PONE-D-25-15453-->-->Where to Invest in Neonatal Survival Programs for Achieving the Targets of Sustainable Development Goals in Nepal?  A Modelling Study Using Lives Saved Tool Through Scaling Key Interventions-->-->PLOS ONE?>

Dear Dr. Khanal,

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.

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

ACADEMIC EDITOR:

Comments:

Reviewer #1: The topic addressed in this paper is highly relevant for Nepal and other low- and middle-income countries (LMICs).

Specific Comments:

Page 1 – Introduction:

While the introduction provides useful background, it omits key factors contributing to Nepal’s progress in maternal and neonatal health. Specifically, the role of integrated programs involving family planning, water, sanitation, and hygiene (WASH), as well as community-based approaches is missing.

Methods Section:

• The rationale for selecting 90% coverage for all nine interventions is not clearly explained. Why were this specific threshold chosen, and why was it uniformly applied across all interventions?

• The decision to assign equal weight to all nine interventions requires justification. Not all interventions may have an equivalent impact on neonatal mortality, so the use of equal weightage should be discussed.

• The inclusion of the Family Planning (FamPlan) and AIDS Impact Module (AIM) is unclear. Why were these modules used in the context of neonatal health and how they contribute to the analysis?

• The assumption of a 0% baseline for fetal growth restriction management and Kangaroo Mother Care (KMC) is unrealistic and should be revisited or supported with evidence.

Key Issue Regarding SDG Target:

Even under the assumption of achieving 90% coverage for all interventions, the SSDG) target of reducing neonatal mortality rate (NMR) to 12 deaths per 1,000 live births by 2030 is not met. The manuscript does not adequately address why 90% coverage was chosen if it does not align with achieving the SDG target. Given that the title suggests alignment with SDG goals, this discrepancy should be discussed more thoroughly.

Discussion Section:

The discussion is overly lengthy and lacks focus, which may reduce reader engagement. Summarizing or condensing context-specific information to improve clarity and maintain relevance for an international audience will strengthen the paper.

Minor Revisions:

• Page 8, Lines 152–153: Citation is missing; please provide appropriate references.

• Page 17: Expand “FCHV” upon first use to ensure clarity for all readers.

Language and Grammar:

The manuscript would benefit from thorough language and grammar editing.

Reviewer #2: Thank you for reaching out to review this important manuscript. The study is very relevent for Nepal considering stagnation of neonatal mortality since 2016, and need to achieve ambitious targets of Sustainable Development Goal and Nepal Every Newborn Action Plan. It would be very valuable to idedentify effective, feasible and affordable interventions to reduce neonatal mortality in Nepal. Use of LiST is a very good approach as it provides roboust model for estimating potential lives saved due to various interventions with varied level of coverage.

As this study is based on a mathematical modelling, it is very important for the authors to check assumptions and apply their judgement of the applicability and limitations of the model, as well as to make attempts to improve the model, values and assumptions. Though the authors have noted in the limitation section, the biggest weakness of this study is to rely on default values for 2024. As per my understanding, the default values provided by the LiST software is only for the reference purpose and the authors are encouraged to identify reliable sources of data to best estimate the value for the baseline and to use those values for the model. For example, as also noted by the authors, 0% fetal growth restriction detection and management and 0% case management of premature babies with KMC in 2024 is not reflective of the true sitation. Another example is, 75.6% baseline coverage of neonatal rescuscitation is over estimation of the coverage considering Nepal's insittutional delivery rate, availibility of skilled birth attendants during birth, skill retention of birth attendants, availibility of newborn rescuitation kits in health facilities.

Authors noted in the Limitation section (line 358) that "LiST relies on default effectiveness estimates derived from global or regional data" but the Spectrum Manual Page 7 guides "Make any modifications necessary to the default baseline data", which reflects that change of default value in the software is possible. As a scientific work, I strongly advise the authors to use reliable estimate for the baseline value, which otherwise will provide under/over estimation of the effect and may misguide the policy-makers and program-planners. For example, this may likely to affect the three priority interventions (case management of premature babies, management of neonatal sepsis, and neonatal resuscitation) or their order.

Also, as noted by the authors, "the assumption of uniformly scaling up all interventions 90% coverage by 2030 oversimplifies implementation challenges and may not be realistic". This is also very important aspect of the study to re-consider. I would suggest considering the targets in key policy documents such as SDG, Nepal Health Sector Strategic Plan, Nepal Every Newborn Action Plan to estimate the best possible level (target) by 2030.

The "Discussion" section is lengthy and not very coherent. Please revise it with a proper logical flow. Considering Nepal's vulnerability (e.g 2015 earthquake, COVID pandemic), please also talk about vulnerablity to achieve 2030 targets and actions needed to make the newborn health system more resilient. Try to evaluate how prepared Nepal's health system is to address newborn health priorities in case of any shocks.

As addressing these comments may require substaintial changes in the manuscript, I would recommed "major revision" for this manuscript.

Few minor corrections:

Line # 69-70: I would not consider Neonatal Strategy as an intervention. Its a strategic document guideing priority interventions. As Nepal still relies on 2004 Strategy for Neonatal health (though there are newer documents guiding newborn health such as Safe Motherhood and Newborn Health Roadmap and Nepal Every Newborn Action Plan). So, please differentiate between policy documents and actual interventions. Please provide an overview of existing key policy documents (with key dates of endorsement) guiding newborn health in Nepal.

Line # 91: rephrase the word "advocates" as it may not fit well with WHO's mandate/role

Sentences after line# 296 is repetation of sentences from line # 267, which might be a copy-paste error. Please check and update.

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

Please submit your revised manuscript by Jul 11 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,

Sabita Tuladhar

Academic Editor

PLOS ONE

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[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: Partly

**********

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

Reviewer #1: I Don't Know

Reviewer #2: No

**********

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

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: The topic addressed in this paper is highly relevant for Nepal and other low- and middle-income countries (LMICs).

Specific Comments:

Page 1 – Introduction:

While the introduction provides useful background, it omits key factors contributing to Nepal’s progress in maternal and neonatal health. Specifically, the role of integrated programs involving family planning, water, sanitation, and hygiene (WASH), as well as community-based approaches is missing.

Methods Section:

• The rationale for selecting 90% coverage for all nine interventions is not clearly explained. Why were this specific threshold chosen, and why was it uniformly applied across all interventions?

• The decision to assign equal weight to all nine interventions requires justification. Not all interventions may have an equivalent impact on neonatal mortality, so the use of equal weightage should be discussed.

• The inclusion of the Family Planning (FamPlan) and AIDS Impact Module (AIM) is unclear. Why were these modules used in the context of neonatal health and how they contribute to the analysis?

• The assumption of a 0% baseline for fetal growth restriction management and Kangaroo Mother Care (KMC) is unrealistic and should be revisited or supported with evidence.

Key Issue Regarding SDG Target:

Even under the assumption of achieving 90% coverage for all interventions, the SSDG) target of reducing neonatal mortality rate (NMR) to 12 deaths per 1,000 live births by 2030 is not met. The manuscript does not adequately address why 90% coverage was chosen if it does not align with achieving the SDG target. Given that the title suggests alignment with SDG goals, this discrepancy should be discussed more thoroughly.

Discussion Section:

The discussion is overly lengthy and lacks focus, which may reduce reader engagement. Summarizing or condensing context-specific information to improve clarity and maintain relevance for an international audience will strengthen the paper.

Minor Revisions:

• Page 8, Lines 152–153: Citation is missing; please provide appropriate references.

• Page 17: Expand “FCHV” upon first use to ensure clarity for all readers.

Language and Grammar:

The manuscript would benefit from thorough language and grammar editing.

Reviewer #2: Thank you for reaching out to review this important manuscript. The study is very relevent for Nepal considering stagnation of neonatal mortality since 2016, and need to achieve ambitious targets of Sustainable Development Goal and Nepal Every Newborn Action Plan. It would be very valuable to idedentify effective, feasible and affordable interventions to reduce neonatal mortality in Nepal. Use of LiST is a very good approach as it provides roboust model for estimating potential lives saved due to various interventions with varied level of coverage.

As this study is based on a mathematical modelling, it is very important for the authors to check assumptions and apply their judgement of the applicability and limitations of the model, as well as to make attempts to improve the model, values and assumptions. Though the authors have noted in the limitation section, the biggest weakness of this study is to rely on default values for 2024. As per my understanding, the default values provided by the LiST software is only for the reference purpose and the authors are encouraged to identify reliable sources of data to best estimate the value for the baseline and to use those values for the model. For example, as also noted by the authors, 0% fetal growth restriction detection and management and 0% case management of premature babies with KMC in 2024 is not reflective of the true sitation. Another example is, 75.6% baseline coverage of neonatal rescuscitation is over estimation of the coverage considering Nepal's insittutional delivery rate, availibility of skilled birth attendants during birth, skill retention of birth attendants, availibility of newborn rescuitation kits in health facilities.

Authors noted in the Limitation section (line 358) that "LiST relies on default effectiveness estimates derived from global or regional data" but the Spectrum Manual Page 7 guides "Make any modifications necessary to the default baseline data", which reflects that change of default value in the software is possible. As a scientific work, I strongly advise the authors to use reliable estimate for the baseline value, which otherwise will provide under/over estimation of the effect and may misguide the policy-makers and program-planners. For example, this may likely to affect the three priority interventions (case management of premature babies, management of neonatal sepsis, and neonatal resuscitation) or their order.

Also, as noted by the authors, "the assumption of uniformly scaling up all interventions 90% coverage by 2030 oversimplifies implementation challenges and may not be realistic". This is also very important aspect of the study to re-consider. I would suggest considering the targets in key policy documents such as SDG, Nepal Health Sector Strategic Plan, Nepal Every Newborn Action Plan to estimate the best possible level (target) by 2030.

The "Discussion" section is lengthy and not very coherent. Please revise it with a proper logical flow. Considering Nepal's vulnerability (e.g 2015 earthquake, COVID pandemic), please also talk about vulnerablity to achieve 2030 targets and actions needed to make the newborn health system more resilient. Try to evaluate how prepared Nepal's health system is to address newborn health priorities in case of any shocks.

As addressing these comments may require substaintial changes in the manuscript, I would recommed "major revision" for this manuscript.

Few minor corrections:

Line # 69-70: I would not consider Neonatal Strategy as an intervention. Its a strategic document guideing priority interventions. As Nepal still relies on 2004 Strategy for Neonatal health (though there are newer documents guiding newborn health such as Safe Motherhood and Newborn Health Roadmap and Nepal Every Newborn Action Plan). So, please differentiate between policy documents and actual interventions. Please provide an overview of existing key policy documents (with key dates of endorsement) guiding newborn health in Nepal.

Line # 91: rephrase the word "advocates" as it may not fit well with WHO's mandate/role

Sentences after line# 296 is repetation of sentences from line # 267, which might be a copy-paste error. Please check and update.

**********

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 #1: Yes:  Sabita Tuladhar

Reviewer #2: Yes:  Deepak Paudel

**********

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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-25-15453R1-->-->Where to Invest in Neonatal Survival Programs in Nepal?  A Modelling Study Using Lives Saved Tool Through Scaling Key Interventions-->-->PLOS ONE?>

Dear Dr. Khanal,

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 Dec 03 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,

Sabita Tuladhar, PhD, MHealSc, MA

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 (if provided): None.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #3: (No Response)

**********

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

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

Reviewer #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: Yes

**********

Reviewer #1: This is an important and timely paper that can contribute to reducing neonatal deaths in Nepal and monitoring progress toward the SDGs. Thank you for addressing all comments carefully. A thorough review of the language, in-text citations, and references would further strengthen the manuscript.

Reviewer #3: Overall Summary

This paper provides a clear, data-driven analysis of neonatal mortality in Nepal using the LiST model to estimate the impact of scaling up national priority interventions. It is strong in its policy relevance, methodological transparency, and integration of national and global health frameworks. The analysis effectively identifies high-impact interventions and links them to actionable policy strategies. There are a few targeted areas for improvement, such as tightening the writing, polishing grammar and some phrasing, and strengthening the connection between results and policy implications, that would enhance coherence and impact.

Abstract

The abstract effectively addresses a critical public health issue - neonatal mortality in Nepal - within a clear global and national policy context. It presents well-organized sections with quantitative, model-based estimates that make the projected impact tangible and actionable. The identification of key priority interventions adds strong practical relevance and supports evidence-based decision-making. There are a few minors areas of improvement you could consider:

• Minor grammatical and phrasing issues need correction for clarity.

• Methods section could briefly clarify use of proxy estimates and modeling assumptions.

• Integrating a few points of how findings can inform policy or program implementation would strengthen conclusion.

• It would be helpful to address the gap between projected NMR (14/1,000) and the NENAP target (11/1,000).

Introduction

The introduction provides a clear, data-driven rationale for the study, effectively situating neonatal mortality within both the global and national (Nepalese) context. It demonstrates strong use of recent data and policy references, highlighting Nepal’s past progress, remaining challenges, and alignment with national and international frameworks such as NENAP, SDGs, and WHO recommendations. The logical flow from problem statement to research gap and study aim is coherent and well-grounded in evidence. A few minor items that would strengthen this section:

• Correct minor grammatical and phrasing errors (e.g., line 111: “….effect of selected maternal and neonatal health interventions to the coverage targets set by NENAP for 2035” would be better phrased as “….effect of selected maternal and neonatal health interventions at the coverage targets set by NENAP for 2035”; e.g., line 117 “setting the evidence-based interventions in newborn survival policies and programs” is a bit awkward – perhaps use “informing” or “guiding” the integration of evidence-based interventions.

• Consider streamlining a few sections to improve readability and maintain focus on key points (e.g., summarize or group Nepal’s MNH programs in lines 73-79 instead of a full list; lines 85-98 could be streamlined a bit as it repeats similar ideas about the need for targeted interventions).

• Strengthen the transition to the study aim by clarifying the research gap.

• Briefly note limitations of past interventions to justify the study’s relevance.

Methods

The methods section clearly describes the modeling tool (LiST) and software used, providing sufficient detail about the data sources and modules involved. It explains the modeling strategy and assumptions well, including how intervention effectiveness and coverage translate into impact. The inclusion of baseline and target coverage data offers transparency and supports reproducibility. A few minor areas to improve clarity and readability:

• Some sentences are long and complex; breaking them into shorter, clearer statements would improve readability (e.g., lines 121–124).

• Minor grammatical issues (e.g., line 125 “affect in health outcomes” to “affect health outcomes”).

• The explanation of effectiveness and impact calculations could be streamlined to avoid redundancy (lines 159–170).

• A short add on to clarify the rationale for selecting the 35 interventions—why these and not others? – would be helpful. For example, “We selected…….model, prioritizing those identified as key drivers of neonatal survival and aligned with national targets for 2035“ or perhaps “…focusing on those with established effectiveness and significant potential impact on neonatal, maternal, and child mortality.”

Results

The results section clearly quantifies the projected impact of scaling up interventions, providing specific numbers of lives saved and highlighting the most impactful interventions. It effectively uses percentages to contextualize the relative contributions of key interventions and causes of death. There is a comprehensive presentation of data. A few minor items to strengthen the results presentation:

• Correct the broken reference ("Error! Reference source not found") to ensure all citations and figures are properly linked and accessible (line 198).

• Avoid repetition in listing the four key interventions twice in consecutive sentences (lines 192–197). For example, the second reference (starting at line 194) could combine into one clear sentence: “These four interventions together could prevent more than two-thirds (70.4%) of neonatal deaths.”

• A few points of awkward phrasing: e.g., line 202 “The finding shows that birth asphyxia accounts the largest share (29.8%)” could be “Birth asphyxia accounts for the largest share (29.8%) of additional neonatal lives saved.”

• To enhance reader understanding, include brief interpretations or implications of the results, rather than just presenting numbers.

Discussion

The discussion is comprehensive and demonstrates a strong command of both the national policy landscape and the study’s implications. It effectively links the model results to real-world challenges in Nepal’s neonatal health system, referencing existing programs, infrastructure, and health system constraints. The integration of evidence and policy history adds depth, and the section maintains alignment with the study’s objectives and global standards. A few items could be addressed to strengthen the discussion:

• Consider places to streamline the discussion section and address minor grammatical issues. For example, can condense overlapping explanations (e.g., repeated statements about Nepal’s progress and NMR stagnation in lines 215–220 and 261–266) or simplify long sentences for readability.

• Focus the policy table (Table 3) by summarizing key milestones or grouping related initiatives rather than listing every program in detail. For instance, combine overlapping entries like CB-NCP, CB-IMCI, and CB-IMNCI.

• You could strengthen the analytical discussion by more clearly distinguishing between what the LiST model adds and what prior research or policy already shows.

Conclusion

The conclusion effectively summarizes key findings and policy implications, maintaining consistency with the results and discussion. It ends with a clear call for a comprehensive, system-wide response, which is a strong way to close the paper. You could consider ending with a lightly stronger emphasis, such as: “Ultimately, achieving the NENAP targets will depend on integrating high-impact neonatal interventions within a strengthened, equitable health system.”

**********

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 #1: Yes:  Sabita Tuladhar

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

Where to Invest in Neonatal Survival Programs in Nepal? A Modelling Study Using Lives Saved Tool Through Scaling Key Interventions

PONE-D-25-15453R2

Dear Dr. Khanal,

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,

Sabita Tuladhar, PhD, MHealSc, MA

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: