Dear Dr. Paudel,

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We look forward to receiving your revised manuscript.

Kind regards,

Vinay Shukla, M.Sc., Ph.D.

Guest Editor

PLOS ONE

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Additional Editor Comments:

The manuscript titled “Effectiveness of Antenatal Corticosteroids in Reducing Morbidities and Mortality in Preterm Neonates: Evidence from a Tertiary Level Hospital in Nepal” presents important findings on the use of antenatal corticosteroids (ACS) in a resource-limited setting. Reviewer 1 raised key concerns regarding clarity on the study design (randomization and ethical considerations), missing information on timing of steroid administration, and minor typographical errors in the results section. Reviewer 2 acknowledged the significance of the study and its potential impact but recommended improving the presentation of statistical data (e.g., consistent reporting of 95% CIs) and addressing possible confounders such as maternal subclinical infections. Addressing these methodological and editorial points will enhance the scientific quality and clarity of the manuscript.

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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

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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: 1-It is not clear how the two groups were chosen. Is this a randomised study? And if so, can this procedure be considered ethically correct?

2- The time between the course of corticosteroids and delivery was not given.

3- the 3rd paragraph of the results table 2 instead of table 1

4- the 3rd line of the results lacks a space between POG. and 206

Reviewer #2: The evidence of the effectiveness of antenatal steroids in high resource setting is undebatable, yet the data for their use in limited resource settings is limited. Here the authors have presented a compelling and needed study supporting the use of antenatal steroid use in a limited resource setting.

Introduction:

SDG target - please write out any acronyms in full on first use

POG - please write out any acronyms in full on first use

Results:

The authors state in the results sections that "distribution of outcomes for both groups, p-values indicating the statistical significance, and adjusted odds ratios (aOR) with confidence intervals (95% CI) for each outcome". When reporting the results in text, there is a lot of repetition to the tables. The authors also do not report 95% CIs in text, but just state 95% CI which makes the results very cluttered and difficult to read, e.g. "administration of ACS is significantly associated with the development of RDS 38.2% (58) vs 21.8% (45), (p-value=<0.0001) and (aOR= 4.181, 95% CI). I would suggest simply reporting percentages and p-values, or just p-values and reference tables reduce confusion and repitition. Otherwise please include the actual 95% CI values in text and not simply state "aOR= ..., 95% CI".

There was a greater number of preterm infants who did not receive ACS that had neonatal sepsis compared to preterm infants that received ACS. Is this due to a greater number developing infection after birth in non-ACS infants compared to preterm infants whose received ACS? Or were there potentially a greater number of non-ACS mothers having sub-clinical bacterial infections that they passed on to their infants, and this lead to sepsis postnatally? Similarly were there a higher number of mothers that had overt infection and received prenatal antibiotics prior to preterm birth that could have influenced this outcome? Subclinical infection in mothers can be a risk factor for preterm birth as well as RSD, could this be a confounder in the outcomes of the study?

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Reviewer #1: Yes:  Mahdi Farhati

Reviewer #2: Yes:  Angela Cumberland

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Effectiveness of Antenatal Corticosteroids in reducing morbidities and mortality in Preterm neonates: Evidence from a Tertiary Level Hospital in Nepal.

PONE-D-24-54032R1

Dear Dr. Paudel,

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,

Vinay Shukla, Ph.D.

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: