Dear Dr. CHAKULYA,

This study effectively identifies factors associated with preeclampsia in Zambia, employing satisfactory methodology and analysis. This study provides valuable indigenous data on preeclampsia factors in Zambia. 

Background Queries

• Include a sentence that emphasises the research gap that relates with the regional context (e.g., Sub-Saharan Africa or your study’s setting), to justify the importance of the study.

• Consider the inclusion of recent citations (preferably within the last 5 years), to emphasise significance (e.g., [1], [2])

• There is insufficient reference to empirical population data, particularly for low- and middle-income countries (LMICs), despite acknowledging their burden: Revise

Methods Queries

• Several grammatical errors are evident, e.g., "form" instead of "from": Revise accordingly throughout

• Clarify the systematic sampling method

• Include the sample size calculation formula

Results Queries

• Whilst the data is adequately presented, a narrative synthesis is required to validate the significance of the key findings

• Some statements ambiguous, for example, “An increase in gestational age increased the odds of having PE by 11% (OR: 0.86...)” - This is contradictory, OR <1 indicates decreased odds, not increased.

• Explain the observations noted in Figure 2. For example: "Women with PE had significantly lower gestational age and higher blood pressure, while hematological parameters did not significantly differ.": Why?

Discussion and Conclusion Queries

• Provide additional information regarding the strength of associations (e.g., AORs of 9.97 and 30.8); the clinical relevance of variables (e.g., why should family history be included in all antenatal intake forms?).

• Explain how the data can inform antenatal screening or referrals

Strengthen the conclusion by including the clinical relevance of the study findings.

References

Please refer to the PLOS ONE Referencing guidelines and revise accordingly.

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

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We look forward to receiving your revised manuscript.

Kind regards,

Nalini Govender, Ph.D

Academic Editor

PLOS ONE

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Additional Editor Comments:

Thank you for your submission. This study effectively identifies factors associated with preeclampsia in Zambia, employing satisfactory methodology and analysis. Future research exploring causal relationships could enhance preventive strategies, benefiting Zambia, and Sub-Saharan Africa, where preeclampsia's disease burden is substantial. This study provides valuable indigenous data on preeclampsia factors in Zambia. Future collaborative research in Sub-Saharan Africa, focusing on causal associations, could inform prevention strategies and help mitigate maternal and perinatal morbidity and mortality in the region.

However, the following queries need to be addressed before it can be considered for publication. Please carefully revise the manuscript by responding to all the reviewers' comments, clarifying methodological issues, ensuring appropriate interpretation of the results, and improving the overall structure and grammar of the text.

Background

The background is well-conceived, and clearly introduces preeclampsia (PE) as a global maternal health concern and outlines its clinical definition and consequences, emphasizing the multifactorial nature of PE. The relevance of genetic, immunological, environmental, and lifestyle factors is well-articulated and aligns with current literature.

Queries

•     Include a sentence that emphasises the research gap that relates with the regional context (e.g., Sub-Saharan Africa or your study’s setting), to justify the importance of the study.

•     Consider the inclusion of recent citations (preferably within the last 5 years), to emphasise significance (e.g., [1], [2])

•     There is insufficient reference to empirical population data, particularly for low- and middle-income countries (LMICs), despite acknowledging their burden: Revise

Language and Grammar

•     Line 1: “fatal health” should be “fetal health”

•     Line 2: “may lead to rapid development of severe complications” consider “can rapidly progress to severe complications”

•     Line 4: “where access to specialized care often falls short” revise to “where access to specialized obstetric care is often limited”

•     Line 6: “external contributors like lifestyle choices” ,replace with “modifiable factors such as lifestyle behaviors”

•     Line 9: “emphasize the hereditary and epigenetic dimensions” consider “highlighting hereditary and epigenetic contributions”

•     Line 13: “dissecting these complex interactions”, could be simplified to “understanding these interactions”

Methods

Revise based the PLOS ONE Guidelines

•     Several grammatical errors are evident, e.g., "form" instead of "from", "patient’s" instead of "patients'"): Revise accordingly throughout

•     Clarify the systematic sampling method: were the files ordered or randomized?.

•     Include the sample size calculation formula, Provide more clarity on assumptions used (confidence level, power, design effect).

•     Group variables into categories (sociodemographic, clinical, laboratory, etc.) to improve readability and reduce repetition.

•     Data collection period should be checked for temporal consistency (dates should make sense in relation to the manuscript’s submission timeline).

•     Use clear definitions with numbered citations and paragraph breaks

Results

Queries

1. Grammatical, punctuation, and formatting issues throughout the document

•     For example: “form different health facilities” should be “from different health facilities”

“Unavailable and multivariable analysis” should be “Univariable and multivariable analysis”

"21.4" in “21 (21,4)” likely a formatting error; use “21 (21.4%)”

Typographic inconsistencies like “ALT; Alanine transferase” and general spacing errors (e.g., “9.97 95%Cl”) should be corrected.

2. Data Presentation

•     Whilst the data is adequately presented, a narrative synthesis is required to provide a more meaningful description. Despite the extensive statistics provided, more emphasis is needed to validate the significance of the key findings.

•     There are inconsistencies in the Figures: Eg.  For "Haemoglobin, gram/dl", it is shown as “31 (25, 34)”: Check throughout and revise where necessary .

•     Consider renaming the variable "Gestational_age_weeks_2" to increase the clarity in the manuscript.

•     Multivariable Model Reporting: Provide a brief explanation regarding the selection of variables from the univariable analysis for inclusion in the adjusted multivariable model (e.g., p-value < 0.2 threshold or stepwise regression?).

•     Ensure the formatting is consistent throughout the document:

o     p-values (e.g., "p < 0.001", not "P=0.0001" or “p<0.0.1”)

o     Units (e.g., "g/dL", "µmol/L", "x10³/µL")

Statistical Accuracy and Interpretation

•     Some statements ambiguous, for example,  “An increase in gestational age increased the odds of having PE by 11% (OR: 0.86...)” - This is contradictory,  OR <1 indicates decreased odds, not increased.

•     Check the use of terms "increase" vs. "decrease" when referring to the direction of ORs.

•     Explain in detail the observation noted in Figure 2.  For example: "Women with PE had significantly lower gestational age and higher blood pressure, while hematological parameters did not significantly differ.": Why?

Discussion

Despite the well formulated discussion, the following queries must be addressed:

•     Evaluate the strength of associations (e.g., AORs of 9.97 and 30.8); the clinical relevance of variables (e.g., why should family history be included in all antenatal intake forms?).

•     Minor grammatical issues were observed, e.g., “unexplained and idiopathic explaining why”;   repetitive phrasing  of “another variable that emerged…”.

•     Rephrase sentences to demonstrate more clarity: For example Revise “Our study revealed a slightly higher prevalence (12.7%) than Mukosha et al. (12%), although both findings are largely consistent.”

•     Avoid redundancy: “history of PE was significantly associated with recurrence” and “prior PE are at increased risk” can be merged.

•     Break long paragraphs into smaller ones to improve readability, especially the third paragraph.

•     Provide more evidence on the public health and/or clinical implications.

o     For example: Explain how the data can inform antenatal screening or referrals

•     Move the sentence on sample size and data verification closer to the beginning of the paragraph to maintain balance.

Conclusion

Consider revising by strengthening the  clinical relevance of the study.

References

Please refer to the PLOS ONE Referencing guidelines and revise accordingly. For example, no italics or bold, no quotation marks, and no brackets around volume or page numbers.

Queries

•     Remove Duplicate References

•     Use full journal titles in title case, not abbreviations or partial capitalizations.

•     Ensure Consistent Author Formatting; List up to 6 authors, then use et al. after the 6th.

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

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:  This study effectively identifies factors associated with preeclampsia in Zambia, employing satisfactory methodology and analysis. Future research exploring causal relationships could enhance preventive strategies, benefiting Zambia and Sub-Saharan Africa, where preeclampsia's disease burden is substantial.

Reviewer #2:  Thank you for your submission. While your manuscript presents important findings, several concerns and queries need to be addressed before it can be considered for publication. Please carefully revise the manuscript by responding to all the reviewers' comments, clarifying methodological issues, ensuring appropriate interpretation of the results, and improving the overall structure and grammar of the text.

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Reviewer #1: Yes:  Dr Revathi Soundararajan

Reviewer #2: No

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Attachments

Attachment

Submitted filename: reviewer comments.docx

<p>Preeclampsia, prevalence and associated factors

PONE-D-25-21925R1

Dear Dr. Chakulya,

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,

Nalini Govender, Ph.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: