PONE-D-25-01359-->-->Does Low Fertility Indicate Better Reproductive Health Status? Evidence from Nationally Representative Survey in India-->-->PLOS ONE?>

Dear Dr. Sikdar,

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PLOS ONE

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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

Reviewer #4: No

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: 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

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: Yes

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Reviewer #1: The paper has novelty and significance in respect to current women health condition in India. But this paper has been analysed and written very well but it has some structural problem that need to improve for better readability of the paper. Here are my following suggestions.

1.Line 45: The authors have written (coefficient = -0.05; CI: -0.06, -0.05), what is the relevance of these values in abstract, I would suggest to remove the values from abstract and only focus on the outcome of analysis.

2.I do not feel the necessary of separate Introduction and Fertility Transition and Reproductive Health section, rather I would suggest to integrate them and strengthen the background of the study.

3.Do you really need this sentence in line 162-163- “The International Institute for Population Sciences (IIPS) in Mumbai conducted the survey with funding from the Government of India's Ministry of Health and Family Welfare”. I don’t feel so. Similar for line 166-167. Streamline the line 161-168, and remove unnecessary lines.

4.After reading the whole methodology I feel that it needs to rearrange, as my previous comment, remove unnecessary writing for data, sample size and Variables and their measurement section. Combine them together in one section, and named the section- ‘study variables, measurements and sources’ something like that. Then in that section first paragraph write data source and samples, then onwards variable measurements.

5.Line 215: Do you want to cite STATA, if not then what is the need for writing this-(Stata Corporation, College Station, TX), as you already stated that you used STATA 17.

6.I would Like to give citation or equation in like 202-206

7.-I would like to give regression equation forms of two poison regression.

8.Line 2015-2017- you wrote that “We use ArcMap for creating maps. The shape file for the maps is downloaded from the official Demographic Health Survey (https://dhsprogram.com/data/available-datasets.cfm) website”. If you really feel that you need to mentioned this, concise the sentences.

9.In table 1: what is the meaning of given two collum for category ? instead you simple in one column, write category and in bracket yes/no (category (yes/no)), is not it represent the same as you did. Think. What you did makes the paper structure unesthetic and reader will lose the concentration while reading.

10.Table 2: similar problem like table one, you can simple write totalvalue and % in bracket- 20,213 (9.8).

11.I do not understand the meaning of “No one” in table 2, can you clarify and reframe.

12.In table 2. For Ever experienced Still Birth/miscarriage- you have written separate percentage for yes and for no, together 100%. Then what is the meaning of given both yes and no, if 74.56 % is for yes, then rest of the % will by default become no. can you explain?

13.In line 246- you write a heading of a section “Mean number of RHI in background characteristics-wise”, I won’t do that, mean is the analysis you did, it doesnot represent the content of the section. Rather write “socio-economic/ecological/political/cultural background of RHI”

14.Which one is figure 1?, author should have basic responsibility to frame the paper.

15.I don’t feel the necessity of writing composite score in the title “District-level Variation in Women’s Reproductive Health Composite Score”

16.Where is figure 2 ?

17.Table 4, what the value inside table represents? standard error? or coefficient? or something else. How do I know? This reflects the lack of professionalism by the authors. I would suggest to follow good article, and carefully check how they represent the regression table in the paper.

18.Your policy suggestions are too generals, based on your study, What policy measure will you take if you become the sole responsible authority.

19.Overall, I feel paper is lengthy, and some part of the writing is exaggerated and over romanticised.

Over all paper is interesting, I feel this structural change make the paper more concise and increase the understandability and readability of the non-subject readers also. I recommend the paper for above minor, not major revision.

Reviewer #2: The manuscript presents a rigorously conducted study characterised by a high level of technical competence. The data is robust, and the conclusions drawn are substantiated by the experiments and analyses executed. The statistical analysis is both appropriate and comprehensive, which enhances the reliability of the findings and their interpretation. Furthermore, the authors have made all underlying data available in accordance with PLOS Data policies, thereby ensuring transparency. The manuscript is well-structured and articulately written in standard English, rendering the content both accessible and easily comprehensible.

Reviewer #3: This cross-sectional study attempts to explore the association between declining fertility rates and women's reproductive health in India, considering socioeconomic and demographic factors as well as regional variations. The objective of this paper is quite relevant & interesting, but has some shortcomings which needs major revisions & rework. Hence, upon preliminary review, my recommendation is for a major revision before considering the manuscript for publication.

Followings are some of my observations that needs further clarification and revision:

1.The article requires substantial revision to address grammatical problems and repetitive sentences (e.g., lines 355-359). Furthermore, the article appears to be very lengthy, and the assertions in the findings, discussions, and conclusion sections are very repeated.

2.Line no. 106-107: ‘By integrating these …….low fertility on holistic well-being”. I have a serious concern in using the term ‘holistic well-being of women’ which can include both mental and social well-being as well (as the author mentioned in 99-101). But in the analysis, there are no indicators on social or mental well being of women. As a result, it is better to avoid using this term or to explain how your seven indicators can justify mental and social well-being.

3.Line no. 224-25: ‘However, 9.78% of deliveries ……remains insufficient.’ Lower percentages of deliveries by skilled persons does not always imply lower access to health care facilities. What about the families who don’t opt for such deliveries and prefer delivery at home?

4.Line no. 258-259: ‘Regarding regional variations…..RHI’. Even northern regions have highest mean RHI (4.42). But the author doesn’t mention that. Additionally, interpretation of regression mentioned (in line no. 316-318) north-eastern region showing lower likelihood of RHI, while the values are positive. Please rework and rewrite the section.

5.In some cases, the OR values are very low. Plus, the author needs to mention the high or low RHI score range as the scores does not vary much (such as 4.33 in West and 4.35 in South). Please elaborate on how far it is justified to say that regional disparities exist (line 316-318)?

6.Line 318-319: ‘Additionally, residence plays…. counterparts (Model 3)’. In model 3 Rural and urban odds are not significant. Therefore, no difference between rural and urban areas.

7.Line 297-300: ‘Model 3 highlights….wealth index’. Please elaborate, as the models do not show that.

8.Please recheck the Poisson regression model. Odds ratio can’t be negative. An odds ratio greater than 1 indicates an increased risk associated with the exposure, while an odds ratio less than 1 indicates a decreased risk. Do the values in Table 4 represent odds or log odds? If log odds, then the interpretation should alter.

9.The author tries to investigate the spatial variation. What about the role of clustering effect on depended variable due to hierarchical nature of NFHS data? Can Poisson regression model consider that effect?

Reviewer #4: 1.The title of the paper does not reflect the analysis presented; the author does not analyse low fertility but rather focuses on the factors associated with women’s reproductive health.

2.The abstract of the paper does not follow the journal's format.

3.The introduction section does not clearly mention the research gap and the objective of the paper.

4.The concept of the Reproductive Health Index (RHI) is not clearly defined in the introduction. The benefits and how NFHS data can be used to measure this index should be explained more clearly.

5.The limitations of the paper should be included in the discussion section, not the introduction section.

6.The justification for using the Poisson regression model should be clarified, especially over other models such as the negative binomial regression.

7.The justification for the equal weighting of indicators in the RHI should be explained. The author could conduct a sensitivity analysis to support this approach.

8.The Northeastern region is associated with higher RHI scores despite socioeconomic disadvantages; this finding needs more discussion.

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Reviewer #1: No

Reviewer #2: Yes:  Papai Barman

Reviewer #3: No

Reviewer #4: No

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PONE-D-25-01359R1-->-->Does Low Fertility Indicate Better Reproductive Health Status? Evidence from Nationally Representative Survey in India-->-->PLOS ONE?>

Dear Dr. Sikdar,

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 15 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,

Pijush Kanti Khan, 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.

Additional Editor Comments:

Dear Authors,

Thank you for your revised manuscript. The paper has substantially improved after the revision, and I appreciate the effort you’ve put into addressing the earlier comments. That said, I believe there are still a few minor issues that need to be addressed before the paper is ready for publication. Therefore, I would like to request a minor revision. Please revise the manuscript accordingly and resubmit it by 15th July, 2025. Feel free to reach out if you have any questions or need further clarification. Thank you,

Best regards

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

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

Reviewer #3: Yes

Reviewer #4: No

**********

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

Reviewer #3: Yes

Reviewer #4: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #3: Yes

Reviewer #4: No

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Reviewer #3: The article addresses a crucial aspect of women's reproductive health and its association with low fertility rates in India. This topic remains relatively underexplored, making the study particularly relevant in the Indian context. After an initial round of revisions, the manuscript is now well-organized and clearly written. The following are some minor suggestions that may further improve clarity:

1. Kindly assess the level of multicollinearity—particularly among variables such as age, age at marriage, and age at first birth—prior to conducting the regression analysis, and include the findings in the manuscript.

2. Please examine the potential presence of endogeneity, as certain variables used in constructing the Reproductive Health Index (e.g., history of stillbirth/miscarriage, type of delivery assistance) may influence the number of children ever born (CEB). A rationale for the absence of endogeneity in the analysis should be provided.

3. Specify the states included in each of the six regional categories, or cite the source from which the regional classification was derived.

4. In the methodology section, please justify the use of the Poisson regression model. Also, check for the presence of overdispersion or under dispersion in the data and report the findings.

5. It is recommended to present Relative Risk Ratios (RRR) in Poisson regression results instead of regression coefficients for clearer interpretation of the results.

6. Ensure that all figures have appropriate titles and are properly numbered.

Reviewer #4: 1.The introduction section includes limited literature; the authors need to add more recent studies.

2.The authors should provide more information about the NFHS data, including the questions asked, which questions were used in this study, and the topics covered by NFHS.

3. The study variables and their measurement methods require further details.

4.In Table 2, the authors report that 75% of respondents have ever experienced a stillbirth or miscarriage. This figure appears inaccurate, as the NFHS report indicates only 7.3% for miscarriage and 0.9% for stillbirth. The authors should verify these figures.

5.In Table 3, the mean RHI varies by women’s age, age at first marriage, and age at first birth. While RHI increases with higher age at first marriage and first birth, it appears to decrease with advancing age of women. This pattern needs further explanation from the authors to clarify the underlying reasons.

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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

Reviewer #4: No

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Does Low Fertility Indicate Better Reproductive Health Status? Evidence from Nationally Representative Survey in India

PONE-D-25-01359R2

Dear Dr. Sikdar,

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,

Pijush Kanti Khan, Ph.D.

Academic Editor

PLOS ONE