Dear Dr. Khatri,

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 Oct 20 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 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,

Kanchan Thapa, MPH, MPhil

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1.Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We note that your Data Availability Statement is currently as follows: All relevant data are within the manuscript and in Supporting Information files.

Please confirm at this time whether or not your submission contains all raw data required to replicate the results of your study. Authors must share the “minimal data set” for their submission. PLOS defines the minimal data set to consist of the data required to replicate all study findings reported in the article, as well as related metadata and methods (https://journals.plos.org/plosone/s/data-availability#loc-minimal-data-set-definition).

For example, authors should submit the following data:

- The values behind the means, standard deviations and other measures reported;

- The values used to build graphs;

- The points extracted from images for analysis.

Authors do not need to submit their entire data set if only a portion of the data was used in the reported study.

If your submission does not contain these data, please either upload them as Supporting Information files or deposit them to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories.

If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially sensitive information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If data are owned by a third party, please indicate how others may request data access.

3. Please upload a copy of Figure 10, to which you refer in your text on page 13. If the figure is no longer to be included as part of the submission please remove all reference to it within the text.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

5. 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. 

Additional Editor Comments:

Dear Authors,

Please work on abstract section to highlight the importance of the paper for global reader, low and middle income countries and why such study is important.

In background section of the manuscript, same information should be added. The paper only highlight the national importance. I suggest to add more information about global, regional and epecially LMICS country context.

In method section, how did you work with sample weight for three rounds of the survey? Please indicate it.

Line 196- You mention something about stata command. How does it address all the statistical calculation for 3 rounds of the survey?

Did you use any checklist such as STROBE for the present analysis? If yes, where it is? If not why? Please includes information for all the three rounds of study?

Total sample= Year I, Year II, Year III

Excluded= Year I, Year II, Year III

Included =

Sample= weighted vs non-weighted in analysis?

Ethics section,

Please include how the ethical approval was obtained. In the latest survey, there was covid 19 how it was addressed? Please cite the relevant DHS report indicating ethics information.

Results

Table 1. provides only information about 2022 survey, is it correct? And how about N or n here?

Table 2-5, you mention about AOR for different determinants. Among these, which are the most powerful factors? And how the impacts of these factors changed over the time? For an example, the impact of education, family size, husband occupations were most important factors in 2012 (let’s say model I). How does it changed over the time in 2022. Are the factors are the same?

Discussion

You stated about the significant inequalities among the groups. Is it based on all the data set of DHS or only based on 2022 information.

Major comments: You paper profoundly stated about equity gap, but nowhere in method section you stated about any test of equity. Please write about the equity test you performed and indicate relevant figure based on the equity test such as Lorenz Curve or others?

Data analysis section:

You indicate about VIF less than or equal to 5, what is the basis for such inclusion. You can present the VIF test results as supplementary file which will guide further researcher how to look at VIF results.

Did you perform any factorial analysis? What is the basis of performing or not performing such analysis?

You have included a lot of information for analysis, among them which are the most important factors, how is its role changed over time?

Figure 1. does it represent your study flow? What is the theoretical basis for such a conceptual framework creation such as any health belief model or any models? Why people come to utilize health services?

Figure 2. is congested, you can mention about % in y axis and remove % in each data text inside figure.

You can rework to make clear about the data reported in each figures. Was the figure based on weighted average or not? Do you want to show CI for each information?

Uniformity in figure design is missing. Please include y- axis as percentage and make the figure less congested.

Figure 6. your y-axis title is missing.

[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

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #8: Yes

Reviewer #9: Yes

Reviewer #10: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: No

Reviewer #7: Yes

Reviewer #8: Yes

Reviewer #9: Yes

Reviewer #10: Yes

**********

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

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #8: Yes

Reviewer #9: Yes

Reviewer #10: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #8: Yes

Reviewer #9: Yes

Reviewer #10: Yes

**********

Reviewer #1: This paper presents a strong, equity-focused analysis of maternal health service utilization trends in Nepal using three NDHS datasets, with an innovative intersectional disadvantage index that adds policy relevance. To further strengthen the manuscript, the authors should deepen theoretical framing (e.g., Three Delays Model), clarify data limitations, enhance discussion with more analytical depth and global comparisons, report statistical significance of trends, and expand on actionable policy implications tailored to Nepal’s federal health system. Please see the attached paper for my suggestions.

Reviewer #2: Thank you for the opportunity to review this manuscript. The topic is very important and highly relevant at this time. However, there are several areas for improvement:

Overall: The authors should avoid common patterns found in AI-generated text and consider redrafting the manuscript in more natural, human language. There are instances of long dash lines (-) appearing in many places, as well as an overuse of phrases such as "underscores" and "highlights."

Here are some of my suggestions.

Abstract:

1. years is missing in the sentence "....among 25 women aged 15–49 who had experienced at least one live birth prior to each survey"

2. Please include some key numbers in the results section.

Introduction

1. 1. The introduction section appears to be too lengthy; it would be better to shorten it.

2. You have talked about socioeconomic status here. Please also talk about the availability, accessibility, and equity gaps in maternal health services in Nepal.

3. There are several terms such as "marginalization," "disadvantage," and "multiple marginalization." Please reconsider these terms and ensure consistency throughout.

Methods:

1. Please include details about the sample size, such as how DHS sampling was conducted. Additionally, specify the type of multivariate analysis performed, such as logistic regression. The tables also need footnotes to clarify the variables adjusted for in the multivariate models.

Results:

1. There are other categories in many tables, better to add what are included in that category.

Discussion:

1. The section on private sector deliveries highlights issues related to “profit motives and unnecessary procedures,” which can help illuminate existing policy gaps, such as weak regulation, inadequate insurance coverage, and ineffective accreditation systems.

2. While the Aama program is mentioned, it is important to address whether it effectively reduces inequities and to explore why its reach in private facilities is limited.

3. Additionally, it would be beneficial to include information about systemic gaps in the continuum of care, such as transportation, health workforce capacity, facility preparedness, and the referral system.

Reviewer #3: (1) As the current manuscript is prepared using the data of three years, however, Determinants of institutional delivery were assessed through multivariable analysis of the NDHS 2022 dataset. Why the data from remaining two years (2011 and 2016) were not utilized for this outcome?

(2) After the completion of all procedures we prepare a manuscript, hence, preparing the final manuscript in the past tense is suitable.

(3) "Analyses" or "Analysis", once go through this as per requirement.

(4) Arrange the key words in the alphabetical orders.

(5) Line 163: "were categories into", is the tense correct?

(6) "(dis)advantages", this word is little bit uneasy to understand by common viewer.

(7) Line 193: "variation inflation factor (VIF)", is it variation or variance?

(8) Line 278, Table 1: N = 981, however, total number of male and female is 982, and same is found in other columns as well, do you have any specific reason please?

(9) Province "Sudurpaschim" has been considered as reference group, if the rational behind it is described it would be easy to readers.

(10) Regarding age group, both the "<20 years" and "20-24" years are taken as reference groups, was there any specific description?

(11) Digits after decimal are expected to be uniform, however, some findings are described with single digit after decimal.

(12) Line 29 says you have applied multivariable analysis, Line 189 says you applied multivariate analyses, did you apply both the methods? As they are different methods.

Reviewer #4: This was a secondary data analysis to reflect the maternal health services in Nepal and provides insightful evidence on this sector. Improving maternal health is a national priority in Nepal, supported by the government’s Aama suraksha program, which provides free delivery care and financial incentives to encourage women to access the maternal health care. Using nationally representative survey data (Nepal Demographic Health Survey of different years), this study examined whether women are receiving the recommended continuum of maternal health services-antenatal care (ANC), delivery in a health facility, and postnatal care (PNC)-and whether there are differences across social and geographic groups.

This study found that most women attend their first ANC visit and deliver in health facilities, reflecting progress in service use. However, far fewer women receive timely PNC, and only a small proportion complete all three essential services. Gaps are especially large among women from disadvantaged groups, rural communities, and those speaking Maithili or Bhojpuri. Private facilities are increasingly used for childbirth, including cesarean deliveries, but maternal incentive uptake remains low in these settings. The findings suggest the need for stronger efforts to improve continuity of care, expand incentives, and address barriers faced by disadvantaged women to ensure more equitable maternal health outcomes in Nepal.

The authors have aroused needy health gaps in low resources settings like Nepal, and have presented the Nationally represented data for more generalizability. However, this study needs some revisions to give audience insightful and non-misguided interpretations. The review comments are attached too.

Reviewer #5: The authors have submitted a technically sound article using the latest data of NDHS. The statistical analysis was done correctly but in some cases few changes can make the results more meaningful. In this manuscript as the figures cant be added, there was some lack of clarity regarding the conceptual frameworks and few more figures. However, The article is helpful for policymakers to plan for the related activities in future. It can surely be published with minor changes.

Reviewer #6: • Comment 1 (Background section):

The statement “Nonetheless, the maternal mortality ratio (MMR) remains high” is vague. Instead of presenting it hypothetically, the authors should provide clear evidence with specific data or figures to support the statements.

• Comment 2 (Introduction section):

The authors mentioned that “Over the past few decades, Nepal witnessed an increase in household income, wealth status, life expectancy, access to education, and basic health services.” However, to my knowledge, this Annual Report of Nepal, does not measure household income and wealth status. The authors should cite appropriate sources such as the Nepal Living Standards Survey or surveys conducted annually by Nepal Rastra Bank.

• Comment 3 (Data analysis section):

The authors reported that they checked the Variance Inflation Factor (VIF) for multicollinearity and excluded some independent variables. It would improve clarity if the authors specified which variables exhibited collinearity and were subsequently removed from the regression models.

• Comment 4 (Ethical section):

The statement “the survey received ethical approval from the ICF Institutional Review Board in the USA and the Nepal Health Research Council, Nepal” is unclear. The authors should write the full form of ICF to avoid confusion, as it could refer to different organizations.

• Comment 5 (Analysis and Results section):

The authors mentioned in statistical analysis section, adjusted odds ratios (AORs) were calculated in bivariate analysis using the Chi-Square test. This is methodologically incorrect because the Chi-Square test does not account for confounders and therefore cannot produce an AOR, whilst only limit on crude (unadjusted) odds ratio (CORs). Logistic regression should be used instead.

The authors should also clarify the criteria used for selecting variables into multivariate analysis. In addition, the table headings currently use the generic term “determinants of…”; it would be more precise to state the exact type of analysis performed.

Reviewer #7: The authors have well prepared the manuscript, which is technically sound. The methodological part is well explained according to the NDHS report. Few queries and suggestions regarding variables and typo error has been provided in the attached file below.

Reviewer #8: The manuscript is well structured and written in standard English. It follows the guideline of PLOS one. The author have used the nationally representative data sets which strengthens the validity of the findings in the study. However there are some minor grammatical errors which needs to be corrected to improve the flow. Some sentences are too long and needs to be shortened.

Reviewer #9: 1. Inconsistent Sample Sizes

The manuscript's "Methods" and "Results" sections present conflicting information regarding the sample size used for the determinant analysis. The abstract and "Methods" section state that the determinant analysis for institutional delivery was performed on the 2022 NDHS dataset. However, the "Methods" section specifies that the total sample size for the determinant analysis of institutional delivery, delivery by CS, and maternal incentives was 796 women who gave birth at a health facility. In contrast, the "Results" section states that the descriptive analysis of institutional delivery was based on 981 study participants. This discrepancy in sample sizes between the methodology and the results section for the same analysis is unclear.

2. Unclear Explanation of the "Disadvantage Status" Variable

The manuscript explains that a new variable, "disadvantage status," was created by combining three background variables: education, wealth status, and ethnicity. It details the process of dichotomizing these variables and then merging the categories. The final variable is said to have four categories: triple, double, single, and no disadvantages. However, the description of how the categories with "at least one form of disadvantage" and "two forms of disadvantage" were merged is confusing and does not clearly explain which specific combinations of the original eight categories were merged to create the final four. This lack of clarity makes it difficult to replicate the analysis.

Reviewer #10: Overall Impression of the Paper:

The paper looks well structured and has provided a glimpse of health inequity and its effects in one of the most important areas, maternal service utilization.

Strengths of the Paper:

Wise use of NDHS data that represent the whole nation

Has provided a good rationale and aim

Areas to improve:

Abstract:

The abstract looks quite lengthy, consider it concise.

Methods:

In the Methods section (line number 151-153) under data sources, the sample size and weighting could be explained quite a little more to make the readers unfamiliar with this concept clearer.

In the study variables under methods, section, explanation of outcomes and exposures could be done in separate paragraphs under these headings to make the picture clear.

Provide reference for advantaged ethnicities.

Creation of marginalization status and disadvantaged status could be better explained using a flowchart.

Figures are yet to be inserted, so it makes the concept cloudy at places.

Results:

The results are well presented but contain many tables, consider merging the tables where relevant. Also highlight the major findings in tables so that the navigation gets easier. If possible, show 2-3 results in a single graph using multiple colors to indicate different findings’ trend and provide indices.

Discussion:

Line number 404 and 405: Terminologies such as catch up rate and keep up rate need to be defined. Also, define what are intersectional groups.

Discussion is done in different paragraphs for different findings which makes things clear and reading easier but considering the length of all the paragraphs can be done to make it concise.

Policy implications are written in a separate paragraph, well-done. Adding recommendations on indications for CS procedure monitoring specially in private health facilities and also providing incentives under Aama Program even in private HFs with reference can be valuable.

In the limitations section, adding the caution for interpretation on a small subgroup (Muslim Dalit, Mountainous regions) can be done.

Conclusion is well-written, consider it breaking down to two paragraphs: Conclusion and Recommendations

**********

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: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: Yes:  Binika Shrestha

Reviewer #6: No

Reviewer #7: Yes:  Vijaya Laxmi Shrestha

Reviewer #8: No

Reviewer #9: No

Reviewer #10: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: PONE-D-25-36549-1.pdf

Attachment

Submitted filename: MaternaHealth_Nepalstudy_Review_PS.docx

Attachment

Submitted filename: Recommendation_Final.docx

Attachment

Submitted filename: review_maternal health.docx

Attachment

Submitted filename: Review MH Service Utilization.docx

Attachment

Submitted filename: Paper Review - PLOS One .docx

Unpacking trends and gaps in Nepal’s progress on maternal health service utilization: insights from the most recent Demographic and Health Surveys (2011, 2016 and 2022)

PONE-D-25-36549R1

Dear Dr. Khatri,

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. At the mean time, I suggest you to address all the minor comments raised by reviewer and also address the typos. 

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.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support .

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Kanchan Thapa, MPH, MPhil

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Authors,

I suggest you to once review the comments raised by peer reviewer and address all the typos. Please provide updated information as raised by reviewer.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

Reviewer #6: All comments have been addressed

Reviewer #7: All comments have been addressed

Reviewer #9: All comments have been addressed

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #9: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #9: Yes

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #9: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #6: Yes

Reviewer #7: Yes

Reviewer #9: Yes

**********

Reviewer #1: Thank you for nicely addressing all the comments and suggestions. I have accepted this manuscript for the publication.

Reviewer #2: Authors have addresses my suggestions. The manuscript now has been improved. I do not have further suggestions. Thank you for genereting this evidence that is very important for LMICs.

Reviewer #3: All the comments have been answered in proper and systematic ways. Similarly, the manuscript is technically sound and data are also informative and they address the conclusion. In this manuscript statistical methodology is also properly applied as per the requirements. As all the data are available and clear to understand. Along with these, the authors have prepared manuscript in standard English which is easy to understand by all the readers.

Reviewer #6: The revised version shows a marked improvement over the previous draft, reflecting the author’s thoughtful incorporation of feedback and diligent revisions. The manuscript is now well-structured and substantially refined. I sincerely appreciate the author’s efforts, and I have no further comments at this stage.

Reviewer #7: The authors have well prepared the manuscript and incorporated few suggestions given earlier. There are still few questions which are unanswered.

Abstract: How can you conclude this statement in Line 54-56 (……..worsens financial burden)? I don’t see the same arguments in Conclusion of the study. Please make sure it is not overstated.

Please explain how did you assess the PNC visit within 48 hours. Government has protocol of 24 hours, 3rd day and 7th day. Did you combine 1st and 2nd PNC visits?

Since, there is no provision of maternal incentives providing by all private facilities, is it fair to make a comparison on rise or decline of up taking incentives in private and public facilities?

There has been a revision on providing maternal incentives such as Rs 1000 in Terai, 2000 in Hills and 3000 in mountain. So, it would be nice to state the updated provision too in introduction part Line 146-150.

Some of the results are found repeatedly stated in discussion section. Avoid redundancy. Repetition of same thing may not be interesting to readers. Try to present your findings in a simpler way.

The authors have analyzed determinants of maternal service utilization individually in multiple levels; however, I couldn’t find if the determinants of continuum of maternal care were analyzed. Since the complete uptake was found only 59% so it would be great to know what were the factors associated with it.

In line 621-623, We limited our sample for those women who had at least one live birth one year prior to the survey to reduce the survey. Is it correct?

The conclusion and recommendations are well written. Please check again for typo error.

Reviewer #9: (No Response)

**********

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: No

Reviewer #2: No

Reviewer #3: No

Reviewer #6: No

Reviewer #7: No

Reviewer #9: No

**********

Attachments

Attachment

Submitted filename: review_maternal 2nd.docx