PONE-D-24-58403Building consensus on revised Emergency Obstetric and Newborn Care (EmONC) signal functions and levels of care: A Delphi process and resultsPLOS ONE

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Reviewers' comments:

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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: N/A

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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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: It is a excellent work which will help in maternal and newborn care in LMIC.

Hence I have some observation mentioned below

Title :

Building consensus on revised Emergency Obstetric and Newborn Care (EmONC) signal functions and levels of care: A Delphi process and results : As Delphi process is a method of coming to a consensus, the title can be made short and more catchy

Abstract :

Result part better to emphasized more.

Result :

Instead of terms like some/ many, these information can be expressed in percentage to quantify it

Discussion:

New signal function proposed for both maternal and newborn health better to include in discussion section for better understanding of reader.

Advantage part can be made short as there are some repeated information

Limitation also can be make specific

Reviewer #2: Thank you for the opportunity to review this paper. It represents a significant contribution to the literature, and I believe it should be published and its publication highlighted by the journal. I have some comments on the study design and conclusions and suggestions to address before publication.

The study design suited the objectives outlined by the authors. Signal functions have been in place for several decades and during that time have undergone minimal revision. Their utility has been debated and, as the overarching project suggests, re-visioning was necessary. Involving multiple stakeholders with varying expertise and experience, was also critical. While the drop out rate seems relatively high, the authors point out that a completion rate of 53% for a Dephi process such as this is not atypical. Might it have been improved and if so, how? Difficulties were faced in recruiting a suitably wide range of participants. Several groups were overrepresented, for example those who identified as academic researchers and program managers. The authors point out that participation from front line care providers was challenging. What impact might this have had on the results? In addition, while the three rounds are clearly described and the iterative process was clear, there appear to have been late additions to the list of signal functions that are not well described. Breast feeding for example, makes a final appearance on the list with the statement that it was added by the newborn expert group to be consistent with WHO guidelines. This is not addressed in the text. Did it meet criteria for a signal function or would it actually fall within routine care? There is some ambiguity about whether the signal functions cover "routine and non-clinical care dimensions." However, the paper suggests a consensus was reached on differentiating emergency from routine care. Further justification is needed for including breastfeeding as a signal function.

At the outset it was stated that in order to achieve consensus, 85% agreement would be sought. Only 14/26 or 53% actually achieved this level of consensus. Why was this the case and was it anticipated? Although it is peripherally addressed in the paper, more attention should be given to the lack of consensus and why this might be. There is mention of transparency, but what were the feelings of participants regarding the lack of consensus and was a plan in place from the beginning to address this (beyond the technical workshops)? Was that fully explained to participants?

In round 2 participants were presented with a scenario that was situated in a Comprehensive EmONC setting. Was consideration given to having participants think in a similar fashion about a first line setting, and if not, why not?

The transfer signal function, one which I believe was felt to be an important addition, is hardly discussed at all. What was the consensus around this signal function and why is it not included In figures 9, 10a or 10b?

I would like to address the signal functions themselves and the figures used to illustrate them. Figure 10a outlines the list of maternal SF’s while 10b lists the newborn SF’s There appear to be 12 in total for maternal, not including the transfer SF and 14 newborn. It is possible that I have miscounted however 10b suggests that there are 2 at the intensive level, 7 at comprehensive level and 5 at basic level (total of 14 not 13). This would be a total of 27 if one includes the referral SF. I suspect that if I am confused others will be as well! In addition it is unclear to me if the term “basic” is being used or “First level” . Figure 7 uses “first level” while figures 10 a and b use “basic”. Have we settled on that terminology?

Figure 1 is helpful historically

Figure 2 does not add to the paper. While it is important that the Delphi process be shown to be embedded in the project as a whole, the figure does not help to visualize this. What might be more helpful would be to indicate where the Delphi process and re-visioning of the signal functions is situated within the framing of the signal function (clinical, health systems and human rights).

My comment above highlights the fact that another graphic similar to Figure 7 with the updated final list would be helpful.

I would also suggest that figure 9 be revised to more clearly indicate which SF’s reached the threshold of consensus. Percentages are included but a different colour or cross hatching might help to visualize how many required more discussion and consensus building.

Finally, what are the next steps in order to operationalize these changes? This should be part of the concluding remarks. How do we develop measurement processes to track and how will countries move forward with these changes? Clearly these issues cannot be addressed fully here, but should be introduced as follow up projects.

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Reviewer #1: Yes:  Sanjoy Kumer Dey

Reviewer #2: No

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A Delphi process to build consensus on revised emergency obstetric and newborn care (EmONC) signal functions and levels of care

PONE-D-24-58403R1

Dear Dr. Moxon,

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Kind regards,

Leonardo António Chavane, M.D., MPH, PhD

Academic Editor

PLOS ONE

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