Dear Dr. Gebretsadik,

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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: No

Reviewer #2: N/A

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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: No

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Reviewer #1: The findings section requires a complete overhaul. Most of the tables are not clear. In Table 2, in the narratives, you mentioned 5 themes, but the table contains only 4 themes. In the same vein, you mentioned 29 subthemes, but the table contains 30 subthemes

Reviewer #2: PONE-D-24-41198_Review comments

General comments

There is a need for English editing of the paper to correct the grammatical errors and improve the clarity of the presentation.

Title

Policy Implications of Preconception Care Services: Experiences, Challenges, and Opportunities in Tigray, Northern Ethiopia; an Exploratory Qualitative Study

I suggest removing “policy implications” from the title as the manuscript does not speak to policy clearly. The current title does not align well with the stated aim of the study to explore experiences, challenges and opportunities. I suggest something along these lines “Awareness and uptake of preconception care services in Tigray, Northern Ethiopia – a qualitative exploration of experiences, challenges and opportunities”.

Methods

Study design

1. The sentence “Since 2020, Ethiopia has strategically integrated PCC into its health system, guided by newly developed guidelines (6, 7).” will fit better in the introduction rather than in the study setting. If available data on the service delivery so far can be provided.

2. “With” needs to be deleted in this statement. “These zones include 591,481 women of reproductive age (23.5% of the population) and employ 1,731 healthcare providers, including 350 with Health extension workers (HEWs).”

3. The reference to a war in the statement “However, the war damaged over 80% of health facilities, leading to a 40% decline in maternal and child health services, including institutional deliveries (26).” needs to be clarified better. It may be useful to include a paragraph in the introduction describing the state of health services before and after the war including dates and possible reasons for the unrest. This will enable readers to understand the context better.

Recruitment of participants

1. The statement “We identified participants communicated with HEWs and women development group (WDGs) from HEW registers using purposive sampling, considering their pregnancy and risks.” is unclear; the sentence appears incomplete.

2. How did the authors determine the “intention to become pregnant”? Was there any screening questionnaire? Where were potential participants identified? The health facility or within the community? Who identified the participants in either instance?

3. Similarly, how did the authors identify the women who had a history of adverse pregnancy outcomes?

4. What do ESOGA & EMA mean?

5. What strategies did the research team apply to “bracket” their prior experiences?

Ethics approval and consent to participate

The statement “Before data collection, we attached a one-page consent form to the questionnaire, explaining participants' autonomy” implies that a survey was conducted whereas the study is described as qualitative. Was there a questionnaire survey in addition to the qualitative data collection? The methods need to be clarified appropriately.

Results

1. What is the justification for including teenagers in the study? Table 1 shows that there are two intending mothers between 15 and 19 years old.

2. Figure 1 – conceptual framework: please provide a brief description of the relationships between the concepts in the framework. A legend describing the directions of the different arrows included will also be helpful.

3. The triangulation of results can be improved. Some sections are fairly clear with opposing ideas around the same theme well presented. In other sections the presentation is not well aligned. It will also be useful to compare the opinions of health care providers and the different groups of women on the points raised to make the discussion more robust.

4. In some places the authors have written St Mary and in others St Merry. If this is a reference to the same religious figure the spellings should be aligned.

Discussion

The “SMART Start model” is mentioned in the results and again in the discussion. Is this a model described in the Ethiopian health care system? It would be useful to provide some explanation of the model and proffer possible suggestions on why it was mentioned as a potential strategy for delivery of PCC care in the study.

It would be useful for the authors to proffer possible solutions to the challenges to PCC service provision and uptake identified in the study rather than only restate the issues already highlighted in the results. Some of the themes in the results can be rephrased as strategies and opportunities for PCC services.

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Reviewer #1: Yes:  Winifred Chinyere Ukoha

Reviewer #2: No

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Attachments

Attachment

Submitted filename: REVIEW FOR PONE.docx

Attachment

Submitted filename: PONE-D-24-41198_Review comments.docx

Dear Dr. Gebretsadik,

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 reviewers have noted a number of suggestions from the previous round of revision that have not been sufficiently addressed. Please take care to address them in this current revision, with particular attention to methodological/analyses details.

Please submit your revised manuscript by Jun 06 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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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,

Avanti Dey, PhD

Staff Editor

PLOS ONE

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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: (No Response)

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: N/A

**********

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

The PLOS Data policy

Reviewer #1: No

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1:  The authors should attach the COREQ checklist

The discussion section is a bit too long and can be shortened

What do you mean by "topic guide"? Line 190

Reprase the last subtheme

The authors still did not provide any justifications for some of their findings

Reviewer #2:  The authors have revised the manuscript adequately, however some of the issues raised in the previous review were addressed in the review table but not inserted into the manuscript. The authors need to check that these revisions are made on the manuscript as appropriate.

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Reviewer #1: No

Reviewer #2: No

**********

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Attachments

Attachment

Submitted filename: PONE-D-24-41198_R1_reviewer_With comments.pdf

Dear Dr. Gebretsadik,

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 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 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,

Wen-Jun Tu

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. 

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)

**********

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

Reviewer #1: Yes

**********

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

Reviewer #1: N/A

**********

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

The PLOS Data policy

Reviewer #1: Yes

**********

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

Reviewer #1: Yes

**********

Reviewer #1: Thanks to the authors for improving the paper by implementing the previous comments. Receive the additional comments below, which may assist in strengthening the paper further.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

**********

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Attachments

Attachment

Submitted filename: PONE SECOND REVIEW.pdf

Preconception Care Services in Northern Ethiopia: A Qualitative Exploration of Awareness, Experiences, Challenges, Opportunities, and Prospects

PONE-D-24-41198R3

Dear Dr. Gebretsadik,

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,

Wen-Jun Tu

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: