-->PONE-D-25-43421-->-->Evaluating the effectiveness of preservice midwifery curricula in Ethiopia: A comparison of neonatal resuscitation and infection prevention practice of midwifery graduates trained in competency-based versus conventional curricula-->-->PLOS ONE

Dear Dr.  Wondie,

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Academic Editor

PLOS ONE

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3. In the ethics statement in the Methods, you have specified that verbal consent was obtained. Please provide additional details regarding how this consent was documented and witnessed, and state whether this was approved by the IRB

4. Thank you for stating the following in the Competing Interests section:

“Conflict of interest

Awoke Giletew Wondie and Tegbar Yigzaw Sendekie designed and implemented the competency-based curriculum at Debre Tabor University. However, these authors had no part in the collection or scoring of data.  The assessment was conducted by trained independent midwife observers blinded to the graduates' curriculum background being evaluated.”

We note that one or more of the authors are employed by a commercial company: name of commercial company.

1. Please provide an amended Funding Statement declaring this commercial affiliation, as well as a statement regarding the Role of Funders in your study. If the funding organization did not play a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and only provided financial support in the form of authors' salaries and/or research materials, please review your statements relating to the author contributions, and ensure you have specifically and accurately indicated the role(s) that these authors had in your study. You can update author roles in the Author Contributions section of the online submission form.

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-->Comments to the Author

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

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Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: This manuscript presents a well-designed study comparing midwifery curricula in Ethiopia, addressing a critical gap in medical education literature for low- and middle-income countries. The findings are compelling and have significant implications for public health and curriculum design. The manuscript is well-written and methodologically sound, providing strong evidence that competency-based curricula improve neonatal care skills. While highlighting persistent skill gaps in both graduate groups, the study is a valuable contribution.

Major Strengths

1. High-Impact Research: The study addresses the crucial issue of how-to best train healthcare providers to improve maternal and neonatal outcomes, providing concrete evidence to support a global shift toward competency-based medical education.

2. Robust Methodology: The study's rigor is enhanced by its comparative design, formal power analysis, use of validated tools, blinding of data collectors, and employment of two independent observers.

3. Strong Data Analysis: Statistical analysis is appropriate and strengthened by the inclusion of Gardner-Altman plots for modern visualization of the effect size.

Areas for Improvement

1. Clarity & Focus: The thesis should be reframed as a debatable argument about the curriculum's effectiveness.

2. Structure & Detail: Improve transitions by more explicitly linking the introduction's critique of theory-based education to the competency-based curriculum. The Methods section needs more detail on evaluation criteria and observer training to improve replicability. The section on infection prevention should be expanded to discuss key practices like hand hygiene and sterile technique.

3. Discussion & Context: The discussion should further analyze why skill deficiencies persist in both groups. It should also acknowledge the limitations of using simulation for assessment and consider how post-graduation work environments might influence graduate performance.

Minor Points & Corrections

• Fix the mismatch between figure captions in the text and the actual figures.

• Consolidate the redundant paragraphs in the "Suggestions" section.

Reviewer #2: This manuscript addresses an important and under-researched area: the assessment of midwifery competencies in Ethiopia, benchmarked against the International Confederation of Midwives (ICM) Essential Competencies. Given Ethiopia’s continuing maternal and neonatal health burden and the global push to strengthen human resources for health, this study is timely and policy-relevant. The use of an international competency framework is a major strength, and the findings could inform reforms in pre-service education, continuing professional development, and regulation of the midwifery profession.

However, the manuscript requires significant revision before it can be considered for publication. The most critical issues relate to methodological clarity, statistical transparency, and the explicit linkage between findings and policy/practice. Without addressing these areas, the paper’s impact and credibility are limited.

1.Technical soundness:

The manuscript is based on empirical data collection and analysis, and in general, the conclusions are aligned with the findings. The description of midwifery competencies and the assessment framework corresponds with international standards. However, the linkage between data and conclusions needs to be strengthened by clarifying how competency gaps were identified (e.g., objective testing, self-assessment, observation, or supervisor reports), providing justification for sample size and its representativeness across Ethiopia’s diverse regions, and indicating whether clinical skills testing (e.g., OSCE) was used or if the assessment was limited to theoretical knowledge.

2. Statistical analysis: The manuscript uses descriptive and inferential statistics, but the methodology is not fully transparent. For examples: Page 7, lines 14–30; Page 9, lines 1–20 – statistical outputs are presented without clear explanation of assumptions, significance tests, or confidence intervals.

Suggestions:

- Specify the statistical methods, including rationale for choice of tests, assumptions checked, and the software used.

- Report measures of reliability (e.g., Cronbach’s alpha for internal consistency).

- Without these details, it is difficult to assess the rigor of the analysis.

3. Language/Clarity: The manuscript is written in standard academic English, but the readability could be improved with editing. For examples:

- Page 4, line 12: “which was highly important to consider” → revise to “which was essential to consider.”

- Page 8, line 22: “respondents were asked competencies” → revise to “respondents were asked about competencies.”

A professional language revision is recommended to improve flow, grammar, and clarity.

Major Comments

1. Methodology Clarity (Page 5, lines 1–25): The manuscript does not specify the exact data collection tools. Were competencies assessed via self-report questionnaires, supervisor/peer evaluations, or OSCEs. The validity and reliability of the tool must be explicitly stated. Without this, the robustness of the findings is unclear.

2. Sampling and Representation (Page 6, lines 12–28): The sample size justification is weak. Please provide power calculation (if available), or at least, and rationale for the selected sample size. Ethiopia is geographically and demographically diverse. Please explain whether certain regions were underrepresented, and if so, discuss the potential impact on the findings.

3. Linking Results to Policy and Practice (Page 11, lines 10–30): The manuscript claims that findings will inform national policy but does not describe the mechanisms for this. Suggestions: Explain how results could feed into curriculum reform, continuing professional development, or accreditation of midwifery programs, and provide specific recommendations for policymakers and professional associations.

4. Statistical Transparency (Page 7–9): Tables and figures present data, but the analytical methods are not clearly reported. Clarify which tests (e.g., chi-square, t-tests, regression) were applied. Indicate levels of statistical significance (p-values) and confidence intervals.

5. Ethical Considerations (Page 4, lines 25–30): Ethical approval is mentioned, but informed consent procedures are not adequately explained. Authors should clarify how consent was obtained (oral/written), ensure anonymity/confidentiality, and confirm that participation was voluntary.

Minor Comments

Formatting: Ensure tables/figures have complete captions. For example: Table 2 (Page 8) lacks sufficient explanation of abbreviations and context.

References: Several references are outdated (pre-2010). Please incorporate recent literature on midwifery education and competencies, particularly from Ethiopia and sub-Saharan Africa (e.g., WHO 2021 State of the World’s Midwifery).

Grammar/Style: Numerous sentences could be shortened for clarity. Example: Page 3, line 22 – “The framework is very comprehensive and globally used by many institutions” → “The framework is comprehensive and widely adopted globally.”

Terminology Consistency: The term “competency gap” is sometimes used interchangeably with “knowledge gap.” Clarify the distinction.

Ethical and Publication Concerns: No evidence of dual publication or plagiarism was identified.

Ethical approval is reported, but more detail on informed consent is required for compliance with international research ethics standards.

Recommendation:

The manuscript has strong potential to contribute to global knowledge on midwifery workforce development, particularly in low-resource settings. However, substantial revisions are necessary to clarify and strengthen methodology, justify sampling and representation, provide transparent statistical reporting, strengthen the link between findings and actionable policy implications, and revise language for clarity and flow.

If these revisions are addressed, the manuscript could make a meaningful and publishable contribution to maternal and newborn health systems research.

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Reviewer #1: Yes: Khim Bahadur Khadka

Reviewer #2: Yes: Dr. Laxmi Tamang

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-->PONE-D-25-43421R1-->-->Evaluating the effectiveness of preservice midwifery curricula in Ethiopia: A comparison of neonatal resuscitation and infection prevention practice of midwifery graduates trained in competency-based versus conventional curricula-->-->PLOS ONE

Dear Dr. Wondie,

Thank you for submitting your manuscript to PLOS ONE. -->--> -->-->Please submit your revised manuscript by Jan 02 2026 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.

Please include the following items when submitting your revised manuscript:-->

• 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'.
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• 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,

Sabita Tuladhar, PhD, MHealSc, MA

Academic Editor

PLOS ONE

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1. 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.

2. 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:

Please find a few additional minor comments from the reviewer. Kindly review and respond to them.

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Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.-->

Reviewer #1: 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?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #3: Yes

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #3: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #1: Yes

Reviewer #3: Yes

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-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: Based on a thorough review of the revisions for manuscript, the authors have comprehensively and satisfactorily addressed all points/feedbacks. The revisions demonstrate a high degree of scholarly diligence and have resulted in a fundamental improvement of the manuscript.

Key enhancements include:

Conceptual Reframing: The study has been successfully elevated from a descriptive analysis to a rigorous, hypothesis-driven piece of scientific research with a clear and debatable thesis.

Methodological Transparency: The manuscript now features increased detail on the study's methodology, enhancing its clarity and replicability.

Contextual Depth: The discussion has been significantly strengthened with a more nuanced analysis of the findings, including persistent skill gaps and the influence of the post-graduation work environment.

The collective impact of these changes is a manuscript with a sharpened argumentative focus that represents a more significant and durable contribution to the field of midwifery education. The work now meets a high standard of scientific communication.

Reviewer #3: This is an important study for LMIC's in light of reports of poor maternal-child health outcomes, and SDG 3, especially the role of midwives. Thank you for your initiative. I am recommending that the manuscript be accepted after these minor but important corrections have been addressed.

I just have a few suggestions related to ethics, and grammar, respectively: Researchers had ample opportunity to request a written consent from midwives during the planning phase unless this was meant to be a surprise assignment. Midwives could have been asked to put in writing their willingness to participate in the study rather than being told by their administrators, who signed a consent allowing researchers to conduct the study. My understanding is that it was the midwives who were being observed so their written consent could have been obtained in advance for that study period. For the women in labor, illiteracy is not a sufficient reason for there being no written consent. They could have been asked to place a check mark ("my mark") on the signature line after the "informed consent" had been read to them. Understandably, seeking care at a facility could be interpreted as implied consent however, research is not routine care, and all attempts ought to be made for objectivity and accountability.

Grammar: 1) Abstract line 25... add "can" reduce ...

2) line 57-58 sequence of actions for preventing infection: it reads better if "early detection of maternal infection" e.g. in the prenatal period, comes before "...using sterile techniques..."

3) line 101 "data [were] collected" as was done later in the report.

4) line 111 statistics- include confidence interval 95% after ..." 80% power" as was mentioned in the data analysis section of the report.

5) line 136 remove /" ... not performed/correctly"

6) line 151 suggest writing IBM Statistical Package for the Social Services (SPSS) this being the first time it comes up in the report.

7) Results- consistency in usage of verb/tense e.g. "Dry", "Assess", "Check"

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Reviewer #1: Yes: Khim Bahadur Khadka

Reviewer #3: Yes: Eunice Dube DSc, MPH, RN, BA(Cur), Trained Midwife/Health Visitor

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Evaluating the effectiveness of preservice midwifery curricula in Ethiopia: A comparison of neonatal resuscitation and infection prevention practice of midwifery graduates trained in competency-based versus conventional curricula

PONE-D-25-43421R2

Dear Dr. Wondie,

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):

Thank you for addressing reviewer's comments promptly and satisfactorily.

Reviewers' comments: