Dear Dr. ABOAGYE,

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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Academic 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?

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: 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: Thank you for the opportunity to review this manuscript.

Strengths

The title is clear and appropriately descriptive of the study’s focus on mother and newborn skin-to-skin contact (SSC) in Ghana.

The abstract is well-structured with distinct sections (Background, Methods, Results, Conclusion), reporting key prevalence and adjusted odds ratios (aORs) for important predictors such as cesarean delivery, birth order, antenatal care, place of delivery, and regional differences. Keywords are relevant and enhance discoverability.

The introduction effectively situates the study within global health goals (SDG 3), highlights neonatal mortality in Ghana, summarizes SSC benefits comprehensively, and identifies barriers and research gaps clearly.

Use of the 2022 Ghana Demographic and Health Survey (GDHS) ensures nationally representative, high-quality data. The cross-sectional design, multistage sampling, and multilevel logistic regression with survey weights are appropriately described and applied.

Clear presentation of SSC prevalence overall and by region, with detailed descriptive statistics and robust multilevel modeling results including random effects and ICC values.

The discussion contextualizes findings well, compares with other countries, explains associations plausibly, and outlines clear policy implications. Strengths and limitations are acknowledged transparently.

Areas for Improvement

Title

Consider refining to “Prevalence and determinants of mother and newborn skin-to-skin contact in Ghana” to better reflect the study’s dual focus on prevalence and predictors, improving clarity and searchability.

Abstract

The extremely large aOR for facility delivery (30.67) and very low aOR for cesarean section (0.04) should be briefly contextualized to caution readers about potential confounding or data distribution effects.

Rephrase “higher birth order showed an incremental increase…” to “higher birth order (fifth or more) was significantly associated with increased odds…” for accuracy.

Ensure consistency in reported prevalence figures (67.2% vs. 62.7%).

Minor language edits for tense consistency and clarity are recommended.

Consider adding keywords like “Neonatal health,” “Maternal health,” or “Prevalence” to broaden indexing.

Introduction

Improve paragraph structure to separate global context, SSC benefits, prevalence patterns, and barriers for easier reading.

Clarify terminology distinguishing SSC from kangaroo care, as the latter includes SSC plus other components.

Strengthen the statement about no prior nationally representative studies by referencing smaller or regional studies and their limitations.

Make the link between SSC and neonatal mortality more explicit to emphasize SSC’s potential impact in Ghana.

Conclude with a clear statement of study objectives.

Methods

Provide more detail on sampling frame specifics (number of clusters, households per cluster) and response rates for transparency.

Clarify handling of missing data and whether imputation was performed.

Elaborate on variable selection process using AIC, specifying which variables were retained or excluded.

Reconsider classifying household wealth index as a contextual variable, as it is typically household-level.

Include checks for multicollinearity, interactions, and model diagnostics.

Explain the intracluster correlation coefficient (ICC) and its interpretation for readers unfamiliar with multilevel modeling.

Results

Correct inconsistency in overall SSC prevalence figures.

Interpret the large aOR for facility delivery cautiously, discussing possible sparse data bias or confounding.

Avoid claiming “incremental increase” in SSC odds with birth order if only the highest category is significant.

Interpret ICC and PSU variation in terms of practical significance.

Discussion

Avoid causal language given the cross-sectional design; rephrase statements suggesting causality.

Critically examine the unusually high odds ratio for facility delivery.

Discuss potential confounders (e.g., socioeconomic status, education) and biases (e.g., recall bias) more thoroughly.

Correct minor typographical errors (e.g., “SCC” instead of “SSC”).

Recommendations

Standardize prevalence figures throughout the manuscript.

Increase transparency on variable selection, missing data handling, and model diagnostics.

Interpret extreme odds ratios with caution; consider presenting absolute risks or predicted probabilities.

Avoid causal language and clearly state cross-sectional design limitations.

Expand discussion on confounders and biases to strengthen validity.

Suggest qualitative follow-up studies to explore cultural and regional SSC differences.

Proofread carefully to eliminate minor error

Reviewer #2: This manuscript uses representative data from Ghana to study factors associated with mother and newborn skin-to-skin contact. The use of multi-level analysis to consider regional context is a strong point. Please see my detailed feedback below.

1. Abbreviation Clarification in Methods

On page 5, the abbreviation "GDHS" is first introduced. For clarity and academic rigor, I recommend that the full term—Ghana Demographic and Health Survey (GDHS)—be spelled out at its first mention, with the abbreviation in parentheses.

2. Sample Size Before and After Missing Data Exclusion

In the Methods section (page 5), it appears that a complete-case analysis was performed, resulting in a final analytic sample of 3,833 mother-child pairs. Please specify the initial sample size before excluding cases with missing data.

3. Details of Variable Selection and AIC Reporting in Statistical Analysis

On page 6, the Statistical Analyses subsection states that "the best-variable selection method was adopted to select the best-fitted variable for the regression analysis." Although the manuscript mentions the use of the Akaike Information Criterion (AIC) as a criterion for model selection, it does not clearly specify which variables were initially considered in the selection process, nor does it provide the actual AIC values. Please clarify which variables were included in the initial stage, describe the selection method used, and report the AIC values or thresholds that guided the final model choice.

4. Interpretation of Prevalence by Birth Order and Sex

On page 8, the statement that "the highest prevalence was observed among third-born children (69.4%), male children (67.7%), and those in higher birth order (65.2%)" is confusing. Since "third" and "higher birth order" (e.g., fifth or more) are distinct and mutually exclusive categories, only one should represent the true highest value.

5. Calculation of 95% Confidence Interval in Table 1

Table 1 presents the bivariate analysis of mother and newborn skin-to-skin contact. Please specify the statistical method used to calculate the 95% confidence intervals for the variables in this bivariate analysis.

6. Criteria for Birth Size Categories in Table 1

Table 1 lists "size of child at birth" categories as: very large, larger than average, average, smaller than average, and small. It is unclear what specific criteria or cut-off points were used to distinguish between these categories. If they are based on quantitative measures (e.g., birth weight ranges or percentiles), please provide the definitions. If based on subjective assessment, please explain the basis for categorization.

7. Omission of Statistically Significant Regions in Results

On page 11, in the fixed effect results subsection, the regions Bono, Northern, and Savannah are not mentioned in the text, despite being statistically significant in Table 2. If there is a specific reason for this omission, please clarify. If not, I recommend including these regions in the written description for consistency and completeness.

8. Formatting and Annotation Suggestions for Table 2

For readability, please use bold formatting for the "Random effect model", as is done for the "Fixed effects results".

Since the number of clusters is consistently 616 across all models, it may not be necessary to present this as a separate row for each model.

In the table footnotes, rather than simply defining aOR and CI, clarify that the reported values are aORs and the numbers in parentheses represent the 95% confidence intervals.

9. Interpretation of ICC Changes in Random Effect Results

On page 11, the random effect results show that the ICC increases from Model 1 to Model 2, decreases in Model 3, and then increases again in Model 4. Providing an interpretation of these changes in the Discussion section would enhance the manuscript.

10. Wording in Discussion: "Estimated the Prevalence and Factors"

On page 15, line 4, the phrase "we estimated the prevalence and factors" is not precise, as only the prevalence was estimated, not the factors themselves. I recommend revising this to "we estimated the prevalence of..." or "we estimated the prevalence and examined the factors associated with...," which would more accurately reflect the analysis conducted.

11. Inconsistency in Practiced SSC Prevalence

On page 15, line 5, there is a discrepancy in the reported prevalence of practiced skin-to-skin contact: Table 1 shows 67.2%, while the Discussion states 62.7%. Please clarify which value is correct and ensure consistency throughout the manuscript.

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Reviewer #1: No

Reviewer #2: No

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Dear Dr. Aboagye,

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 note that the Reject recommendation from reviewer #3 is not supported by sufficient detail and should be disregarded. Please address the concern raised by the other reviewers.

Please submit your revised manuscript by Nov 17 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.

• 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 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,

Ricardo Q. Gurgel, PhD

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

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

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

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: No

**********

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

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: No

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: (No Response)

**********

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

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #3: No

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Reviewer #1: I recommend the manuscript is for publication in PLOS One journal. the authors have address most of the comments raised in the previous round of review. However, a few areas still require attention, as noted below.

1.Abstract

The statement in the background could be better expressed as follows: “Despite the well-established role of skin-to-skin contact in reducing neonatal mortality, its implementation varies significantly across geographical regions, particularly in sub-Saharan Africa. Therefore, we estimated the prevalence of mother-newborn skin-to-skin contact at birth and investigated the factors associated with its practice in Ghana.”

Introduction

Authors were advised to conclude the introduction with a clear statement of the study objectives. They responded by repeating the research title at the end of the introduction. Instead, authors should clearly specify the study objectives rather than restate the title.

Variables

Authors should review paragraph 2, line 6, where “wanted las pregnancy” appears to be a typographical error and make the necessary correction.

Results

Authors should specify the statistical method used to calculate the 95% confidence intervals for the variables in Table 1. This was not explicitly mentioned in the Results section.

Reviewer #2: (No Response)

Reviewer #3: The article has fundamental methodological flaws and is written in a scientific manner.

Suitable for publication in local journals

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

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Prevalence and determinants of mother and newborn skin-to-skin contact in Ghana

PONE-D-24-56054R2

Dear Dr. Aboagye,

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.

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Kind regards,

Ricardo Q. Gurgel, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: