Dear Dr. Endale,

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 Nov 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'.
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We look forward to receiving your revised manuscript.

Kind regards,

Sabita Tuladhar, PhD, MHealSc, MA

Academic Editor

PLOS ONE

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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

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2. We note that your Data Availability Statement is currently as follows: [All relevant data are within the manuscript and its 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 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 .

4. We are unable to open your Supporting Information file [SBA.DTA]. Please kindly revise as necessary and re-upload.

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:

Reviewer #1:

I want to thank the authors for their valuable contribution and the extensive use of a large dataset in their work. However, the manuscript would benefit from substantial revisions. Specifically, the Introduction, Results, Discussion, and Conclusion sections need to be improved. Additionally, the paper contains multiple editing errors that should be addressed to enhance overall readability and scientific rigor. I have also listed some of the comments as shown below.

Title: The title seems like for the case-control, I recommend a little bit to modify

Abstract: List the abbreviation of SBA when you use in the first line of the sentences (Line 38 & 233) and similar comment throughout the paper. In this section mention the AOR for the factors positively associated with SBA. In the recommendation what are the targeted polices (it is general, but the other recommended ideas are good).

Introduction: Although the authors highlighted several important points in the introduction, they failed to adequately address the issue of maternal death and the SBA, particularly by omitting recent evidence and trends from global to regional (Africa) levels. Also cite the reference for Line 63-64 (for the maternal death in Lesotho).

Methods: Change “methods and Materials” to Method; In the operational definition I recommend changing “Community Poverty Level” to Economic status or other word; the media exposure is also not clear for readers. Change “Data management and analysis” to Data analysis. Change “Ethics approval and consent to participants” to Ethical consideration

Result section: I recommend categorizing into background and reproductive health related characteristics separately with subhead instead of “descriptive characteristics”

Discussion: In the discussion of the magnitude of skilled birth attendant (SBA) utilization, comparisons with both higher and lower prevalence rates reported in other studies should be presented and briefly discussed. These comparisons should include logical justifications for the observed differences relative to the current findings. For instance, in Line 175, only a lower prevalence was mentioned, and the cited reference lacks clarity, making it difficult for readers to interpret the comparison effectively.

The discussion in the factors section is well-articulated; however, there are a few minor points that require attention. Specifically, I recommend the authors include the AOR for each factor discussed to provide clear information to readers. Additionally, the study location should be mentioned for each referenced study. For example, in Line 180, references 28 and 29, the geographical area where each study was conducted should be specified. I recommend Similar revisions for Line 210, Line 212, and other sections where contributing factors are discussed.

Conclusion: “Addressing these challenges through targeted policies and programs is essential. Strategies aimed at improving healthcare accessibility, availability, and financial support should be prioritized to enhance SBA coverage and ultimately improve maternal health outcomes.”

The statement is general; it would be more effective to recommend specific actions based on the findings.

Table 1: The number of participants is 1407 but for the variables Age, marital status, Meidia exposure, health insurance coverage, SBA, community level media exposure is 1406.

Distance to health facility: what do you mean ‘Big problem or No big problem”

What is the difference between media exposure and community level media exposure in this paper?

Reviewer #2:

Thank you for this excellent paper. It has analysed recent data resulting in succinct and readable paper with appropriate conclusions. You have speculated on some of the possible reasons behind the findings. This is important because it is only the answers to those questions of "why did a certain group act in a certain way" that can provide real understanding and lead to necessary interventions. I would have suggested that in the conclusion you might have alluded to a need for more detailed qualitative research to be conducted to further elucidate this point, but this is not a criticism. I rarely find that I can make a recommendation for a paper to be accepted without alteration but in this case I feel this recommendation to accept is well justified.

[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

**********

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

Reviewer #1: Yes

Reviewer #2: 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

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: I want to thank the authors for their valuable contribution and the extensive use of a large dataset in their work. However, the manuscript would benefit from substantial revisions. Specifically, the Introduction, Results, Discussion, and Conclusion sections need to be improved. Additionally, the paper contains multiple editing errors that should be addressed to enhance overall readability and scientific rigor. I have also listed some of the comments as shown below.

Title: The title seems like for the case-control, I recommend a little bit to modify

Abstract: List the abbreviation of SBA when you use in the first line of the sentences (Line 38 & 233) and similar comment throughout the paper. In this section mention the AOR for the factors positively associated with SBA. In the recommendation what are the targeted polices (it is general, but the other recommended ideas are good).

Introduction: Although the authors highlighted several important points in the introduction, they failed to adequately address the issue of maternal death and the SBA, particularly by omitting recent evidence and trends from global to regional (Africa) levels. Also cite the reference for Line 63-64 (for the maternal death in Lesotho).

Methods: Change “methods and Materials” to Method; In the operational definition I recommend changing “Community Poverty Level” to Economic status or other word; the media exposure is also not clear for readers. Change “Data management and analysis” to Data analysis. Change “Ethics approval and consent to participants” to Ethical consideration

Result section: I recommend categorizing into background and reproductive health related characteristics separately with subhead instead of “descriptive characteristics”

Discussion: In the discussion of the magnitude of skilled birth attendant (SBA) utilization, comparisons with both higher and lower prevalence rates reported in other studies should be presented and briefly discussed. These comparisons should include logical justifications for the observed differences relative to the current findings. For instance, in Line 175, only a lower prevalence was mentioned, and the cited reference lacks clarity, making it difficult for readers to interpret the comparison effectively.

The discussion in the factors section is well-articulated; however, there are a few minor points that require attention. Specifically, I recommend the authors include the AOR for each factor discussed to provide clear information to readers. Additionally, the study location should be mentioned for each referenced study. For example, in Line 180, references 28 and 29, the geographical area where each study was conducted should be specified. I recommend Similar revisions for Line 210, Line 212, and other sections where contributing factors are discussed.

Conclusion: “Addressing these challenges through targeted policies and programs is essential. Strategies aimed at improving healthcare accessibility, availability, and financial support should be prioritized to enhance SBA coverage and ultimately improve maternal health outcomes.”

The statement is general; it would be more effective to recommend specific actions based on the findings.

Table 1: The number of participants is 1407 but for the variables Age, marital status, Meidia exposure, health insurance coverage, SBA, community level media exposure is 1406.

Distance to health facility: what do you mean ‘Big problem or No big problem”

What is the difference between media exposure and community level media exposure in this paper?

Reviewer #2: Thank you for this excellent paper. It has analysed recent data resulting in succinct and readable paper with appropriate conclusions. You have speculated on some of the possible reasons behind the findings. This is important because it is only the answers to those questions of "why did a certain group act in a certain way" that can provide real understanding and lead to necessary interventions. I would have suggested that in the conclusion you might have alluded to a need for more detailed qualitative research to be conducted to further elucidate this point, but this is not a criticism. I rarely find that I can make a recommendation for a paper to be accepted without alteration but in this case I feel this recommendation to accept is well justified.

**********

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

**********

[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.

PONE-D-25-34001R1

Determinants of skilled birth attendant delivery among reproductive age women in Lesotho: a multilevel analysis of Demographic and Health Survey Data

PLOS ONE

Dear Dr. Endale,

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.

We have received a few additional comments on your manuscript. We therefore invite you to submit a revised version that addresses the points raised during the review process.

Please submit your revised manuscript by Jan 03 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'.
• 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,

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.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

**********

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

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #3: I Don't Know

Reviewer #4: I Don't Know

**********

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

The PLOS Data policy

Reviewer #3: Yes

Reviewer #4: Yes

**********

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

Reviewer #3: Yes

Reviewer #4: Yes

**********

Reviewer #3: Overall Assessment

The manuscript is well-organized and follows a clear structure; however, several methodological and interpretive issues require further refinement to meet the standards for publication in PLOS ONE. While the topic is relevant and timely, much of the content repeats already well-established findings, and the discussion lacks contextual depth for Lesotho. The clarity, methodological description, and analytical interpretation should be strengthened.

Major Comments

Novelty and Context:

The study does not sufficiently highlight what is new compared to previous evidence. Authors should clearly identify how this analysis adds to the existing body of knowledge on SBA utilization in Lesotho.

Introduction:

The global and country-level maternal mortality figures are inconsistent and somewhat confusing (e.g., 566.2 vs. 529 per 100,000).

Clarify whether these are WHO estimates and ensure consistency between the abstract and introduction.

Define “healthcare professionals” and ensure comparability with the operational definition of SBA.

The rationale should be reframed to justify the study in light of persistently high MMR despite high SBA coverage.

Methods:

Clearly describe why random effect analysis was used and mention it explicitly in the methodology.

Explain the rationale for including specific variables (e.g., community-level indicators).

Ensure consistency in terminology (e.g., “Economic status” vs. “Community poverty level”).

Results:

Present rural–urban differences, as this was not visible in the results despite being an important determinant.

Ensure figures and tables have consistent sample sizes (1407 vs. 1406).

Clarify variable meanings (e.g., “distance to health facility: big problem/no big problem”).

Discussion:

Focus on key findings with policy or programmatic relevance to Lesotho rather than reiterating general determinants.

Some comparative interpretations are contradictory (e.g., Nepal results cited with conflicting conclusions).

The discussion overemphasizes descriptive comparison and lacks deeper explanation of why these associations persist.

Conclusion:

Recommendations are too general. Since SBA coverage is already high, emphasize addressing equity and quality gaps.

Consider aligning conclusions with findings, avoiding overly broad or repetitive policy statements.

Inclusion of a recommendation for future qualitative research is appropriate and should be expanded slightly.

Minor Comments

Ensure consistent abbreviation use.

Improve wording clarity (e.g., “area,” “domain,” “healthcare professionals”).

Check grammar, punctuation, and spacing (comma vs. hyphen use for example in CI in abstract).

Ensure data access and ethics sections meet PLOS ONE requirements precisely.

Reviewer #4: The authors have adequately addressed the comments provided by the previous reviewers. However, the use of abbreviations can be improved, starting from page 1.

**********

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 #3: Yes:  Khim Bahadur Khadka

Reviewer #4: Yes:  Sabita Tuladhar

**********

[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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures 

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Determinants of skilled birth attendant delivery among reproductive age women in Lesotho: a multilevel analysis of demographic and health survey data

PONE-D-25-34001R2

Dear Dr. Endale,

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.

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,

Sabita Tuladhar, PhD, MHealSc, MA

Academic Editor

PLOS One