Dear Dr. Appelbäck,

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 Jun 12 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'.
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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,

Hale Teka

Academic Editor

PLOS ONE

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

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Before we proceed with your manuscript, please also provide non-author contact information (phone/email/hyperlink) for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If no institutional body is available to respond to requests for your minimal data, please consider if there any institutional representatives who did not collaborate in the study, and are not listed as authors on the manuscript, who would be able to hold the data and respond to external requests for data access? If so, please provide their contact information (i.e., email address). Please also provide details on how you will ensure persistent or long-term data storage and availability.

4. 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,

I commend you on a relevant maternal health issue. I kindly ask you to revise few minor comments.

Abstract

Result - "All the uterine ruptures and 12 out of 13 both stillbirths and hysterectomies were among referrals." Please rewrite this. This is not clear.

The results section fails to show level of significance. This has to be revised as referrals vs non-referrals with 95% CI and p-value.

Suboptimal wellbeing is not a medical term. What do you mean by suboptimal wellbeing?

Introduction - The data you used for the global maternal mortality is old. Please use recent reports by the interagency group released in 2025.

Methods - The justification put forth for the sample size is not scientific. It does not matter if your study is descriptive or analytic an appropriate sample size should be sought.

Results - Could you please calculate the p-value for each variable being compared in between the two groups to see the level of significance of the differences?

Discussion - please remove 'summary'

First paragraph - start with restating your objective, and then follow summarizing the main findings that you will subsequently discuss.

Most of the graphs are not necessary and they can be described within text.

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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

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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

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: Review of the Manuscript on Postpartum Hemorrhage Management at Kawempe National Referral Hospital

This manuscript addresses a critical public health issue — postpartum hemorrhage (PPH), which remains the leading cause of maternal mortality globally, particularly in low-income countries. The authors effectively highlight the significance of PPH as a major contributor to maternal deaths and severe maternal morbidity, particularly in Uganda, where PPH is responsible for approximately 35% of maternal deaths. The focus on Kawempe National Referral Hospital (KNRH) — Uganda’s largest obstetric referral hospital — is highly relevant, as this facility receives numerous emergency cases, including severe PPH. By investigating adherence to national guidelines, the study provides valuable insights into the quality of care delivered in this high-risk setting.

The study is well-prepared and presents significant findings that have the potential to inform both clinical practice and policy improvements. However, I suggest minor revisions to enhance clarity and ensure the manuscript’s completeness.

Suggested Revisions and Clarifications

Clarification of Acronym (DHS)

In line 6, the abbreviation DHS is mentioned for the first time without explanation. To ensure the readership understands its meaning, I recommend defining this acronym in its first use (e.g., Demographic and Health Survey).

Route of Misoprostol Administration

The manuscript references the use of misoprostol, but it is unclear which route of administration was employed — buccal, vaginal, or rectal. Given that the route of administration may significantly influence the drug’s efficacy and absorption rate, I suggest providing this detail.

Overall Assessment

This is a well-prepared manuscript that addresses an important and timely topic. The authors provide valuable insights into the challenges associated with managing severe PPH at KNRH, with a particular focus on adherence to national guidelines. The findings have important implications for improving the quality of obstetric care and reducing maternal morbidity and mortality in Uganda and other low-resource settings.

With the above minor revisions and clarifications, this manuscript will strongly contribute to the literature on maternal health. I commend the authors for their thorough work and thoughtful analysis.

Recommendation: Minor revisions are required.

Sincerely,

Reviewer #2: Severe postpartum haemorrhage at a large referral hospital in Uganda: a prospective observational study

Comments

1. Abstract

• Background: Does not provide the rationale for the study

• Methods: should clearly show the study period and summary of the analysis

2. Introduction

• Should contain the global MMR of the post-SDG era (decreeing, increasing, or stagnated?)

3. Methods

• Participants and procedure:

� If the recruitment period was from 5th April to 30th May, approximately two months, the data collection period should be more than two months. Because the mother who was recruited on 30th May will be studied again after 42 days. Therefore, the data collection time is more than two months.

� Why were the minors excluded from the study?

• Data collection tools and procedures

� Instead of “participants and procedures”, I would recommend “data collection tools and procedures.”

� Additionally, they have to show in this section that they used EpiData during data collection

• Sample size

� The justification for the sample size to be 60 is not satisfactory.

• Data quality assurance

� There is no evidence of efforts to ensure data quality

• The statistical methods:

� Lacks specific details. What type of descriptive statistics have they used?

4. Results

• Should describe if there were non-responses and why.

• Remove the name of the figures in the body of the manuscript, e.g., on line 249, 263 and so on

5. Discussion

� Remove the word “summary” on line 301

� Implications of the study on maternal and child health practice and policy should be boldy discussed

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: Yes:  Mengistu Hagazi Tequare

**********

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Attachments

Attachment

Submitted filename: recenzja PLOS.docx

PLOS ONE

Dear Dr. Mia Appelbäck,

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 address the following few comments and resubmit the manuscript including two forms. 

1) Please state that this is a pilot study in the title, in the abstract, and the main body and state that a large RCT will be conducted. 

2) Please use option A for the resubmission. 

==============================

Please submit your revised manuscript by  Aug 30 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,

Hale Teka

Academic Editor

PLOS ONE

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 

2. 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 very much for addressing all my comments and the reviewers comments including preparing the revision in 2 options. 

Please address the following few comments and resubmit the manuscript including two forms.

1) Please state that this is a pilot study in the title, in the abstract, and the main body and state that a large RCT will be conducted.

2) Please use option A for the resubmission.

[Note: HTML markup is below. Please do not edit.]

[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.

Severe postpartum haemorrhage at a large referral hospital in Uganda: a prospective observational pilot study

PONE-D-25-07686R2

Dear Mrs Mia Appelbäc, 

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,

Hale Teka

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: