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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

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

Reviewer #1: Yes

Reviewer #2: 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: No

Reviewer #2: 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

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Reviewer #1: Review Report of the manuscript titled “Coexisting Maternal and Child Undernutrition in Ethiopia: Spatial Modeling and Multilevel Analysis of Consecutive EDHS Data.”

The reviewer appreciates the authors for their efforts in tackling the important and very pertinent public health problem of concurrent undernutrition in Ethiopian mothers and children. Using geographic modeling, multilevel analysis, and many rounds of EDHS data (2000–2016) offers important insights into long-term trends and regional differences. It is praiseworthy that geospatial methods and hierarchical models have been combined, and this has great potential to guide focused actions and policy development. Overall, the paper addresses a significant issue with a big dataset; nonetheless, a number of significant changes are required to improve methodological rigor and clarity. In order to improve the manuscript's representation in front of a global audience and ensure that it complies with PLOS ONE standards, the authors are asked to make the following major as well as minor changes.

1. The abstract (Lines 27–60) is unnecessarily long and includes repetitive background information. It would be much stronger if it were shortened to the essential elements: the main objective, a brief method summary, the key findings, and a final implication sentence.

2. The introduction (Lines 72–122) contains several overlapping explanations about global undernutrition. These paragraphs should be merged and streamlined so that the central research gap in the Ethiopian context becomes clearer.

3. The spatial analysis component (Lines 185–209) needs more methodological depth. The manuscript should include the formulas and proper citations for Moran’s I and Getis–Ord Gi*, and it should also clarify the type of spatial weights matrix used, the variogram model selected for kriging, and the statistical settings applied in SaTScan.

4. The multilevel modelling section (Lines 210–244) would benefit from additional clarity. Introducing the actual model equation, noting whether DHS sampling weights were incorporated, and briefly explaining how multicollinearity and variable selection were handled would strengthen this part.

5. Figure 3 (Lines ~289–294) is of low resolution and appears pixelated. It should be replaced with a minimum 300-dpi version that has clearer boundaries, a visible scale bar, a north arrow, and a more readable legend.

6. Figure 4 (Lines 295–303) also lacks visual sharpness and color clarity. A higher-resolution version with cleaner symbology and clearer regional labels is needed for publication quality.

7. Figure 5 (Lines 305–312), which presents the hotspot analysis, is blurry. It should be regenerated with higher resolution and should include proper cartographic elements like a scale bar, north arrow, and a more legible legend.

8. Figure 6 (Lines 313–320), the kriging interpolation map, appears pixelated and the color gradient is uneven. A smoother, higher-quality rendering with improved symbology would greatly enhance interpretability.

9. Figure 7 (Lines 321–330), showing the SaTScan clusters, is difficult to read because of overlapping cluster circles. This figure should be redrawn with clearer marker sizes, improved separation, and a refined legend.

10. The reported sample size is inconsistent between the Methods (Lines 38–44) and the Results (Lines 44–50). The manuscript should present one consistent figure throughout.

11. The results section (Lines 270–330) is too descriptive in several places. Presenting the findings in a more succinct, quantitative manner would improve readability.

12. The discussion (Lines 364–425) frequently restates the results instead of interpreting them. This section would be stronger if it focused more on explaining the findings, connecting them to previous research, and examining underlying mechanisms.

13. The conclusion (Lines 426–433) could be enhanced by adding a few explicit directions for future work, such as incorporating environmental variables, dietary diversity indicators, or more advanced spatial modelling approaches like GWR or MGWR.

14. Several typographical and referencing issues appear throughout the manuscript (e.g., Lines 92, 185, 572). These include spelling errors, inconsistent EDHS notation, and the use of non-academic sources like Wikipedia, which should be replaced with authoritative references.

15. The operational definition of CMCU (Lines 165–169) needs stronger justification. In particular, using maternal height under 155 cm as a measure of undernutrition should be supported with literature, and a sensitivity analysis would be advisable since height reflects long-term rather than current nutritional status.

16. Although the dataset spans from 2000 to 2016, temporal patterns are not adequately explored. Including a brief trend analysis or highlighting shifts across survey years would strengthen the interpretation.

17. The manuscript should acknowledge the effect of DHS geographic displacement on spatial accuracy, especially regarding Moran’s I, Gi*, SaTScan, and kriging. This is an important methodological limitation that should be mentioned.

18. The discussion would benefit from incorporating environmental and agro-ecological context. Interpretation of spatial clusters should consider factors such as drought frequency, agricultural productivity, and dominant livelihood systems in each region.

Reviewer #2: This manuscript presents a robust and much-needed analysis of the Coexisting Maternal and Child Undernutrition (CMCU) in Ethiopia using consecutive Demographic and Health Survey (EDHS) data spanning 2000–2016. The study addresses a critical public health challenge, employing advanced analytical techniques.

Study Design and Data: The use of large, nationally representative, and consecutive EDHS data (with a weighted sample of 33,445 mother-child pairs) is a major strength. The cross-sectional design is appropriate for assessing prevalence and associated factors.

Statistical Methods: The analytical approach is appropriate and rigorous. The authors correctly employed multilevel binary logistic regression to account for the hierarchical nature of the EDHS data (individuals nested within Enumeration Areas/clusters), which is essential to produce valid standard errors and risk estimates. The inclusion of standard measures like the Intra-class Correlation Coefficient (ICC), Median Odds Ratio (MOR), and Proportional Change in Variance (PCV) demonstrates a thorough and rigorous approach to model construction and fit assessment.

Spatial Analysis: The range of spatial methods employed (Global Moran’s I, Getis-Ord Gi hot spot analysis, ordinary kriging, and SaTScan) is comprehensive and correctly used to identify geographical clustering and high-risk areas. The finding that CMCU is spatially concentrated in the northern regions (Tigray, Amhara, and parts of Benishangul-Gumuz) is a key finding for targeted intervention.

Conclusions: The conclusions logically follow from the results, identifying maternal education, household wealth, child’s age, antenatal care utilization, improved toilet facilities, and region as significant factors associated with CMCU.

Data Availability Statement

Please make all data available

The authors state, "No—some restrictions will apply," and specify that the data is publicly available through the DHS Program but requires registration and approval.

Recommendation: While the data is publicly accessible via a third-party repository, the need for registration and approval constitutes a technical restriction. Please ensure the manuscript's Data Availability Statement clearly and explicitly states that the data is owned by the DHS Program and is accessible upon request and approval as outlined to fully comply with transparency requirements.

Presentation and Writing Quality

The manuscript is well-structured and intelligible, making the scientific content easy to follow.

Minor issues: I recommend a thorough copyedit to correct minor typographical and grammatical errors. For instance, check for spelling of technical terms (e.g., ensure "Spatial authocorilation" is corrected to "Spatial autocorrelation") and refine a few instances of phrasing for maximum clarity (e.g., in the abstract/objective: "consecutive data the EDHS 2000-2016" )

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Reviewer #1: Yes: Dr. Arghadeep Bose

Reviewer #2: No

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Attachments

Attachment

Submitted filename: review report.docx

Coexisting Maternal and Child Undernutrition in Ethiopia: Spatial Modeling and Multilevel Analysis of Consecutive EDHS Data.

PONE-D-25-40555R1

Dear Dr. Aweke,

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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Staff Editor

PLOS One

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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

Reviewer #1: Yes

Reviewer #2: (No Response)

**********

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

Reviewer #1: Yes

Reviewer #2: (No Response)

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

The PLOS Data policy

Reviewer #1: No

Reviewer #2: (No Response)

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

Reviewer #1: Yes

Reviewer #2: (No Response)

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Reviewer #1: I appreciate the authors' comprehensive and thoughtful responses to all comments made during the review process. The edits significantly improved the manuscript's clarity, methodological rigor, analytical depth, and presentation quality. The abstract and introduction are now shorter and more focused, the spatial and multilevel modelling approaches are clearly justified and openly provided, and the findings and discussion sections are more interpretative and founded in current literature and contextual aspects.

The authors have also appropriately addressed concerns about figure quality, sample size consistency, operational definitions, temporal trends, and methodological restrictions, such as DHS regional displacement. Overall, the work now passes publishing requirements and adds significant value to the literature on mother and child undernutrition from a spatial and multilayered perspective.

I am pleased with the improvements and suggest the manuscript for publication.

Reviewer #2: (No Response)

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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

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