Dear Dr. Adewuyi

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Additional Editor Comments :

Introduction

This section could benefit with some critical appraisal

e.g Line 86-87; you mentioned the MSS and conditional cash transfers; however MSS was not sustained and conditional cash transfer was not widespread; provide a critical analysis of this and its probable contribution to differential outcomes across states/regions

line 97- home birth in Nigeria and LMICs; home birth in Nigeria is currently mostly TBA provided or unsupervised ‘SBA’, this is the core of your paper, hence will be useful to note this, and explore the whys of the contributions of these two ‘providers’ to poor maternal outcomes, including briefly touching why women will opt for a home birth based on past literature ( be careful when doing this in not giving too much away) as this is the focus of your research

line 161 –it will be useful to provide specific maternal health initiative that align with global health rather than just saying ‘some initiatives…

Discussion

You mentioned using the theoretical frameworks Andersen’s Behavioural Model of Healthcare- this has not been integrated or applied explicitly in your discussion; will be beneficial to do this and not just limit to using it in identifying your explanatory variable. Consider how you can apply this to strengthen your discussion

line 375-376- decline mentioned is from which data, kindly indicate what, and/or is it the previous DHS and why might this decrease have happened?

Lines 380-382; similar to line 97-99 your introduction- possible repetition?

Line 384-385, explore further why urban residence alone does not guarantee for that region

Line 389- what constrained options? This is too vague, kindly provide details/examples

Line 396- you wrote “This premise also supports the urgent need for a social justice approach—one that goes beyond individual-level interventions to confront systemic barriers.”

Elaborate on what you mean by social justice approach in the context of your study

Lines 436-439; you wrote “birth among women in the middle wealth category in urban settings only, possibly reflect the reality of urban poverty, where families live in informal settlements or slums, underserved by health infrastructure, or the erosion of the middle class in urban Nigeria”

This is too long, kindly split and rephrase to improve clarity

Lines 464-467- some critical analysis required in your suggestion on digital inclusion and integration of internet access into maternal health; will this not widen the existing health inequality, considering digital inclusion means access to smart phones- in the current climate of lack of basic infrastructure including electricity, poor internet connectivity, high cost of internet services; is this feasible across all states and all regions?

Kindly note it is not just about suggesting policy that promote digital inclusion, what about the enabling factors to allow for the implementation of the policy, provide a crtiical discourse on this point

Line 475-477 you wrote “The markedly higher odds of home birth in the rural North-West and South-South may also exemplify how rurality and regional deprivation intersect to perpetuate maternal health disparities”.

Kindly expand on what you mean – noting the keen differences in North and South of Nigeria

Policy and programmatic implications

The way you have listed them all out in this section, your implications all appear like the typical suggestions. Going forward in rewriting this section; a critical consideration of feasibility will be beneficial in presenting this. Also, it is good for you to focus on innovative means (cost effective, community driven initiatives) that could be employed:

Consider the MSS that was started and abandoned due to number of reasons, including lack of collaboration from all partners. How can MSS be revamped and resuscitated? How do we address the user fee issue that limits access? What innovative community driven financial scheme can be used by women to address the use of user fee?

In considering the systemic/structural issues, what can you learn from the Abiye programme in Ondo state, why did it succeed and why has it gone down? What take home point can you use from this in addressing the systemic/structural issues

Still in line with above, controlling all other factors (like culture, ethnicity, or religion), the bottom line to the poor maternal outcome is the absence of good maternal health care system(systemic/strucutral factors) that meets the requirement of UHC (hence the need to look at the Abiye as mentioned above) what lessons can we learn and apply

Finally, since you used the social justice lens, kindly organise this section along that line so it does not appear like a ‘textbook prescription’,

Minor corrections

Proofread and review for typo errors. E.g check your acknowledgement line 562, what is figs?

Kindly refrain from the use of dash (-) in academic writing it sets an informal tone, and it is associated with AI generated work

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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: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: 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

Reviewer #3: Yes

Reviewer #4: No

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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

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Reviewer #1: 1. Since you are using the Andersen model, kindly provide a brief description of the healthcare facility distribution in Nigeria (e.g., availability across states).

2. Line 185: Ethical approval was granted by the Nigerian National Health Research Ethics Committee, could you provide the ethical approval reference number from the Nigerian National Health Research Ethics Committee for this study?

3. Table 1, the wording used for the enabling factors included was quite informal:

"Distance to health facility (big problem/not a big problem)"

"Permission to visit health facility (big problem/not a big problem)"

"Getting money for health services (big problem/not a big problem)".

Suggested revisions:

Difficulty due to distance (Yes/No)

Decision-making autonomy (Independent/Requires permission)

Affordability issue (Yes/No)

4. Table 2: Would you consider rearranging the order of the variables based on domain in Andersen model (to be similar to the order in Table 1)?

5. Table 2: Please consider adding a p-value column for clarity.

6. Line 454: Higher-parity women have higher odds of home birth; Line 502, Younger women have higher odds of home birth. However, younger women usually have lower parity, while higher-parity mothers are older. Could you reconcile or further explain these findings?

7. Line 500: You noted higher odds of home births among Muslim mothers. Could you provide supporting evidence on Muslim perspectives toward maternal health services in Nigeria, since you suggest culturally sensitive services?

Reviewer #2: as far as i searched the study is original research and not published else where.

starting from the research topic it is impactful and pertinent issue but I have doubt on its novelty. since it was done before based on 2013 Nigeria demographic and health survey , it needs pertinent justification.

even if conclusion lacks some reference data but recommendations were stated based on the finding data

better to select pertinent keywords in the abstract part

introduction part is well written but significant impact of home birth not mentioned briefly

add reference at the end of 1st paragraph of introduction part line number 87-89

in Methods part how informed consent was applicable from secondary data? how do you get the participant? line number 185-187)

operational definition should included in the method part to clarify some variables like rich house hold and poor house hold

discussion part is well written and appreciated

Reviewer #3: General remarks about the manuscript

This manuscript tackles a crucial public health issue—the ongoing challenge of home births in Nigeria and the disparities that exist between rural and urban regions. Utilizing a substantial, national dataset to examine these variations is a notable strength of the study. The emphasis on identifying related factors is particularly pertinent for shaping public health policies and interventions. The manuscript is well-articulated, and the research question is clearly defined. My following observations are aimed at enhancing the paper and preparing it for publication.

Specific comments

1. In result part of your abstract add confidence interval and p- value for all prevalence value or remove all, it is better to be similar. And also better to add p- Value and CI for the AOR value of significant variables and home birth.

2. Maternal morbidity and mortality, which are the results of home delivery, are discussed in the first paragraph of your introduction. But your first paragraph of introduction part is better to deal about home birth and the consequence of it in globally. Therefore, it is preferable to eliminate the first paragraph or reorganize the introduction's sequence.

3. In your methodology part, the total 41,821 mothers were surveyed, but you take only 21,512 mothers why? Or how can you select those sampled mothers?

4. In your analysis section, you assess the multicollinearity assumption, which is good, but what about other other logistic regression assumptions like outlier detection, the Hosmer and Lemeshow test, and the independence of observations?

5. In you discussion part, the manuscript title highlights a comparative analysis between rural and urban settings. The discussion should not only present these differences but also delve into the potential underlying reasons for them. For instance, are the rural-urban disparities due to differences in healthcare infrastructure, socioeconomic status, cultural beliefs, or a combination of these factors? A deeper interpretation would significantly strengthen the findings.

6. Ensure consistent use of terminology throughout the manuscript. For example, "home birth" and "childbirth outside health facilities" appear to be used interchangeably. A single, clear definition at the beginning of the manuscript would be beneficial.

Reviewer #4: Thank you for the opportunity to review this excellent and important paper. Overall, I think it is well done. I do have some concerns that this paper was published with data from Nigeria without any authors who have an affiliation in Nigeria. I understand that maybe there are connections to Nigeria that I am not aware of but would like it to be addressed and explicitly stated if there is. If not, I would like to see this addressed in the limitations or potentially adding a reflexivity statement https://gh.bmj.com/content/9/1/e014743.

Line 81-specify "maternal and neonatal" mortality rates

Line 85-it is not just extremely high but the highest of any country in the world, I think this should be added.

Line 88-Nonetheless, maternal and neonatal mortality remain unacceptably high in Nigeria, with the continued prevalence of home births emerging as a likely key contributing factor. -this should be referenced.

line 99-lack of skilled birth attendants is also a significant factor here based on data and should be specifically called out.

line 101- Hence, ensuring facility-based births with access to emergency care remains essential to reducing

these deaths. you should add and access to skilled birth attendants here

I really love this dual approach -This dual lens shifts the focus beyond individual behaviours to systemic

137 constraints in maternal healthcare access.

the methods are sound and well done

Line 391-also women not be empowered also likely plays a role here and should be called out here as well as later when you discuss it more

I would also add a line in the conclusions tying back in the maternal and newborn mortality to remind the readers why it is important to address home births.

Very nice job with this paper

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Reviewer #1: No

Reviewer #2: Yes:  Lubaba Ahmed Mohammed

Reviewer #3: No

Reviewer #4: No

**********

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Dear Dr. Adewuyi,

Thank you for revising and resubmitting 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. And there are few minor revisions required to achieve this standard. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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

ACADEMIC EDITOR: 

Address the following

1. Repetition observed in lines 91-94 and 193-194

"91 In response to this ongoing challenge, the Nigerian government has introduced several initiatives

92 aimed at increasing access to skilled care and improving maternal and newborn outcomes. These

93 initiatives include the Midwives Service Scheme (MSS), conditional cash transfers (CCTs), and the Basic

94 Health Care Provision Fund (BHCPF) [15-22]".

"193 To improve maternal and neonatal health and align with global health goals, the Nigerian government

194 has implemented initiatives such as the MSS, CCTs and BHCPF [15-18, 20-22]."

Consider  merging this last paragraph under Study Setting with the paragraph above it and reframing lines 193-194 to read something like this:

"Despite the Nigerian government’s efforts to improve maternal and neonatal health in line with global health goals, through initiatives such as the MSS, CCTs, and BHCPF mentioned earlier; poor maternal and neonatal health outcomes continue to persist"

2. Sentence in line 235-236 should be in past tense, amend accordingly

235 We adopt Andersen’s Behavioural Model as the conceptual framework and utilise the model in

236 selecting explanatory variables

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.

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We look forward to receiving your revised manuscript.

Kind regards,

Hannah Mafo Degge, Ph.D

Academic Editor

PLOS ONE

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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. 

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Editor's comments

SEE ABOVE

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Home birth and associated factors in Nigeria: a comparative study of rural and urban settings—analysis of national population-based data

PONE-D-25-25157R2

Dear Dr. Adewuyi,

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Kind regards,

Hannah Mafo Degge, Ph.D

Academic Editor

PLOS ONE