PONE-D-24-27119Quality of antenatal care and its potential impacts on delivery services and postnatal care compliance among reproductive women of BangladeshPLOS ONE

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Reviewer #1: Partly

Reviewer #2: Partly

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: 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: This manuscript examines the characteristics of women of child-bearing age who had recently given birth or were pregnant during data collection and who had accessed ANC. Data was collected in 2017 as part of the Bangladesh Health Survey. Appropriate statistical tools were used to create a dichotomous variable of quality ANC which became the outcome variable for a regression analysis.

I have the following comments before the manuscript can be considered for acceptance.

Abstract:

-Results: Please add odds ratio and 95%CI for significant variables.

Introduction:

-The authors should focus on key points. At its current form it is lengthy. The authors should reduce the length of introduction.

Methods:

if the BDHS2017 has been described elsewhere, it would be advisable to reference it and describe it more concisely. They way it is described suggests that the authors collected the data.

The data analysis part would need more details and also what cutoff was used at the

univariate stage to include variables for MV analysis or were all variables included in

the MV analysis. Ideally there is a cut-off for variables to be included in the MV.

Results:

Table: 4 Please explain why the OR for some variables (Birth order) could not be calculated.

Discussion:

Discussion needs a fair bit of work. In its current state it is repetitive, and the recommendations are too often vague. What the authors recommend from each of the key observations they have made.

Limitations section is not included: Several limitations should be included.

I propose the authors use, consult, and add the following references that is a similar study in another LMICs.

Stanikzai, M.H., Tawfiq, E., Jafari, M. et al. Contents of antenatal care services in Afghanistan: findings from the national health survey 2018. BMC Public Health 23, 2469(2023). https://doi.org/10.1186/s12889-023-17411-y

Reviewer #2: Title and Abstract

- The title is clear and informative. It may benefit from explicitly mentioning that the data is derived from the 2017 Bangladesh Demographic and Health Survey (BDHS) to emphasize the scope and rigor of the dataset used.

- Some comments provided in other sections may require addressing within the study itself. If adjustments are made, corresponding revisions in the abstract may also be necessary to ensure alignment with the study’s main findings.

Introduction

The introduction may require some restructuring for clarity. Specifically, consider the following suggestions:

- In lines 72–82, global mortality data is referenced multiple times. A more cohesive flow—from global data to South Asia, and finally to Bangladesh—would strengthen clarity and relevance. Streamlining this information could avoid redundancy.

- In lines 93–98, the eight WHO standards for quality assurance are mentioned, which may imply that these standards will be utilized in the study. Since they are not, it would be helpful to clarify their purpose here to avoid potential misunderstandings.

- The section on Focused Antenatal Care (FANC) (lines 106–117) is somewhat outdated, as the 2016 WHO guidelines now recommend a minimum of eight ANC visits to improve outcomes. Including this updated recommendation would align the background with current global standards, while also providing context for the historical use of FANC.

- Lines 112–114 suggest that reduced ANC visits (aligned with FANC) lead to reduced financial expenditures, which may inadvertently endorse lower visit frequency. This seems to contradict WHO’s updated recommendation of more frequent visits. Clarifying this point could prevent potential confusion for readers.

- In lines 125–127, ANC's impact on reducing maternal and newborn deaths is quantified using a single study reference. To strengthen this point, either generalize the impact of ANC on mortality reduction or support the statistic with additional studies.

- Lines 128–129 state, “Therefore, to properly understand the extent of reduction in MMR and NMR that could be achieved over the coming years, it is highly essential to understand the quality of ANC in Bangladesh.” This sentence could be rephrased to better connect the quality of ANC directly with maternal and neonatal mortality reductions.

- The research gap could be articulated more clearly by briefly summarizing what is already known about ANC quality in Bangladesh and identifying the specific gap this study addresses. Currently, the text alternates between discussing ANC’s role in delivery and postnatal care without clearly addressing why this gap exists in the context of Bangladesh.

- Introducing the five indicators of quality ANC earlier in the introduction, with a clear explanation, would improve clarity and set up the context for the methods and findings.

Methods

- Distinguishing between the original national survey methodology and the specific approach used in this study would enhance clarity. Briefly describing the BDHS 2017 methodology and referencing its report for further details, followed by a focused explanation of this study's specific analytical approach, would clarify the distinction.

- While I am not an expert in quantitative analysis, I recommend that another reviewer with expertise in survey methodology or statistical analysis evaluate this section for rigor and accuracy.

Results

- The demographic description of the mothers/women in BDHS 2017 at the beginning of the results section could be clarified. If the study used the full BDHS 2017 sample, rephrasing slightly to indicate that this is the sample used in the present analysis would prevent any confusion.

- The five ANC services used as indicators of "quality ANC" are main components but may not fully capture the WHO's broader definition of quality ANC. Acknowledging this limitation in interpreting quality ANC would add nuance and transparency to the findings.

- Several times, the terms "SBA delivery" and "facility delivery" are used, which may confuse readers. Given that SBA deliveries may occur outside health facilities while facility deliveries are generally attended by an SBA, a brief explanation of these terms and their distinct roles in the analysis would be helpful.

- In lines 265–267, the authors note that “a considerably higher percentage of facility delivery, delivery by an SBA, and PNC services was observed amongst mothers who had either completed their secondary education, were engaged in skilled/unskilled manual labor, belonged to the richest wealth quintile, or had a birth parity of 1.” However, the role of quality ANC in these associations is unclear. It would be beneficial to clarify how these factors interact with or are influenced by quality ANC.

- In lines 279–283, the association between demographic characteristics (e.g., education level, wealth quintile) and outcome variables such as PNC and facility delivery is discussed. It would be helpful to clarify how these relationships relate to quality ANC, as it currently appears somewhat disconnected from the main study objective.

Discussion

- The discussion could benefit from additional context on the specific challenges and barriers to providing quality ANC in Bangladesh. Including this background would enhance the relevance of the findings.

- In lines 314–323, the discussion returns to the association between education/income and delivery/PNC services. However, this seems tangential to the study’s primary focus on quality ANC. Shifting the emphasis toward findings directly related to ANC quality and maternal outcomes would make this section more cohesive and aligned with the study's objectives.

Limitations

- Adding a section on the limitations of the study regarding the measurement of quality ANC would be beneficial. Currently, only five core components of ANC are used to assess quality, which may not fully capture the comprehensive content and scope of quality ANC as defined by WHO standards. This narrower definition could limit the study’s conclusions on the true quality of ANC.

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Reviewer #1: Yes:  Muhammad Haroon Stanikzai

Reviewer #2: Yes:  Massoma Jafari

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Quality of antenatal care and its potential impacts on delivery services and postnatal care compliance among reproductive women in Bangladesh: a situation analysis from the Bangladesh Demographic and Health Survey 2017

PONE-D-24-27119R1

Dear Dr.Nurunnahar,

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Kind regards,

Essa Tawfiq

Academic Editor

PLOS ONE

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