Dear Dr. karim,

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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Kind regards,

Dinaol Abdissa Fufa, Mph

Academic Editor

PLOS ONE

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When submitting your revision, we need you to address these additional requirements.

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“University Grant Commission (UGC), Bangladesh support the research grant (2022-23) to public university teacher.  ”

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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?

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: Yes

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

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??>

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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Reviewer #1: Interesting idea of this study, my recommendations are the following:

Lines 22-25 I recommend to write as a single sentence, for example - assessment of malnutrition status and associated characteristics in children.

I recommend expanding the Introduction section by mentioning the main aspects regarding the mental health of mothers and the risk of associated conditions. Description based on specialized literature of the main mental conditions in breastfeeding mothers.

Line 109 I recommend mentioning the bibliographic index as a number from the bibliographic references, according to the editing rules.

Assessment of Maternal Mental Health – I recommend mentioning the reliability of the questionnaires by calculating Cronbach's alpha regarding the results of this study.

Characteristics of the study subject – I recommend that when interpreting the results, the information should not be duplicated with those mentioned in table 1, I recommend clarifications.

I recommend that in tables regarding the p-value index, the standard symbol should be mentioned: <, >.

I recommend that future research directions and practical implications be mentioned at the end of the Discussions section.

Reviewer #2: The manuscript presents a well-executed study on an important public health issue, exploring the relationship between maternal mental health and child undernutrition in low-income settings. The use of validated mental health assessment tools (PHQ-9, GAD-7) and standardized anthropometric measurements strengthens the reliability of the findings. Additionally, the application of multivariate logistic regression and appropriate model validation enhances the robustness of the statistical analysis. The study’s conclusions are well-supported by the data, and the policy implications are clear, emphasizing the need for maternal mental health interventions in child nutrition programs.

However, the manuscript has several areas that require improvement. The writing quality needs refinement, as certain sentences are overly complex, making it difficult to follow key findings. For instance, in the Discussion section, some interpretations of the regression results could be rewritten more concisely to improve clarity. Additionally, there is some repetition in how maternal depression and anxiety are discussed across different sections, particularly in the Results and Discussion, which could be streamlined to avoid redundancy. Statistical interpretations should also be made more precise—for example, rather than stating that maternal depression “considerably increases” the odds of stunting, specifying the exact percentage increase based on odds ratios would make the findings more accessible to readers.

Furthermore, the manuscript would benefit from clearer terminology. The terms “malnutrition” and “undernutrition” appear to be used interchangeably, though they have different meanings—malnutrition includes both under- and overnutrition, while this study focuses specifically on undernutrition. Consistently using the correct term would enhance clarity. Similarly, the description of the child feeding index could be expanded slightly to help readers unfamiliar with the methodology understand how scores were calculated.

Overall, this is a valuable study with important findings, but revisions to improve clarity, reduce redundancy, and refine statistical explanations would strengthen the manuscript further.

Reviewer #3: The study titled “Child Undernutrition is Associated with Maternal Mental Health and Other Sociodemographic Factors in Low-Income Settings in Dhaka, Bangladesh” by Karim et al. discusses an important topic. However, to further improve their study, I recommend the following edits:

• Pages 11-13, Introduction Section: Given that this study focuses on maternal health, it is important for the authors to elaborate further on maternal mental health and its impact on child nutrition. While the introduction mentions maternal mental health as a factor, it does not sufficiently explain the mechanisms through which maternal depression or anxiety may lead to child undernutrition. Adding a few lines on why maternal mental health is crucial—such as its influence on feeding practices, healthcare-seeking behavior, and overall child well-being—would strengthen the argument and provide a clearer rationale for its inclusion in the study, especially in the context of Bangladesh.

• Page 12, Lines 78-85: As the authors mention that non-slum low-income areas remain unexplored, they should expand on this point and highlight it more, as it represents the novel aspect of their study. Many studies have already been conducted on maternal health in low- and middle-income countries like Bangladesh, so it is important to explain why non-slum low-income areas need separate attention. Clarifying how this population differs from those previously studied would help strengthen the focus and contribution of this research.

• Page 13, Lines 93-99: The study setting and population are well described; however, the inclusion and exclusion criteria for participants are not mentioned. Clarifying these criteria would enhance the transparency and reproducibility of the study. Were there any specific factors that determined participant selection or exclusion?

• Page 14, Lines 119-125: The methodology for anthropometric measurements is unclear. Were these measurements taken by trained professionals, or were they self-reported? Clarifying this would aid in evaluating the accuracy and reliability of the data.

• Page 15, Lines 127-138: The study provides a clear description of the PHQ-9 and GAD-7 scales, but it is unclear whether they have been validated for use in the Bangladeshi population. Given that cultural differences can influence responses to mental health questionnaires, providing this information would strengthen the study’s validity.

• Page 31, Lines 365-378: The authors imply that socio-cultural preferences for male children lead to better nutrition but do not provide direct evidence. Citing studies on gender-based food distribution would strengthen this claim. Adding references would enhance clarity and support the argument.

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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: Yes:  Badau Adela

Reviewer #2: No

Reviewer #3: No

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Child undernutrition is associated with maternal mental health and other sociodemographic factors in low-income settings in Dhaka, Bangladesh

PONE-D-24-58026R1

Dear Dr. karim,

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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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,

Dinaol Abdissa Fufa, Mph

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: The article entitled Child undernutrition is associated with maternal mental health and other sociodemographic factors in low-income settings in Dhaka, Bangladesh, was revised in accordance with all suggested recommendations.

The introduction has been carefully revised and supplemented with relevant aspects from the specialized literature, in line with the recommendations.

The Methods section has been revised, the calculation of the reliability index is good, which means that this instrument can be applied to the sample of subjects.

Reviewer #2: The authors have made significant improvements to the manuscript, addressing all the reviewers' concerns thoroughly. Key aspects of the study, including the impact of maternal mental health on child nutrition, have been clarified and expanded. Statistical analysis has been appropriately revised to enhance clarity and precision, with odds ratios now expressed in a more interpretable manner. Additionally, terminology has been standardized, and redundant sections have been streamlined, ensuring better readability.

Specific improvements include:

1.Expansion of the introduction to detail the mechanisms by which maternal mental health influences child nutrition.

2.Validation of the PHQ-9 and GAD-7 scales for the Bangladeshi population, along with Cronbach’s alpha values indicating reliability.

3.Inclusion of inclusion/exclusion criteria and clarification of anthropometric measurement procedures.

4.Addressing all technical issues with data presentation, including p-value formatting and avoiding duplication of information in the results and tables.

The manuscript is now clear, concise, and impactful, making it suitable for publication in PLOS ONE. No further revisions are recommended.

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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: Yes:  Badau Adela

Reviewer #2: No

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