Dear Dr. Tamir,

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Thank you for submitting this important and comprehensive paper to PLOS ONE journal. I appreciate the time and efforts authors have given in drafting this manuscript. The authors should revise their manuscript based on esteemed reviewers any my comments. 

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Muhammad Haroon Stanikzai

Academic Editor

PLOS ONE

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Additional Editor Comments :

- Please provide page and line number in the revision.

- Abstract: Please use adjusted odds ratio for significant factors in abstract as suggested by reviewer 1 too.

- Please use capital letters where needed. Only the first letter of headings and subheadings should be capital.

- Page 20-26 on PDF file: Is it low and middle countries or the author means low-and-middle income countries.

- I suggest the authors can use, cite, and consult recent publications published on ANC non-utilization in LMICs (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0309300, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0326130).

- As per journal requirements, the ethical approval should be mentioned in methods section.

- The references are not as per journal style as suggested by reviewer 2. Reference 5: Organization WH. I am not sure what does this mean. I believe the authors are using a software for reference managing. I ask them to manually edit them before submission as per journal style.

- The manuscript would benefit from language editing.

[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?

Reviewer #1: Yes

Reviewer #2: Yes

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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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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

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Dear Editors and Authors,

Thank you for giving me the opportunity to review the manuscript, under the title “Magnitude, Geographic Distribution and Contributing Factors of Non-Utilization of Antenatal Care (ANC) Services among Women in Low- and Middle-Income Countries (LMICs): Insights for implementation of WHO recommendations”.

The authors chose a very important topic on maternal health care services in LMICs. This study examined data from DHSs (2015-2024) from 47 LMICs. The authors employed spatial analysis to show geographic distribution of ANC non-utilization and hierarchical analysis to identify factors associated with ANC non-utilization. The authors found that pooled magnitude of ANC non-utilization was at 10.59%, ranging 40.05% in Afghanistan to 0.76% in Burundi. Many regions in several countries identified as hotspots for ANC non-utilization. Factors significantly associated with higher odds of non-utilization were: no or low education, being unmarried, being in low wealth index, living in rural areas, distance to health facilities, and low-income levels of a country.

The manuscript is well written. The findings from this study have the potential to influence health interventions and policies to improve the use of ANC services in LMICs. The authors need to address the following issues before the manuscript can be considered for publication.

The full title seems a bit long. The authors may opt to use the short title and add few words to it.

In the abstract, the results should report the ORs (95%CI) for the factors significantly associated with non-utilization of ANC. If word count is an issue, the authors can summarize the prevalence of pooled non-utilization by stating for example, “Pooled prevalence of non-utilization of ANC among women in LMICs was at 10.59%, ranging from 40.05% in Afghanistan to 0.76% in Burundi.”, with many regions in several countries identified as hotspots for ANC non-utilization. Then, the authors can report the ORs for factors significantly associated with non-utilization of ANC.

Throughout the manuscript, the authors don’t need to write the full low- and middle-income countries. They just use it in full low- and middle-income countries (LMICs) when they use it first time in the manuscript; and then use the short term (LMICs) instead of the full term.

Under the sub-section “Magnitude of non-utilization of ANC services in LMICs”, the author should add in text that “Afghanistan had the highest non-utilization at 40.05% and Burundi had the lowest at 0.76%”.

For figure 4 (Hot spot analysis …) and figure 5 (Interpolation of non-utilization of ANC…), the authors should use a landscape of the maps as the current figures seem to be a bit confusing, showing the Asian countries (e.g., Tajikistan, Pakistan, India….) above Albania, Armenia, and Europe.

Reviewer #2: thank you for the opportunity to read your manuscript on a very important subject.

In LMICs, the issue is not only inadequate ANC visits, but also the timing of the ANC visits. do you have any information about timing of ANC to make your study stronger or not, if you have add this information otherwise just ignore it.

Most of the conditions studied are similar in LMICs, but why are some countries most affected? can you discuss more about it?

please, check all your references as there are some . fro example reference number 5.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: reviewers comments.pdf

Magnitude, Distribution and Determinants of Non-Utilization of Antenatal Care Services among Women in Low- and Middle-Income countries: Insights for Implementation of WHO Recommendations

PONE-D-25-13560R1

Dear Dr. Tamir,

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

Journal office comments: We note that the academic editor has recommended that you cite specific previously published works. As always, we recommend that you please review and evaluate the requested works to determine whether they are relevant and should be cited. It is not a requirement to cite these works.

Additional Editor Comments (optional):

Thank you for your diligent edits to the manuscript.

Please carefully proofread the entire manuscript at Proof correction.

- Abstract: Line 54: low-and middle-income countries.

- Line 542: Please remove 1 after services.

- Line 658: Please make the first letter of study in lower-case.

Reviewers' comments: