Spatial patterns and predictors of antenatal care interruption in war-torn Tigray, northern Ethiopia: Spatial modelling approach

Assefa Ayalew Gebrselassie; Mussie Alemayehu; Haftu Gebrehiwot; Brhane Ayele; Hailay Gebretnsae; Ferehiwot Hailemariam; Tsegay Wellay; Adhena Ayalew; Araya Abrha Medhanyie; Znabu Hadush Kahsay; Liya Mamo; Mebrahtu Kalayu Chekole; Reda Shamie; Mohammedtahir Yahya; Melaku Abraha; Hayelom Kahsay; Tsegay Hadgu; Fana Gebreslassie; Asfawosen Aregay; Kiros Demoz; Mulugeta Tilahun; Mulugeta Woldu; Ataklti Gebrtsadik; Abraham Aregay Desta; Gebrehaweria Gebrekuristos; Amanuel Haile; Rieye Esayas; Tsegay Berihu; Abrham Gebrelibanos; Tadele Tesfean; Ashenafi Asmelash; Afework Mulugeta Bezabh

doi:10.1371/journal.pone.0328802

Peer Review History

Original SubmissionFebruary 27, 2025
21 May 2025 Decision Letter - Kahsu Gebrekidan, Editor PONE-D-25-08979Spatial patterns and predictors of antenatal care interruption in war-torn Tigray, northern Ethiopia: spatial modeling approachPLOS ONE Dear Dr. Gebreslassie, 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 Jul 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. 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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 note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. 3. Thank you for stating the following financial disclosure: [UNICEF, WHO, Amref Health Africa and UNFPA and Tigray regional heal bureau and Mums for Mums (MfM) for all rounded support in ensuring a successful and productive integrated research data collection process we assure there is no any competing programming and any other support that influences the research output]. Please state what role the funders took in the study. If the funders had no role, please state: ""The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."" If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 4. Thank you for stating the following in the Acknowledgments Section of your manuscript: [We extend our heartfelt gratitude to the Tigray Health Bureau (THB) for leading this integrated research and mobilizing technical staff for data collection. Lastly, we thank the participants, as well as the data collectors and supervisors, particularly those from Mekelle University College of Health Sciences and Tigray Health Research Institute (THRI), for their commitment and integrity in generating quality data.] We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: [UNICEF, WHO, Amref Health Africa and UNFPA and Tigray regional heal bureau and Mums for Mums (MfM) for all rounded support in ensuring a successful and productive integrated research data collection process we assure there is no any competing programming and any other support that influences the research output]. Please include your amended statements within your cover letter; we will change the online submission form on your behalf. 5. 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[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? 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 ******** 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 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 ****** 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: No ****** 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: Title: Spatial patterns and predictors of antenatal care interruption in war-torn Tigray, northern Ethiopia: a spatial modeling approach I am happy to review this manuscript, which is well-written for the “Spatial patterns and predictors of antenatal care interruption in war-torn Tigray, northern Ethiopia: spatial modeling approach” and has brought some important findings. However, I have encountered some typos error in many instances. That is proofread is needed. • Why you used mixed methods? • In Abstract: Result Part: A result should be interpreted well and written to the nearest value. It seems vague. • Conclusion of abstract, should be written again, especially recommendation part. Theoretically, recommendation should be emanated from result. Which result leads to this recommendation “Improving infrastructure and security, implementing targeted interventions, enhancing mass media health information dissemination, and further research on geographic disparities are essential.”? • General comment: In introduction, it seems good. Please, rephrase and conceptualize in your own words. Basically, your introduction also should focus on a) what we already know from the literature, b) what new concepts this study can address that make a distinct contribution beyond the prior studies? People want to see the effect of war in the ANC use? Previous distribution should be written well. • Methods part: Good but describe study area in connection to your title in detail. • Perhaps, I am expecting from you special distribution of the problem in the map. Geographical map is needed to show the existence of the problem at the end of the result as a result or at the end of the introduction as the concept of indication. • Measurement and variables should be written in detail. • Ethical considerations part: Ethical approval and consent to participate part should follow the Helsinki declaration of human participants while you are writing ethics. • In results part, good to narrate in this way. However, the study should show new insights and should enhance practical relevance while clarifying the scientific concept. In Discussion part: • Please do not repeat result (Numbers). Rather the implication of each association should be clearly explained. • Under the discussion section, you have to start a discussion by summarizing the main findings. • Possible scientific justification is required for each association whether it agrees or not with other studies. Good luck! Reviewer #2: The research project's title is scientifically sound, and I believe it will significantly contribute to the body of knowledge in maternal health. However, the document is not written in standard English and requires revision. Additionally, some areas need substantial changes and improvements. All comments and suggestions are tracked changes. Comment # 1 Introduction: Explain these new Guidelines. It does not make sense to readers. Comment #2 Materials and methods: Please clarify whether this research utilised secondary data from the "Evaluating" survey, "Cost-Effectiveness in Post-Conflict Settings in Tigray, Ethiopia," or relied on primary data. Comment#3 Result: Please specify the model's fitness and describe the methods employed to assess multicollinearity. Comment #4 Result: Indicate the variables with a P-value of less than 0.05 or significant. Comment #5 Discussion: What is the data from the study conducted in Syria? Comment # 6 Discussion: How can you compare the distance to health facilities with the impact of conflict and war on the interruption of antenatal care services? Comment # 7 Discussion: Justify why this particular zone has higher odds of ANC interruption. Compare and contrast with similar findings. Comment #8 Discussion: Correlate these findings with similar studies. Comment # 9 Discussion: You should move this sentence to the recommendation section. Comment # 10 Discussion: You need to establish a connection between the increased distance to healthcare facilities in war-torn areas and the discontinuation of the ANC program in rural regions. Rural areas often suffer from inadequate infrastructure, particularly in terms of roads, which hinders access to health facilities even in peaceful places. Consider how you can uniquely frame this argument to support your position. Comment # 11 Discussion: The argument lacks clarity. Does the North-West zone have more rural kebeles compared to the South-West zone? How can you formulate an argument regarding the rural population in this context? Comment # 12 Discussion: Move this paragraph to the recommendations section. Comment # 13 Discussion: You need to provide reference findings. Comment # 14 Discussion: You need to provide reference findings. Comment # 15: Add the strengths and limitations of the study. Comment # 16: Declare any conflict of interest. ****** 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: Yes: Feleke Doyore Agide 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: PONE-D-25-08979_reviewer_Commented.docx https://doi.org/10.1371/journal.pone.0328802.r001
Revision 1
12 Jun 2025 Author Response Response to editor and Reviewers PLOS ONE Thank you for the opportunity to revise our manuscript titled "Spatial Patterns and Predictors of Antenatal Care Interruption in War-Torn Tigray, Northern Ethiopia: Spatial Modeling Approach Manuscript ID: PONE-D-25-08979. We appreciate the constructive feedback from you and the reviewers. Below, we address each comment in detail. 2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. Response: our funding had not grant number because the budget was utilizing through perdiem . Thank you for stating the following financial disclosure: [UNICEF, WHO, Amref Health Africa and UNFPA and Tigray regional heal bureau and Mums for Mums (MfM) for all rounded support in ensuring a successful and productive integrated research data collection process we assure there is no any competing programming and any other support that influences the research output]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript Please state what role the funders took in the study. If the funders had no role, please state: Response thank you for your comment we have revised as you suggested UNICEF, WHO, Amref Health Africa and UNFPA and Tigray regional heal bureau and Mums for Mums (MfM) for all rounded support in ensuring a successful and productive integrated research data collection process we assure there is no any competing programming and any other support that influences the research output. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript In the research on antenatal care interruption in Tigray, we maintain a strong commitment to avoiding conflicts of interest. We ensure that our funding sources do not create biases, as we do not have any conflicts with organizations that might have vested interests in the outcomes, such as government agencies UNICEF, WHO, Amref Health Africa and UNFPA and Tigray regional heal bureau and Mums for Mums (MfM with specific agendas. Our collaborative relationships with local health authorities and NGOs are structured to prevent any conflicts, as these entities do not have a stake in the research findings that could influence our work. Additionally, the researchers do not have personal ties to the region or its healthcare systems that could compromise the interpretation of data or reporting results. We are also vigilant against publication bias, ensuring that we do not face conflicts that would pressure us to publish only positive outcomes aligned with funding interests, which could distort the integrity of our research. Ethical considerations are paramount; we adhere to rigorous ethical guidelines to address the unique challenges of working with vulnerable populations in conflict zones, recognizing the dilemmas that may arise. To mitigate potential conflicts, we prioritize transparency by disclosing all funding sources and potential conflicts in our publications. We are committed to an independent review process, welcoming input from independent experts in study design and data analysis to ensure objectivity. Finally, we uphold ethical oversight by obtaining approval from relevant review boards Tigray health research institute (THRI) as mentioned above to safeguard participant welfare, reinforcing our dedication to conducting responsible and ethical research 4. Thank you for stating the following in the Acknowledgments Section of your manuscript: [We extend our heartfelt gratitude to the Tigray Health Bureau (THB) for leading this integrated research and mobilizing technical staff for data collection. Lastly, we thank the participants, as well as the data collectors and supervisors, particularly those from Mekelle University College of Health Sciences and Tigray Health Research Institute (THRI), for their commitment and integrity in generating quality data.] We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: [UNICEF, WHO, Amref Health Africa and UNFPA and Tigray regional heal bureau and Mums for Mums (MfM) for all rounded support in ensuring a successful and productive integrated research data collection process we assure there is no any competing programming and any other support that influences the research output]. Please include your amended statements within your cover letter; we will change the online submission form on your behalf. Response: thanks we have removed from the acknowledgements section 5. We note that your Data Availability Statement is currently as follows: [Data is available within the manuscript] Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition). For example, authors should submit the following data: - The values behind the means, standard deviations and other measures reported; - The values used to build graphs; - The points extracted from images for analysis. Authors do not need to submit their entire data set if only a portion of the data was used in the reported study. If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If data are owned by a third party, please indicate how others may request data access. Response: Thank you we will submit the data set if our manuscript will be accepted 6. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical. Response: Thank you for your comment we have made identical 7. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript. Response ;it is only in the methods sections 8. 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. Response: I have added six references 31-Mesfin, B., Demise, A. M., Shiferaw, M., Gebreegziabher, F., & Girmaw, F. (2023). The Effect of Armed Conflict on Treatment Interruption, Its Outcome and Associated Factors Among Chronic Disease Patients in North East, Amhara, Ethiopia, 2022. Patient Related Outcome Measures, 14, 243–251. https://doi.org/10.2147/prom.s388426 32-Tessema, Z. T., & Akalu, T. Y. (2020). Spatial Pattern and Associated Factors of ANC Visits in Ethiopia: Spatial and Multilevel Modeling of Ethiopian Demographic Health Survey Data. Advances in Preventive Medicine, 2020, 4676591. https://doi.org/10.1155/2020/4676591. 33-Akseer, N., et al. (2020). Progress in maternal and child health: How has Afghanistan fared in the last decade? The Lancet Global Health, 8(3), e351–e360. 42-Asah, M., & Moses, A. L. (2025). The Effects of Armed Conflict on Healthcare in Nigeria – A Scoping Review. International Journal of Research and Scientific Innovation, XI(XV), 883–900. https://doi.org/10.51244/ijrsi.2024.11150067p 43-Ikpongifono, U. (2024). Enhancing Healthcare Access in Conflict Zones: Identifying Challenges and Proposing Solutions. Public Health Open Access, 8(1). https://doi.org/10.23880/phoa-16000286 44-Mavole, J. (2023). Protection and Maintenance of Healthcare Services for Civilians’ Well-Being in Conflict Affected Areas: Comparative Analysis of The African Situation. European Journal of Health Sciences, 9(2), 1–17. https://doi.org/10.47672/ejhs.1507 General Comments 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: Title: Spatial patterns and predictors of antenatal care interruption in war-torn Tigray, northern Ethiopia: a spatial modeling approach I am happy to review this manuscript, which is well-written for the “Spatial patterns and predictors of antenatal care interruption in war-torn Tigray, northern Ethiopia: spatial modeling approach” and has brought some important findings. However, I have encountered some typos error in many instances. That is proofread is needed. • Why you used mixed methods? Response: in the integrated survey it was used to collect the qualitative one but I did not use the qualitative because it is mixed up with others like COVID19 socio-behavioral drivers, other maternal health services that is why I did not use for ANC interruption. • In Abstract: Result Part: A result should be interpreted well and written to the nearest value. It seems vague. Response :Great I made like this This finding underscores significant accessibility challenges posed by security checkpoints and conflict-related dangers. Geographic zone location significantly affected ANC interruptions. Women in the southeast and eastern zones experiencing lower log-odds of interruption compared to the northwest zone. Indicating zonal disparities in access to care. Moreover, the number of children under five years old in a household was associated with a 0.083134 increase in log-odds of ANC interruption (SE = 0.017295, p < 0.001). This suggests that larger family sizes may contribute to greater challenges in accessing ANC services. Additionally households without a radio had a 0.08939 lower log-odds of interruption (SE = 0.033425, p = 0.007489), indicating the importance of access to information to mitigate ANC interruption. • Conclusion of abstract, should be written again, especially recommendation part. Theoretically, recommendation should be emanated from result. Which result leads to this recommendation “Improving infrastructure and security, implementing targeted interventions, enhancing mass media health information dissemination, and further research on geographic disparities are essential.”? Response: Thank you this is really good here I amend like this Conclusion The findings indicate significant interruptions in antenatal care (ANC) in Tigray, Driven by geographic disparities, household dynamics, and access to information. Specifically, the increased log-odds of interruptions with additional travel time highlight the urgent need for improved infrastructure and security. The lower log-odds of interruption in the southeast and eastern zones suggest that targeted interventions could be beneficial in areas most affected. Furthermore, the association between household dynamics and ANC interruptions emphasizes the importance of enhancing mass media health information dissemination to improve access to care. Therefore, further research on geographic disparities is essential to inform tailored strategies for improving ANC services in the region. • General comment: In introduction, it seems good. Please, rephrase and conceptualize in your own words. Basically, your introduction also should focus on a) what we already know from the literature, b) what new concepts this study can address that make a distinct contribution beyond the prior studies? People want to see the effect of war in the ANC use? Previous distribution should be written well. Response: I tried to incorporate it is acceptable • Methods part: Good but describe study area in connection to your title in detail. Response: Study area: The study was conducted in Tigray region, Northern Ethiopia. Tigray borders on the north by Eretria, on the west by Sudan, on the south by Amhara, and on the east by Afar. The region has a total population of 7,969,000 []. The region’s health system consisted of two specialized comprehensive hospitals, 14 general hospitals, 24 primary hospitals, 231 health centers, and 743 health posts. The survey was conducted in selected 19 districts of the six zones of the region (excluding western zone for security reasons). Data were collected from July 1 to 30, 2023 • Perhaps, I am expecting from you special distribution of the problem in the map. Geographical map is needed to show the existence of the problem at the end of the result as a result or at the end of the introduction as the concept of indication. Response: At the end of introduction At the end of results were added and at the introduction The spatial distribution of ANC interruptions across the Tigray region is as follows: Northwestern zone 22.8%, Central zone 29.1%, Eastern zone 17.7%, Southern zone 16.7%, Southeastern zone 6.4%, and Mekelle zone 7.3%. However, the Western zone of Tigray was not accessible for our study due to security concerns. For more details, see Fig 1. • Measurement and variables should be written in detail. Response Study Design: Community based cross sectional study Measurements and variables Dependent variable; antenatal care interruption: Measured as a binary variable indicating whether ANC services were interrupted (1) or not interrupted (0) during the conflict period. This was assessed through participant’s interviews in selected households of mothers who were following ANC visit during the conflict and interrupted their care of different reasons. Independent Variables Independent variables include a range of socio-economic, geographical, and conflict-related factors: Socio-economic factors: age of mother, education level, occupation, marital status, Geographical Factors: zone of residence, distance to health facility: Measured in kilometers and time taken to double trip from the home to the nearest health facility providing ANC services. Accessibility index a composite measure reflecting road conditions, transportation availability, and geographic barriers, security. Conflict-related Factors; displacement status whether the mother or household has been displaced due to conflict (yes/no).Perceived security a qualitative measure based on survey responses regarding feelings of safety when accessing health services. Loss, damage of property and nearby persons who care for them. Data collectio Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0328802.r002
26 Jun 2025 Decision Letter - Kahsu Gebrekidan, Editor <div>PONE-D-25-08979R1Spatial patterns and predictors of antenatal care interruption in war-torn Tigray, northern Ethiopia: spatial modelling approachPLOS ONE Dear Dr. Gebreslassie, 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 Aug 10 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, Kahsu Gebrekidan, Ph.D. 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. [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 #1: All comments have been addressed Reviewer #2: (No Response) ******** 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 ****** 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 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 Response) ****** 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: No ****** 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: (No Response) Reviewer #2: You have addressed the majority of the comments and suggestion. However, the manuscript did not write in format of academic English. So, I recommend proofreading. I also have one comment. Comment #1: Please separate the conclusion and recommendation into distinct paragraphs. First, summarize the significant findings, followed by the recommendations. Currently, they are intermixed. ****** 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: Yes: Feleke Doyore Agide 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: PONE-D-25-08979_R1 Commented.docx https://doi.org/10.1371/journal.pone.0328802.r003
Revision 2
4 Jul 2025 Author Response Response to Editors and reviewers Kahsu Gebrekidan, Ph.D. Academic Editor PLOS ONE Dear Dr. Kahsu Gebrekidan and esteemed reviewer, I hope this message finds you well. I am writing to submit a revised version of our manuscript titled Spatial Patterns and Predictors of Antenatal Care Interruption in War-Torn Tigray, Northern Ethiopia: Spatial Modeling Approach (PONE-D-25-08979R1: Spatial patterns and predictors of antenatal care interruption in war-torn Tigray, northern Ethiopia: spatial modelling approach) in response to the valuable comments and questions provided by the editor and reviewers. We sincerely appreciate the reviewers' thorough evaluations and insightful feedback, which have greatly enhanced the quality of our work. Below, I summarize our responses to each of the reviewers' comments, along with an outline of the revisions made in the manuscript. We have attached the revised manuscript, a version with track changes, and our one-on-one responses in the system. Regards Assefa Ayalew Mekelle,Tigray ,Ethiopia . Thank you so much for reviewing our work 1. One of the comments from our reviewers were to separate conclusion and recommendation, thank you so much accepted and we separated as the reviewer recommendation 2. The other comment was proof reading just we read and read by other co-authors too. Response to editor The issues raised by the editor was about referencing thank you so much the following references were replaced by other proper references just the replaced once are in the manuscript . 1. WHO, UNICEF, UNFPA and TheWorld Bank. Trends inMaternalMortality: 2000 to 2017WHO. Geneva:WHO (2019). 2. O’hare BAM, David PS. First do no harm: the impact of recent armed conflict on maternal and child health in Sub-Saharan Africa. J R Soc Med. (2007) 100:564–70. doi: 10.1258/jrsm.100.12.564 3. Akseer N, Wright J, Tasic H, Everett K, Scudder E, Amsalu R, et al. Women, children and adolescents in conflict countries: an assessment of inequalities in intervention coverage and survival BMJ Global Health. (2020) 5:e002214. doi: 10.1136/bmjgh-2019-002214 4. Abay ST, Gebre-Egziabher AG. Status and associated factors of birth registration in selected districts of Tigray region, Ethiopia. BMC international health and human rights. 2020 Dec;20:1-0. 5. Stamidis K, Bologna L, Losey L. CORE Group Polio Project (CGPP) Final Evaluation Report 2017. 6. Asah, M., & Moses, A. L. (2025). The Effects of Armed Conflict on Healthcare in Nigeria – A Scoping Review. International Journal of Research and Scientific Innovation, XI(XV), 883–900. https://doi.org/10.51244/ijrsi.2024.11150067p 7. Ahmadi A. Assessing Participation in Women's Development Projects in Afghanistan 2017 8. Owen, D. J., Wood, L., & Neilson, J. P. (2004). Antenatal care for women with multiple pregnancies: the Liverpool approach. Clinical Obstetrics and Gynecology, 47(1), 263–271. https://doi.org/10.1097/00003081-200403000-00026 Attachments Attachment Submitted filename: Response_to_reviewers_auresp_2.docx https://doi.org/10.1371/journal.pone.0328802.r004
8 Jul 2025 Decision Letter - Kahsu Gebrekidan, Editor Spatial patterns and predictors of antenatal care interruption in war-torn Tigray, northern Ethiopia: spatial modelling approach PONE-D-25-08979R2 Dear Mr. Assefa, 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, Kahsu Gebrekidan, Ph.D. 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 ******** 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 ****** 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: The manuscript was edited very well. It is scientifically sound and methodological rigorous research. I support the acceptance. ****** 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: No ******** https://doi.org/10.1371/journal.pone.0328802.r005
Formally Accepted
Acceptance Letter - Kahsu Gebrekidan, Editor PONE-D-25-08979R2 PLOS ONE Dear Dr. Gebreslassie, 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 Dr. Kahsu Gebrekidan Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0328802.r006

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