest to add citation: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0309300

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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

Reviewer #3: Yes

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: 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: Yes

Reviewer #3: Yes

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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: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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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: Peer Review Report

Title: "More Than Just Visits: Timing, Frequency, and Determinants of Effective Antenatal Care in Bangladesh - BDHS 2007 to 2017-18"

General Assessment:

This manuscript presents a comprehensive analysis of antenatal care (ANC) utilization patterns in Bangladesh using nationally representative data from two time points. The study makes a valuable contribution to understanding the factors influencing both the timing and frequency of ANC visits, with important implications for maternal health policy and practice.

Strengths:

The study demonstrates several notable strengths through its approach to addressing an important public health issue with clear policy implications. The use of nationally representative data from two time points (2007 and 2017-18) allows for meaningful temporal comparison and trend analysis. The statistical methodology is robust, employing multiple analytical approaches including spatial mapping and classification trees. The theoretical framework is well-conceived and appropriately applied to the research context.

Major Concerns:

Methodological Issues:

The authors need to better justify their choice of cutoff points for "late" ANC initiation. While they follow national guidelines, a discussion of alternative definitions used in the literature would strengthen the paper. The potential for recall bias in self-reported data should be more thoroughly addressed in the limitations section.

Analytical Concerns:

The classification tree analysis, while innovative, requires more detailed explanation of the methodology and interpretation criteria. The spatial analysis would benefit from statistical tests of spatial autocorrelation to support the observed patterns.

Results Presentation:

Some figures (particularly Figure 2) need clearer labeling and legend explanations. The tables would benefit from consistent formatting and clearer presentation of confidence intervals.

Technical Corrections:

Throughout the manuscript, several acronyms are not defined at first use. There is inconsistent use of decimal places in reported statistics. Some references need updating to more recent sources to reflect current understanding of the field.

Specific Recommendations:

Introduction:

The rationale for comparing 2007 and 2017-18 specifically needs strengthening. Additional context about global ANC recommendations and how Bangladesh's guidelines differ would enhance the reader's understanding of the study's framework.

Methods:

The authors should provide more detail about the handling of missing data and clarify the criteria for inclusion/exclusion of variables in the regression models. The choice of classification tree parameters requires additional explanation to ensure reproducibility.

Results:

Effect sizes should be included alongside p-values consistently throughout the results section. The authors should expand their analysis to include more detailed subgroup analyses for urban/rural differences. Sensitivity analyses for different definitions of "late" ANC would strengthen the robustness of the findings.

Discussion:

The policy implications of the findings need expansion, particularly regarding practical implementation strategies. The comparison with other low- and middle-income countries should be strengthened to provide broader context. The sustainability of observed improvements requires more thorough examination.

Major revision is recommended. While the core analysis is sound and the findings are important, several methodological and presentation issues need to be addressed before publication. The authors should carefully consider each point raised in this review and provide detailed responses to strengthen the manuscript's contribution to the field.

Reviewer #2: Dear Editors and Authors,

Thank you for giving me the opportunity to review the manuscript, titled “More Than Just Visits: Timing, Frequency, and Determinants of Antenatal Care in Bangladesh - BDHS 2007 to 2017–18”.

The authors of the study chose a very important topic related to maternal health in Bangladesh. This study examined the factors contributing to delayed ANC and <4 ANC visits, and the association between delayed ANC and <4 ANC. The authors used data from Bangladesh DHS-2007 and DHS2017–18 from women of reproductive age. Geospatial mapping and logistic regression were used to study special pattern and to identify factors associated with delayed ANC and <4 ANC visits. The authors found that late ANC was associated with a significant increase in the odds of <4 ANC visits both in 2007 and in 2017–18.

My assessment of the manuscript is that it is well written. The findings from this study have the potential to impact health interventions and policy to improve initiation of timely ANC visit and use of ANC services in Bangladesh and developing countries. The authors need to address the following issues before the manuscript can be considered for publication.

Throughout the manuscript, the authors should be specified with <4 ANC vs. ≥4 ANC, and should not use the term “adequate or adequacy or inadequacy” because currently WHO recommends ≥8 ANC visits and I don’t think 4-7 ANC visits can be considered adequate based on the revised WHO’s guide.

Abstract

• The purpose of the sentence “… while also evaluating the impact of late ANC initiation on the overall inadequacy of ANC visits.” is not clear, because this study did not examine the impact of late ANC on inadequacy of ANC; but rather examined their associations. This needs to be revised.

• The authors should define the two outcomes of “late ANC, and “<4 ANC visits” in the abstract

• The authors should clarify that they studied the association between the two outcomes, using logistic regression, and provided the ORs of 4.60 for 2007, and 4.68 for 2017-2018, with 95%CIs.

Theoretical framework

• The authors state in lines 101-103 that their analysis explored “accessibility, acceptability, affordability, and awareness of ANC visits” and the data constraints limited the exploration of the dimension of availability”. I’m not sure if this is correct to say all these dimensions. The authors need to state the aspects they actually examined in this study. For example, they did not examine the affordability dimension.

Results

• In Table 1, the authors need to add “total number” for late ANC, and for <4 ANC. The presentation for descriptive statistics is normally column %, and this should be here as well. Currently the percentage for the respective variable becomes 100% only for total sample in 2007 and in 2017-18. This should be the case for the total number for late ANC and for <4 ANC.

• In Table 2, the authors need to add “total number” for late ANC and for <4 ANC. They should also use the term late ANC and <4 ANC, instead of timing of ANC and number of ANC, because they did not use them as continuous variables, but rather binary variables. Also results of 2007 should be presented first in the column, then results from 2017-2018 (the same issue is there in Table 3).

Reviewer #3: the authors have to brings some minor changes to increase the quality of their manuscripts.

they used appropriate statistical tests and the tables are designed well.

the authors mentioned that all the data are available if its need it.

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Reviewer #1: No

Reviewer #2: Yes:  Essa Tawfiq

Reviewer #3: No

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Attachments

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Submitted filename: reviewers comments.pdf

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Submitted filename: recommendation.docx

<p>More Than Just Visits: Timing, Frequency, and Determinants of Effective Antenatal Care in Bangladesh - BDHS 2007 to 2017–18

PONE-D-24-52692R1

Dear Dr. Jitu,

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.

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Kind regards,

Muhammad Haroon Stanikzai

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for addressing reviewers' comments.

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

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 #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

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 #1: Yes

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 #1: Yes

Reviewer #2: Yes

Reviewer #3: 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: Many thanks to the authors as all my comments have been addressed. The manuscript is technically sound now and I have no further comments.

Reviewer #2: Dear Authors and Editors,

Thank you for sharing this article with me for a peer review. All comments I raised in my previous review of the article have been adequately addressed in this revised version.

Kind regards,

Essa Tawfiq

Reviewer #3: (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 #1: No

Reviewer #2: No

Reviewer #3: No

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