-->PONE-D-24-39443-->-->Effective coverage of antenatal care services in post war Tigray, Northern Ethiopia: An analysis of community and health facility-based surveys-->-->PLOS ONE

Dear Dr. Gebretnsae,

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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Awol Yemane Legesse

Academic Editor

PLOS ONE

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Additional Editor Comments:

I congratulate the research team for conducting such a big study.

The paper requires drastic improvement for English language. There are multiple issues such as typos, grammatic errors, word usage, and formatting. I recommend you seek proof reading from proficient individual.

Background

The entire background needs to be rewritten, the AI score is 90%.

Please improve the flow of the background,

Lines 68-73 have complementary ideas but you have tried to connect them as if they were conflicting.

Please address this in your introductions. How can health care providers and policy makers effectively mitigate the challenges in resource and quality of care in the region. What strategies have been implemented to improve effective ANC coverage in war affected areas like Tigray.

Methods

You are advised to cite the source for the information regarding population data. For instance, Line 108-111.

Please cite the study, or if you are unable to do so, remove the statements 118-120.

The sample size and sampling procedure is difficult to decipher for the readers. Schematic presentation, i.e figure, would make it easier. Furthermore, you have to explain why you selected 8 urban/16 rural. Why 30% Tabias, and why 30 women.

‘. In the first stage, a total of 24 districts (8 urban and 16 rural) were randomly selected from 78 accessible districts of Tigray. The second stage, 30% Tabias were selected randomly (a total of 78 tabias) from the 24 selected districts. Finally, 30 women with under one year child were randomly selected from each selected Tabia’

Why 32 primary hospitals and what is the basis for the proportion of 9 primary hospitals vs 23 health center. How did you come up with the 250 ANC clients, and the proportion of 5 to 15 ? Justify it/ cite reference.

ANC 4, It would help if you mentioned it as a limitation, why most of your metrics fall within the old ANC recommendations of 4 visits instead of contacts of the revised WHO recommendations for positive pregnancy experience.

Discussion

The discussion needs a massive upgrade. It is important to showcase the importance of the study more precisely. Currently, the argument utilized in the discussion is shallow/superficial. A more detailed comparison with pre war conditions is important. Furthermore, please compare it with other conflict ridden areas. Most importantly, emphasize on showcasing how the impact of the Tigray war varies from the effects of other wars on ANC utilization and ANC quality. Please factor in the dynamics of the war in this context.

Conclusions

You have to stick to your study findings. Some of the recommendations put forward are from preexisting knowledge that predates your findings.

What is the implication of your study?

Please attend to the comments by the reviewers.

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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: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: No

Reviewer #2: Yes

**********

-->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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Reviewer #1: No

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: First, I would like to congratulate the authors for conducting this important study, which aims to determine the state of antenatal care (ANC) in the post-war period.

However, there are some grammatical issues that should be addressed throughout the manuscript.

Methods

This study uses multistage survey data. The authors employed a multistage cluster sampling technique to select districts, tabiyas, and households. Typically, multistage surveys require sample weighting to account for unequal probabilities of selection. Based on the selection criteria described, not all households had an equal chance of being included in the study. Applying sample weighting would adjust for this unequal probability and improve the representativeness of the findings. If feasible, I recommend incorporating sample weighting to make the results more reflective of the target population.

Results

Page 12, line 242: The subtitle reads, “Reasons for not had ANC follow-up.” Please revise this to correct the grammar. Additionally, ensure consistency in language usage throughout the manuscript. For example, while both "centre" and "center" are correct spellings, they belong to British and American English, respectively. Consistency in style is recommended.

Discussion

The study was conducted in early 2024, at least a year after the war ended. An ANC coverage of 87.4% is not particularly low and warrants further explanation in the discussion. For example, what was the ANC1 coverage during the war (very likely it was much lower than 87.4%)? What actions were taken in the one-year post-war period that led to this coverage to 87.4% level? Although it is lower than the pre-war period, it is still relatively high, and understanding these dynamics would enhance the discussion.

Strengths and Limitations

The main limitation of this study is that it did not adjust for potential confounders, which may have contributed to the observed lower ANC coverage during the post-war period. This limitation should be clearly mentioned.

Conclusions

Page 19, line 352: The conclusion is not fully supported by the findings. The authors state that inadequate facility readiness and suboptimal quality of care contributed to the lower ANC coverage, but no analysis was conducted to support this claim. I suggest revising the conclusion to align with the results.

Reviewer #2: Effective coverage of antenatal care services in post war Tigray, Northern Ethiopia: An

analysis of community and health facility-based surveys

Overall comment

• I am delighted to come across with the manuscript. It was organized very well

Comments

• As the WHO currently revise the schedule for 8 ANC visit, but the author uses 4 visits? What is your justification.

• As this study was done in a post recovery from the war, dealing on quality could be matter. However, it was cognizant that 70% of the health facilities were damaged or looted?

Abstract

• On the background section, the authors described that … Although promoting high-quality care is particularly important in post-conflict settings, little is known. However, in post conflict setting despite the quality of the service matter but the priority should be to enhance access for the service as the service was dramatically damaged due to the war.

• In line with this, what is the real gap for conducting such study should be described in a brief manner.

• On the method section, there are two populations

o 2340 mothers of children under one year

o 250 antenatal care (ANC) clients from the selected health facilities were included in

� What is the difference between these two populations?

o Add the type of analysis employed to answer the objective of the study

o The research put an output for the Input-and intervention-adjusted ANC and what about for the contact coverage and Quality adjusted coverage related to the variable?

Results

• Do you have quality-adjusted antenatal coverage estimates?

Introduction

• Overall, it was organized very well. However, what could be the justification for emphasising on quality than in access in area where the 70% of the health facilities were not functional or partially functional.

Methods

The authors described that this study was part of a large study. Does the large study published? If yes add the reference rather than describing a sampling procedure of the Ethiopia demographic health survey

• Do you have a sampling frame to select the eligible women as what they did in the EDHS?

• Does the tool part of the large study or you develop a tool specifically for this study?

• On the measurement section to describe the variable of interest under your investigation?

o Intervention coverage. This refers to the proportion of women who received iron-folate tablets.? what about TT vaccination

Results

• Can you organize the table 2 and 3 information using graph?

Discussion

• How conducting a study in community and health facility setting which increased its reliability.

• What mechanism does the authors uses to reduce Howerton effect bias?

• What type of observation, does the authors use to observe for the process quality?

• The exclusion of some districts as result of security issue mentioned as limitation of the study. Is that real limitation?

o Do you have methodological limitation like not including TT vaccination in the measurement of intervention coverage.

On conclusion

• The first paragraph…. You conclude that he overall effective coverage of ANC services in post war Tigray is very low

o It was obvious as the study was done in post conflict setting.

Introduction

Methods

Results

Discussion

Conclusion and recommendations

**********

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Reviewer #1: No

Reviewer #2: Yes:  Mussie Alemayehu

**********

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-->PONE-D-24-39443R1-->-->Effective coverage of antenatal care services in post war Tigray, Northern Ethiopia: An analysis of community and health facility–based surveys-->-->PLOS ONE

Dear Dr. Gebretnsae,

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 Mar 19 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'.
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-->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,

Kindu Yinges Wondie, MSc

Academic Editor

PLOS ONE

Journal Requirements:

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:

Comments on Manuscript:

"Effective coverage of antenatal care services in post war Tigray, Northern Ethiopia: An analysis of community and health facility–based surveys"

Thank you, the authors, for the great job. Here are my concerns I suggest you to revise:

1. Introduction

# The introduction provides adequate background on the importance of ANC and the challenges in post-conflict settings. However, the emphasis on quality over access in the introduction may seem contradictory given the context where 70% of health facilities were damaged or looted. Clarify how the study aims to balance these priorities.

# Ensure the research gap is clearly articulated. For example, why is effective coverage of ANC particularly relevant in this context compared to contact coverage or access alone?

2. Methods

# The methods section is detailed but could benefit from more organization. For instance, separating sampling procedures for the community based and health facility based components into distinct subsections would improve readability.

# The tools adapted from EDHS and WHO should be briefly described.

# Some details (e.g., exclusion of districts due to security issues) are mentioned but not fully explored in terms of their potential impact on the findings.

2.1 Sampling Technique

# The use of a multi stage cluster sampling method is appropriate for a study of this scope and geography. However, your justification for selecting 30% of Tabias and 30 households per Tabia could be made more clear. While resource constraints are valid, citing additional evidence or methodological guidelines (beyond referencing the EDHS standards) would strengthen this decision.

# The claim that 8 urban and 16 rural districts were selected "by chance" could use more elaboration, as this may raise concerns about the balance and representation of the sampling frame.

# please ensure clarity on the randomization process used at each stage (districts, Tabias, households). A flowchart was added as per the editor’s suggestion, which helps, but detailed descriptions would enhance transparency.

2.2 Sample Size Determination

# While the manuscript provides some rationale for the sample size (e.g., EDHS standards and resource constraints), a clearer power calculation or justification based on the study’s primary outcomes would strengthen the methodological rigor.

# The selection of 250 ANC clients (15 per primary hospital and 5 per health center) appears arbitrary. The justification provided (based on client load) is insufficient and should be supported with references or additional details.

# Please genuinly address why weighting was not applied to account for multi stage sampling, as noted by the reviewers. Even if you assume equal probabilities of selection, explicitly discussing this decision would preempt concerns about representativeness.

3.Discussion

# The discussion is repetitive in places and could be restructured for clarity. For instance, comparisons with pre-war data and other conflict-affected regions should be consolidated into one cohesive argument rather than scattered across multiple paragraphs.

# While the authors highlight the uniqueness of the Tigray conflict, they could delve deeper into how this impacts ANC differently compared to other conflict settings. For example, the widespread looting and destruction of health facilities could be linked to specific quality gaps observed in the study.

4. Recommendations

# The recommendations lack specificity in some areas. For instance, while promoting early ANC booking is essential, practical strategies to address barriers (e.g., transport issues, health facility readiness) could be more explicitly stated.

# Suggestions for training healthcare providers are too broad. Details about the specific gaps in provider competencies and the type of training required would make it actionable.

# The call to improve facility readiness is valid, but given resource constraints in post conflict settings, prioritization of specific interventions could be emphasized.

# Recommendations should clearly align with the findings of the study. For example, the observed drastic drop off from ANC1 to ANC4+ coverage should be linked to targeted interventions to address this continuity gap.

This study provides valuable insights into effective ANC coverage in a challenging post-war setting. By addressing the above points, particularly around sampling, recommendations, and methodological clarity, the manuscript can significantly enhance its rigor and impact.

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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 #1: (No Response)

Reviewer #3: (No Response)

**********

-->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 #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: 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 #1: 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 #1: 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 #1: Dear Reviewers,

Thank you for addressing all my comments, except one, which I still don't think is fully addressed.

The authors responded the following "In our sampling strategy, all individuals or households within the sampled Tabias were selected with equal probability using simple random technique."

However, inside the document, I did not see a section that states simple random sampling was used. Also, the only way all the participants could have equal probability of being selected without using sample weighting is, if you conduct simple random sampling of the individuals, which is impossible, because it is not feasible to list all individuals from 24 districts. All districts have different number of tabyas and all tabyas have different number of household, and all households have different number of individuals, which is why sample weighting is very crucial here. So, I suggest, if sample weighting is not feasible at this time, the authors should at least mention this as a limitation.

Reviewer #3: Dear editor,

I would like to thank the editor for the opportunity to review this interesting manuscript. After carefully evaluating the study, I find that it has merit; however, I recommend the following revisions to enhance its clarity and rigor.

Comments and Suggestions for the Authors:

1. Sampling Technique: The methodology regarding participant selection is not clearly described. The authors should provide a detailed explanation of the sampling process and illustrate the number of participants recruited from each district using a diagram.

2. Data Quality Assurance: The manuscript states that the questionnaire underwent a pre-test in a different location to assess response accuracy and estimate the required time. Please specify the location where the pre-test was conducted and describe any adjustments made based on the pre-test results.

3. The results are well-articulated and clearly presented.

4. Given the reported low effective coverage of antenatal care (ANC) services in post-war Tigray, it is important to specify the baseline used for comparison. Clarifying this will help contextualize the findings.

5. Strengths and Limitations: The section discussing the strengths and limitations of the study is not well-developed. A thorough revision is needed to clearly highlight the key strengths and potential limitations.

6. It would be beneficial for the authors to suggest directions for future research based on the study’s findings.

7. The conclusion does not fully reflect the study’s key findings. A thorough revision is needed to ensure alignment with the results and key discussions.

8. References: DOIs should be included for all referenced articles where applicable

**********

-->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.

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Reviewer #1: No

Reviewer #3: No

**********

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Attachments

Attachment

Submitted filename: comments to the Authors.docx

-->PONE-D-24-39443R2-->-->Effective coverage of antenatal care services in post war Tigray, Northern Ethiopia: An analysis of community and health facility–based surveys-->-->PLOS ONE

Dear Dr. Gebretnsae,

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 07 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,

Kindu Yinges Wondie, MSc

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.

Additional Editor Comments:

Academic Editor Decision on PONE-D-24-39443R2

First and fore most I want to appreciate the authors for dealing this important component of the maternal continuum of care which often gets disruptions in areas affected by war.

I accept the publication of your manuscript with minor revision for the following concerns.

# the first concern is the use of the term "post-war Tigray". While it is well justified in the contextual timeline of the study, caution must be taken given that the conflict dynamics were continuing throughout the period of this study. This means while open hostilities may have officially ended, insecurity persists in some zones. Thus, Using “post-war” may oversimplify ongoing humanitarian and systemic challenges including incomplete health system recovery. If the authors want to retain the term “post-war”, I suggest adding a clarification sentence in the Introduction or Methods section. Or they may acknowledge that the post-war label may not universally apply across all districts.

# the second concern is in the measurement of effective coverage. While the omission of outcome-adjusted and adherence-adjusted coverage in the measurement of the effective coverage is clearly acknowledged, they are advised to acknowledge sensitivity of the multiplicative method (ANC4+ × readiness × intervention coverage × process quality) to small changes in any variable, which may lead to very low estimates (3.8% in this case). In addition giving each component the equal weight may not reflect their real-world impact (e.g., process quality may matter more than one missing tracer item). The use of Iron-folate supplementation as the sole intervention in the calculation of "intervention coverage" also need clarification as it may underestimate the broader scope of ANC content. In addition giving each component the equal weight may not reflect their real-world impact (e.g., process quality may matter more than one missing tracer item). The use of Iron–folate supplementation as the sole intervention in the calculation of "intervention coverage" also may underestimate the broader scope of ANC content.

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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 #1: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #4: (No Response)

**********

-->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 #1: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: Yes

Reviewer #4: 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 #1: Yes

Reviewer #3: Yes

Reviewer #4: 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 #1: Yes

Reviewer #3: Yes

Reviewer #4: 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 #1: The authors has addressed all my comments. I believe that the manuscript is now suitable for publication.Thank you

Reviewer #3: thank you the author.The comments I provided earlier have been addressed, and I have no further comments regarding the effective coverage of antenatal care among pregnant women in post-war Tigray.

Reviewer #4: The issue it investigates sound great.

Comments:

1. A justification statement that appear at line 98-100, which indicates the inconsistency of the previous study findings, is not an appropriate justification for a primary study. Such kinds of justifications will be addressed by conducting a review (like Systematic review and/or Meta analysis) of the previous inconsistent studies not by primary study like the current one.

2. The introduction section better address the significance of the study.

3. You used very old data, almost 20 years ago, to indicate the population size of Tigray (line 116). I would rather recommend to use the estimated one (if available) since we do not have a recent census.

4. You better use an appropriate English term for "Tabias" at line 121 and other lines. It can be "Sites" or any other.

5. The study population, specially facility based study population, are vague as well as contradictory with the consequent descriptions. It is stated as if the facilities are the study population (line 121-123) but it is not like that as stated in the next sections and according to the general essence of the study.

6. Your sampling procedure is unclear.

Eg. line 128: "..... 2340 women (78 Tabias x 30 Households per tabia).......". The computation in the bracket will give number of households in the the 78 Tabias not the number of women. Or did you assume 1 women in a household?

7. You better specify the type of observation you used at line 160-161. Is it overt or covert(concealed)? If it is overt, how did you manage the bias?

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Reviewer #1: No

Reviewer #3: No

Reviewer #4: Yes:  Mengistu Abate Belay

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Effective coverage of antenatal care services in post war Tigray, Northern Ethiopia: An analysis of community and health facility–based surveys

PONE-D-24-39443R3

Dear Dr. Gebretnsae,

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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Miquel Vall-llosera Camps

Staff Editor

PLOS One

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 #1: All comments have been addressed

Reviewer #4: 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 #1: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #4: 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 #1: Yes

Reviewer #4: 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 #1: Yes

Reviewer #4: 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 #1: (No Response)

Reviewer #4: I do not have any comments for now. The authors adress all my concerns.

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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.

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Reviewer #1: No

Reviewer #4: Yes:  Mengistu Abate Belay

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