PONE-D-24-53690 Factors influencing herbal medicine utilization during labour and delivery among women of reproductive age in Butiama, Tanzania: A community-based cross-sectional study PLOS ONE

Dear Dr. SICHALWE,

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.

The manuscript has been assessed by two reviewers, and their comments are appended below.

Please submit your revised manuscript by Mar 09 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Jianhong Zhou

Staff Editor

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?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

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

Reviewer #1: Yes

Reviewer #2: No

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

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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: This is an interesting paper about use of herbal medicine in a Butiama, Tanzania during labour and delivery among women of reproductive age. The study is well done, I underline some brief points:

1. The title does not reflect the entire content of the article; it needs to be reviewed.

2. Table 1 should be eliminated because the majority of the information has been repeated in Table 2. The latter is largely sufficient to present the results.

3. Please correct in the Page 10, table 1 the value, ‘’never used HM = 165’’ et Utilization of HM during childbirth, No = 164) ?

4. Table 1 : this question is not correct ‘’ Type of HM used during childbirth’’, because the proposed answers are varied.

5. In Table 2, the sum of the values for all the variables studied does not give 233, which is the total of participants who confirmed the use of plants. All the values in this table must be corrected.

Reviewer #2: Dear Authors,

Thank you for the possibility to read your interesting paper.

Assessing the statistics is challenging. I downloaded the Excel-file and imported it to SPSS to check some data and calculations.

First of all, I found that there seems to be several errors in Table 2. For “Age group” the percentages are mixed up (% for “all participants” come under “No”, % for “Yes” belong to “No” etc). This made me do the analysis in SPSS and I get different values for both counts and p-values for most of the factors in the table. I struggle to see why you have chosen a significance level of 0.25. that is very high. And talking about significance, it is difficult to see what is significantly higher or lower than what.

For Table 3 many confidence intervals are overlapping – does that mean anything for the results?

Table 4 has some numbers in bold and marked with stars – what do those markings refer to? They normally refer to significant values, but if that is the case here, what method is used for the analysis? Remember that a table should always be understandable in itself so this one needs some sub-text with explanations.

Other comments:

A definition of “herbal medicine” would be useful. How did you explain to the participants what you were asking about? And is it necessary to make the abbreviation “HM”?

Where does reference 1 say that “conventional and alternative therapies contribute to 80% of global healthcare”?

You say that “Studies show that herbal medicine during labour induces intense, prolonged contractions….etc…” but which herbal medicines? It can not be a general statement about herbal medicines. Reference 8 mentions one herb.

What does the number of modes of administration have to do with the cultural significance of herbal medicine?

Your section about training research assistants is rather detailed.

Ethics: I guess you mean “Muhimbili University of Health and Allied Sciences”.

Results:

Response rate: This is not about how many you aimed to include but about how many you asked to participate versus how many who were willing.

Please reconsider how you write the sentences with numbers and percentages – it does not flow as it is now.

I suppose you KNOW how many participants used herbal medicines during childbirth – not “around 233” (which is an approximate number) but “233”. Same goes for “About 272” participants with primary education – it is 272 – not “about”.

Why do you mention “roots” and “leaves” but not which roots or leaves? Does this matter? Is it interesting? Why?

Discussion:

The statement “Women’s desire to maintain mariages,….. reliance on HM” requires a reference.

Significance of educational level: there is a significant difference between those with none (reference) and those with primary education, but what can you say about those with primary vs. those with secondary education? Overlapping confidence intervals – does that matter? Confidence intervals including “1” – does that matter?

Please also revise abstract accordingly.

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6. PLOS authors have the option to publish the peer review history of their article (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: No

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PONE-D-24-53690R1 Prevalence and determinants of herbal medicine utilization during labour among women of reproductive age in Butiama, Tanzania: A community-based cross-sectional study PLOS ONE

Dear Dr. SICHALWE,

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 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.

Please include the following items when submitting your revised manuscript:

• 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 you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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,

Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

After thorough re-evaluation, we commend the authors for addressing the first round of reviewer comments with care. The study covers an important and under-explored topic in maternal health within Sub-Saharan Africa. However, several methodological, analytical, and presentation-related weaknesses remain, which must be addressed to meet the publication standards of PLOS ONE.

In light of the below concerns, in addition to those of the reviewers. We encourage a major revision that addresses the outlined issues comprehensively.

Key points to be addressed:

1. Statistical Justification and Analysis Approach

The use of a significance threshold of p<0.25 for including variables in multivariate analysis is uncommon and insufficiently justified. While cited literature is acknowledged, this approach may lead to overfitting and misinterpretation.

Table 3 is mislabeled as Poisson regression while results appear to be from logistic regression. This should be corrected, and the statistical method clarified.

Overlapping confidence intervals and the inclusion of 1 in some adjusted odds ratios raise interpretive concerns. A clearer explanation of how these results are interpreted would improve the scientific rigor.

2. Language, Syntax, and Clarity

The manuscript contains awkward phrasing, such as “higher likely,” and inconsistent use of statistical language. For instance, “55.6% higher likely to use herbal medicine” should be rephrased for clarity.

Reporting of percentages should be precise (e.g., avoid “about 233” when the actual number is known).

3. Redundancy and Table Narration

In the results and discussion sections, there is excessive repetition of values already presented in tables. A more interpretive approach that highlights significant findings and their implications is preferred over verbatim restatements.

4. Introduction and Reference Support

Several claims are not adequately referenced, including statistics on global use of traditional medicine. For example, the WHO citation regarding 80% usage needs to be directly traceable and accurately quoted.

The link between cultural beliefs and herbal medicine use is mentioned frequently but would benefit from more empirical support or references.

5. Discussion and Critical Interpretation

The discussion would be strengthened by a more critical appraisal of causal inference limitations, potential confounding, and biases (recall and social desirability).

While cultural influences are acknowledged, the discussion sometimes overgeneralizes and lacks nuance in differentiating between association and causality.

6. Methodological Clarification

Further clarification is required regarding the questionnaire's validation process (e.g., reliability testing metrics such as Cronbach’s alpha were not reported).

The detailed section on training of research assistants, while informative, could be streamlined for conciseness.

7. Terminology and Table Design

Inconsistencies remain in table formatting and terminology, such as mislabeling of columns and unclear indicators of statistical significance (e.g., asterisks not always explained).

The title of Table 3 should accurately reflect the statistical method used.

We appreciate your contribution to this important field of research and look forward to reviewing a significantly improved version of your manuscript,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Partly

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. 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 #2: Thank you for your good replies to all my questions. I only have a few more questions or comments:

Please remember that the number of decimals indicates the accuracy of the number given. You seem to be using one, two or three decimals randomly.

Results:

Lower education p=0,094 is said to be significant – is it?

How do you know that the “adverse effects” mentioned are actually adverse effects of the herbs used? They could be “suspected adverse effects” but do you know for sure that they ARE?

Please consider and discuss confounders: Is “living more than 5 km from nearest clinic” and “attending fewer than 4 ANC visits” the same thing? Or at least interconnected?

Table 3 needs a comment in the subtext explaining the meaning of the * And in the top line you have to put COR [95% CI] and AOR [95% CI].

It is also of interest that Education and Wealth index did not seem to affect the use of herbs.

There are some places in the discussion where I am not sure whether it is your finding/opinion or whether it needs a reference:

- Community education on herbal remedy risks………………..complications.

- Additionally, involving community leaders, ……………..maternal care.

- Enhancing community education on the safe use…….informed choices.

I agree that the “community based” approach is an advantage. It is not very well known in Europe so a comment on WHY it is a strength would be good.

Reviewer #3: Dear corresponding author

The topic is relevant and interesting; however, the authors should address the following points to improve the manuscript:

1. The statement of the study’s purpose at the end of the introduction (last three lines, reference 23) is confusing and appears redundant. This phrasing is more appropriate for a research proposal rather than a journal article introduction. I recommend deleting this sentence and instead refining the purpose as stated earlier in the introduction.

2. In the Materials and Methods section, given that this is a cross-sectional (descriptive) study, the use of terms such as "independent variable" and "dependent variable" is inappropriate. Cause-and-effect relationships are not applicable in descriptive studies but rather in cohort, case-control, or intervention designs. It would be better to refer to all variables as contextual or descriptive.

3. The description of obtaining written informed consent from unmarried participants under 18 years old is unclear. Since the inclusion criterion requires prior childbirth experience, it is questionable whether unmarried individuals under 18 would meet this criterion, especially considering cultural contexts such as those in many Middle Eastern countries. The authors should clarify this point in the manuscript.

4. The study population consists of women who gave birth between 2021 and 2024, with data collected from June to July 2024. Given this timeline, recall bias is a potential concern, particularly regarding herbal medicine use during childbirth. The authors should discuss how recall bias was addressed or minimized and provide more information on the validity of the questions related to herbal medicine use.

5. The distinction between herbal medicines and medicinal plants needs clarification. Herbal medicines typically refer to products that have undergone formulation processes (e.g., medicines, syrups, creams), whereas medicinal plants are raw or minimally processed. The authors should specify their definition and approach regarding this distinction.

6. The limitations of the study should be presented before the conclusions. Furthermore, the conclusions and recommendations should be aligned strictly with the study’s actual findings.

Overall, the article is suitable for publication after major revisions addressing the above points.

Thank you for considering these comments.

Sincerely,

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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 #2: No

Reviewer #3: No

**********

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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.

PONE-D-24-53690R2 Prevalence and determinants of medicinal plants utilization during labour among women of reproductive age in Butiama, Tanzania: A community-based cross-sectional study PLOS ONE

Dear Dr. Sichalwe,

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 Sep 06 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.

Please include the following items when submitting your revised manuscript:

• 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 you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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,

Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

PLOS ONE

Journal Requirements:

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. 

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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Partly

**********

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

Reviewer #2: I Don't Know

Reviewer #3: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. 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 #2: Dear Author,

Thank you for the replies to my questions.

Please check once again for spelling mistakes.

Please be consistent: write all Latin names in italics (f.x. page 3 and Table 2, but could be anywhere), English/African names should NOT be in italics (f.x. page / "Main outcome variables", but could be other places as well).

"...pregnancy and or labour" should be "pregnancy and/or labour".

All tables and figures should be understandable "in themselves".

Table 2: "suspected adverse effects" - not only in text but in the table too.

Page 12 "Predictors of ....": numbers of decimals says something about how exact a number is - please be consistent and perferably use no more than one decimal when you say that "X had x.y times higher odds than Y" (to be "1.823 times more likely to use medicinal plants" is overdoing it - 1.8 would be fine). And please change in the abstract too.

Table 3: what does the * refer to? Needs to be explained below the table. And I still think it is incorrect to say that "distance" and "number of visits" are both significant as they are most probably interrelated. A comment would be good.

Page 14: "Perceptions and beliefs...": I don't see 48.7 in the table? Maybe say that"... 48.7% strongly agreed or agreed...". The same goes for the other numbers.

Table 4: the sub-text about "bolded values" is unclear - please rephrase. Item 2 and 3:" ... medicinal plants are ...."

Reviewer #3: Dear author

Thank you for giving me another opportunity to review the article titled " Prevalence and determinants of medicinal plants utilization during labour amongwomen of reproductive age in Butiama, Tanzania: A community-based cross-sectional study". “PONE-D-24-53690R2” I have carefully read the previous reviewers' comments, examined the authors' responses, and reviewed the revised manuscript. While the authors have made significant improvements, some ambiguities still require further clarification and revision, as outlined below.

1. Given that participants were asked about their use of medicinal plants "during labour and delivery," I would like to clarify how this period was defined for the participants to avoid confusion with the pregnancy period. Could you please provide an operational definition of "labour and delivery" as used in your study? Specifically, from what point in time was this period considered to begin and end. The use of medicinal plants for labor induction, labor acceleration, or other purposes during pregnancy among women with previous pregnancy and childbirth experience is still unclear. Given that participants were asked about the purpose of use, we kindly request that you define and clarify the operational meaning of "labor induction and acceleration" in the Materials and Methods section of the manuscript.

2. The sample size should be clearly specified in Table 3.

3. What are the study limitations? Please address potential issues such as participants possibly misunderstanding the questions, external factors like time constraints, resource availability, or local conditions, variations in sampling or data collection methods, and even the sample size itself.

4. The data collection method needs to be described more clearly and with greater detail. Considering the participants’ educational levels and literacy, was a uniform data collection method applied to all? Please provide further explanation

5. Regarding the reviewer’s previous comment: "A definition of 'herbal medicine' would be useful. How did you explain what you were asking about to the participants? And is it necessary to abbreviate it as 'HM'?" — and the authors’ response, the explanation provided seems more useful for the readers of the article rather than addressing how the concept was explained to the participants. Although the authors gave good explanations to help participants understand, these may still be insufficient, as participants might have varied interpretations. If this is the case, it should be acknowledged as a limitation of the study.

6. Regarding the validity of the questionnaire on participants’ perceptions and beliefs about the use of medicinal plants during childbirth, which was evaluated by five experts in public health, maternal and child health, and linguistics, the reported content validity index (CVI) of 0.90 for each item and over 0.90 overall (0.93) requires further clarification. Specifically, how was the 3% increase in the overall CVI achieved?

Additionally, considering the internal consistency of the questions, with a Cronbach’s alpha coefficient of 0.84, it is expected that the results section—especially the part related to Table 4—will include a classification of participants’ beliefs into levels such as weak, average, and good, or any other categorization the authors find appropriate. This classification would enhance the discussion and interpretation of the findings.

Best regards

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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 #2: No

Reviewer #3: No

**********

[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.

PONE-D-24-53690R3 Prevalence and determinants of medicinal plants utilization during labour among women of reproductive age in Butiama, Tanzania: A community-based cross-sectional study

PLOS ONE

Dear Dr. Sichalwe,

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.

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Form letter of Editorial (SEE Framework)

Dear Authors,

Thank you for the opportunity to review your revised manuscript - "Prevalence and determinants of medicinal plants utilization during labour among women of reproductive age in Butiama Tanzania: A community based, cross-sectional study" (PONE-D-24-53690R3). I read your manuscript carefully to provide you with feedback, and I have organized the comments to you based on the SEE (Statement-Explanation-Example) framework.

Title and Abstract

Statement: In general, the title and abstract were sufficiently informative, with the caveat that the abstract could be tightened up.

Explanation: The authors repeated "labour and/or delivery" to a fault, which overall resulted in a wordy paper, in part because the ambiguous end to their text.

Example: The summary sentence for this section could have simply been: "Over fifty percent of participants reported utilizing medicinal plants during childbirth, with various socio-economic status and health care access factors indicating that education and interventions targeted around medicinal plants would be advantageous.

Introduction

Statement: Overall, I thought the introduction was decent, but a bit bogged-down with bloated content.

Explanation: The sheer number of plants (some with awkward language (helpful info overall), broke my flow and allowed me to disengage with it.

Example: I think you can talk about prevalence and risk factors more than you can plant descriptions. You could have situated plant examples in the Discussion.

Methods

Statement: Overall, I thought the reporting approach was strong, and my understanding of the reporting was clear, but there were areas that were unnecessary details that went above and beyond relevance to the study.

Explanation: The ethical considerations and validation testing were aptly described, but it seems the authors devoted a substantial amount of detail to more lengthy operational definitions of "labour induction/acceleration".

Example: The broadness of "labour induction/acceleration", or detailed specificities could have been included in the results section with the other operational definitions in a paragraph of precise text.

Results

Statement: Overall the results were clear, with identified predictors and estimates of prevalence, but could have been expressed more efficiently.

Explanation: Mostly the results section was legibility by primarily expressing some details in both the tables as well as in the text.

Example: Highlight the key predictors and odds ratios as indicated for example "Women who used less than 4 ANC visits (AOR=0.556, p=0.006)" were more likely to use medicinal plants. The participants were asked every percentage?

Discussion

Statement: The discussion is thorough and fairly contextualized, perhaps too extensive.

Explanation: Comparisons from region to region were useful for comparisons, however sometimes they pulled away the uniqueness of this study.

Example: It would help to remain focused on the three themes, explain socio-economic / cultural factors, and access to health care and ANC utilizations, and be explicit regarding the unique findings for Butiama district.

Limitations

Statement: The authors are honest limitations, although overall fairly lengthy.

Explanation: Some details (environmental conditions) fails to be relevant overall your manuscript.

Example: Can summarize: The main limitations were cross-sectional and recall bias, and the potential misinterpretation of 'medicinal plants'even with clear explanation from interviewer.

Conclusions and Recommendations

Statement: The conclusion was solid, with some degree of verbal blurring with the recommendations.

Explanation: It would be useful to gain a little more distance from our findings to make suggestions, but the recommendations would still be sectioned distinctly from the conclusions.

Example: Conclude the statements summarized in the conclusion with, "This study brought timely attention to the importance of speaking about the use of medicinal plants as we provide maternal health services." and just keep the recommendations as a section.

References

Statement: Overall the references are appropriate to the context of the research and largely current, however some were lesser sources.

Explanation: In general, less of the websites or unlabelled attribution would be helpful in not pulling from potential sources.

Example: Source potential from other peer-reviewed literature (i.e., the systematic reviews that review herbal medicine use during childbirth) or methodologies.

Overall, the manuscript is methodologically rigorous, ethically sound and a contribution to the knowledge in maternal health (and maternal health research) literature base in sub-Saharan Africa.

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Please submit your revised manuscript by Oct 18 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

PLOS ONE

Journal Requirements:

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. 

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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #2: I Don't Know

Reviewer #3: Yes

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

Reviewer #3: Yes

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6. 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 #2: Dear Authors,

Now I only have a very few comments tot he manuscript, as you have done a good job revising it.

Please check for a few more "and or" which should be "an/or".

First line in Introduction: The World health organisation (WHO) and various (not "other" as WHO is not a study).

Same page, line 11: ".... and increased risk of cesarean section" (or increased number of cesarean...)

In Materials and methods, Sampling technique, First stage you talk about "wards" - is that the right word? Or is it "clinics"?

Main outcome variables, you mention "pumpkin roots" - are the roots actually used? Or the pumpkin it self or the seeds?

Pre-testing of data collection instruments: the questionnaire was administered "orally" - not "verbally".

Table 2: Here it still says "to enhance labour" (should be "hasten" as in the text above the table).

With those minor changes, I think your paper is ready for publishing.

Reviewer #3: Dear Author

Please ensure all abbreviations are spelled out in full when first used in the abstract, main text, or footnotes for clarity.

Best regard

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Reviewer #2: No

Reviewer #3: No

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Prevalence and determinants of medicinal plants utilization during labour among women of reproductive age in Butiama, Tanzania: A community-based cross-sectional study

PONE-D-24-53690R4

Dear Dr. Sichalwe,

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,

Ammal Mokhtar Metwally, Ph.D (MD)

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: (No Response)

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

Reviewer #2: (No Response)

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: (No Response)

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6. 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 #2: (No Response)

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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 #2: No

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