Dear Mr. Endalew,

Please submit your revised manuscript by Mar 30 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.. 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.. 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.. 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,

Agegnehu Bante

Academic Editor

PLOS ONE

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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: No

Reviewer #2: Yes

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

Reviewer #1: No

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 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.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 #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: Yes

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Reviewer #1: 1. A revision of Abstract is mandatory, because of too much words and irrelevant result.

2. since revisionof result is needed, it is too difficult to conclude based on the above findings.

3. revision of background section is also seems mandatory because, most of the introduction section deems methods section

4. who were included and excluded in this study?

5. some operational difinitions need clarification

6. If the study was retrospective, would the authors revise the title and study design stated above???

7. How did yous assessed independent variables from a chart recorded, for instance distance from health facilities??

8. I advise to revise the entire document, especially result and discussion section again.

Reviewer #2: Line 83 "one third of one million" is a very unorthodox means of expressing a number. Please convert to the correct numbber

In table 2 it is not clear whether the complications refer to a previous or the current pregnancy. Pleaee make this clear.

To the reader when you discuss and present results concerning effective coverage it is confusing because for the various interventions, not all are recommended to be done at each visit. For example, ultrasound is recommended but nornmally only to be done once, whereas blood pressure ought to be meansured at each encounter. I think you need to include a clear description of the various essential interventions together with a description as to how many times it is recommended each are done throughout a pregnancy.

This could then be incorporated into Table 4 for greater clarity

The limitations section is incomplete and stops mid-sentence (lines 202-203) There are several more limitations that should be mentioned.

The discussion should be expanded to include some consideration as to the limitations of so called "effective care". Fully effective care includes not simply taking measurements but also acting upon them if the results give cause. For example, taking a blood pressure measurement is not effective unless there is evidence that high blood pressure receives appropriate attention and subsequent action to treat the problem.Whilst you might not have enough data available to measure this it is still a very important point to discuss and I would like you to do so.

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Reviewer #1: No

Reviewer #2: No

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Dear Dr. Endalew,

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 Sep 11 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.. 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.. 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.. 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 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 . 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 . 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 . 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,

Agegnehu Bante

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.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #3: (No Response)

Reviewer #4: (No Response)

Reviewer #5: (No Response)

Reviewer #6: (No Response)

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

Reviewer #3: Partly

Reviewer #4: Yes

Reviewer #5: Partly

Reviewer #6: No

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

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: No

Reviewer #6: No

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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.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 #3: Yes

Reviewer #4: Yes

Reviewer #5: No

Reviewer #6: Yes

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

Reviewer #3: No

Reviewer #4: No

Reviewer #5: Yes

Reviewer #6: No

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Reviewer #3: Manuscript title:

Effective Coverage and Associated Factors of Antenatal Care Service among Women Who Attended Antenatal Care at West Gojjam Zone Public Hospitals, Northwest Ethiopia

Competing interests: I have no competing interest.

This manuscript addresses a critically important topic: the effective coverage of antenatal care (ANC) services in a specific region of Ethiopia. The study's focus on "effective coverage," which integrates need, utilization, and quality, is a valuable approach. The findings highlight a concerningly low effective coverage rate and identify several associated factors. While the topic is highly relevant and the study design is appropriate for its stated aim, the manuscript has some methodological and reporting clarity issues that need to be addressed before publication.

The document exhibits several writing issues that should be addressed. A thorough proofread by a native English speaker or a professional editing service would be highly beneficial. Focus specifically on:

• Correcting all "data was" to "data were."

• Ensuring all percentages in the "Results" section have clearly defined and correct denominators.

• Reviewing interpretations in the "Discussion" for logical consistency with the findings.

• Improving transitions between sentences and paragraphs.

• Adding the crucial missing limitations (selection bias from population definition, short study period).

• Refining precision in word choice and sentence structure throughout.

Please find the attached file for my point by point comments .

Reviewer #4: Abstract: There are a few points that would help sharpen the focus of the abstract. For example, in the phrasing “due to ineffective coverage of antenatal care service and other reason” (line 17), “other reasons” should be specified (e.g., poor health infrastructure, socioeconomic barriers) or removed to sharpen the focus. The phase (line 19) “Despite, there is limited information on effective coverage of Antenatal care in Ethiopia” is grammatically incorrect and should be revised (such as, “However, there is limited evidence on the effective coverage of antenatal care in Ethiopia”). The abstract would also benefit from an overall grammatical and stylistic editing, such as inconsistent capitalization (antenatal and Antenatal – line 18 versus line 20) t improve the overall clarity.

Introduction: The introduction addresses the critical health issue of maternal mortality and introduces “effective coverage” as a key health system performance metric that integrates the concepts of need, utilization, and quality. This is a highly relevant concept, particularly in the context of maternal and antenatal care (ANC) in low-resource settings. It is also important to see continued work in better measurement of quality-related concepts versus numbers-only indicators to truly measure progress.

In general, it may help to strengthen the introduction to reverse the current order of ideas so that the argument cascades logically from the global to specific. The narrative currently starts at the micro-level by explaining ANC’s benefits, and then shifts abruptly to global inequities with the EC framework concepts interspersed. The ideas are already there, but a more logical sequence of the global-to-specific would provide a more logical sequence would build a stronger case for the reader. It will also help readers more readily understand the study’s rationale and the added value of examining effective coverage specifically in the Ethiopian context.

For example, you could consider opening with the striking global statistics on maternal mortality, highlighting women in low- and middle-income settings face a higher burden than those in high-income settings (lines 81-85). Then moving to the more specific situation in the Ethiopian setting which provides the context for this study (lines 85-90). This can help establish up front the scale and urgency of the problem. From there, narrowing to the focus on ANC as one of the most important evidence-based interventions for detecting and averting life threatening maternal conditions. This shows readers why ANC quality matters in solving this global challenge (lines 48-57; lines 91-97). Once this context has been established, then you could introduce the concept of effective coverage as the lens through which the study investigates not merely if women attended ANC and enough sessions of ANC, but whether or not they received the quality of services needed (starting with line 58 and remaining sections not cited above).

There are also some points where some adjustments to phrasing would be helpful to more clearly convey the concepts. For example, introducing the concept of effective coverage (line 54), while it is conceptually strong, would benefit from clearer phrasing, such as “Effective coverage is a composite indicator of health system performance…” or perhaps other phrasing that would more clearly express this concept and the intended meaning. Related, there are some circular sentence structures. For example, “use refers to the use of services” (line 58) which offers no additional meaning as is.

There are also some confusing or differing definitions. For example, quality is first defined as “the actual health benefit experienced from the service” (lines 58-59), but later operationalized in terms of receiving the recommended content (lines 62-64). Clarifying this conceptual leap would help improve the flow and strengthen the case you are building.

The formula (lines 69-70) is a bit hard to read that just appears to be a formatting issue. Ensuring the equation is formatted more clearly would be helpful to improve comprehension.

Another point where the phrasing could be improve is the study objective (lines 101-103). While the objective is clearly stated and aligns well with the background, the wording could be more concise and grammatically polished, such as “The study aimed to assess he effective coverage of antenatal care and identify associated factors among women attending ANC at public hospitals in West Gojjam Zone, North west Ethiopia.”

It would also strengthen your argument to provide some more evidence of the situation in Ethiopia around lines 87-90 – such as regional disparities, policy interest in quality improvement, and existing studies (or lack thereof the highlight an important knowledge gap that your study helps to address).It would also help strengthen how this study addresses a knowledge gap by providing some examples of prior studies that focused on crude coverage or perception rather than EC and that none examined the specific zone of the study in order to justify the study’s objective more convincingly.

There are some areas where citations are needed, such as the maternal death statistics provided in lines 67-70. There are also some grammatical and stylistic errors that detract from the content. Line 73-76 has a run-on sentence that could be adjusted to two sentences: One possible reason for the persistently high maternal mortality rate could be the poor quality of care, which is not reflected in crude coverage measures. Additionally, the poor uptake of essential interventions during routine ANC visits may have contributed to the stagnant or slow rate of reduction in maternal mortality.

In summary, the content is relevant and valuable but needs improved logical flow, clearer definitions, accurate equation formatting, and some careful language editing to convey the message more effectively.

Methods: The methods section provides a clear overview and includes all the required elements of the study design, setting, and sampling approach. However, several issues reduce the clarity and rigor that can be addressed. Tightening the language, clarifying the sampling procedure, and improving the structure for readability and methodological transparency would benefit this section. Also, please check the size and font of the headings. It seems that everything up through sample size is other “Methods” heading and the remaining (data management, data quality, etc.) under the “Measurement and Variables” heading. It is a bit confusing if this was what was intended.

Study design and setting – The setting is well described but is overall detailed regarding geographic distances and hospital names. This could be condensed for focus and readability.

Population – The phrases “the study population of this study” are redundant (lines 124 and 126). It is also unclear whether “women who completed ANC follow-up” (line 127) means they had all four recommended visits (line 125) that is cited before or a different criterion.

Sample size determination and sampling procedures – The sample size calculation is methodologically sound but presented with inconsistent formatting and minor typographical errors (such as line 122 “1.5 design effect” lacks spacing). Consider rephrasing the formula and description of what was used to enhance clarity – perhaps start with the formula that was used, justifying a single population proportion formula, and then the assumptions used for the calculation.

The multi-stage random sampling approach is appropriate but the description could be clarified. For example, the phrase “multi-stage simple random sampling” (line 138) is confusing as multi-stage sample and simple random sampling are typically distinct. A more precise explanation of each stage would help. It would also be helpful to note how confidentiality and randomness were ensured with the use of the medical registration numbers (lines 140-142).

Measurement and variables – While this section presents the outcome and explanatory variables clearly in general terms, it would also benefit from further clarity, organization, and precision.

The initial sentence outlining the outcome variable (effective coverage of ANC) is appropriate, but the paper would benefit from further clarity in the definition. The text describes this further in lines 152-156 and notes that women with four or more ANC visits who received “WHO recommended interventions at least once” were considered to have achieved effective coverage. However, this definition is vague in its treatment of timing and frequency. It is unclear whether receiving the interventions only once is considered sufficient, even when guidelines may emphasize repeat or time-specific administration. The list of WHO-recommended interventions (lines 157-160) is presented in a run-on sentence and should be formatted as a clear, concise list to aid readability.

But the subsequent listing of independent variables is dense, inconsistently phrased, and lacks logical structure (lines 144-151). The grouping is also confusing, with some sociodemographic variables and some infrastructure variables. Clinical and facility-level variables are intermingled without sub-categorization, which makes this section hard to follow. Organizing by thematic groups (individual-level, clinical history, health system/infrastructure) would significantly improve readability and comprehension.

There are a number of abbreviations that are not defined - PROM, APH, PIH, PPH (line 147); PID (line 148); SFH (line 157); HCT,VDRL, BG^RH,U/A (lines 161-162); IESO (line 164); and BP (line 166).

The language used throughout this section is often vague or awkward. Terms such as “Gynecology related factors” (line 146) and “Investigation and infrastructure related variables” (lines 148-149) lack specificity and are not clearly defined. Additionally, the phrase “presence of adequate trained human power” (line 150) is grammatically incorrect and could be replaced with more natural phrasing such as “availability of adequately trained personnel.”

There are also typographical errors that detract from the professionalism of the text, such as “pervious History of Gynecology Complication,” (line 148) which should read “previous history of gynecological complications.” Such errors can undermine the credibility of the methodological description.

Data collection tools and procedure - This section provides basic information on the data collection tools and procedures but lacks sufficient detail and clarity. While it notes that data were collected using an adapted structured questionnaire translated from English to Amharic, it does not specify the source of the questionnaire, the nature of the adaptation, or whether the tool was pretested or validated. Additionally, the description of data collectors and supervisors is brief and imprecise; stating that three diploma and two BSc nurses were recruited is helpful, but it would be more informative to mention any training they received, how data quality was ensured, and how supervision was conducted.

Data quality control - The description in this section is quite general and could benefit from greater specificity. For example, it is unclear what specific adjustments were made following the pretest, or how issues of reliability and data entry accuracy were handled. Additionally, a one-day training duration seems insufficient for complex data collection tasks, especially if the questionnaire included technical or clinical components. More detail on the rationale for that limited training or the quality assurance during data collection and entry to minimize bias or errors would strengthen the credibility of this section.

Data management and analysis - This section needs clearer language and technical precision. There are grammatical errors (e.g., “cheeked” should be “checked” on line 185) and unclear phrasing around model fit. Standard terms like bivariate versus bivariable; multivariate versus multivariable should be used consistently. While the use of p-values to select variables is appropriate, the rationale and handling of issues like multicollinearity or missing data are not discussed. Overall, the section covers key steps but requires clearer writing and more detail for full transparency.

Limitation of this study – There is an incomplete sentence here. This section should be reviewed and ensure the full limitations are discussed. Other factors such as the cross-sectional design, possible issues with record-keeping, lack of timing for interventions may also be important limitations to discuss in this section.

Overall, while this section contains the essential elements required for transparency, it would benefit greatly from improved structure, clearer language, and more thoughtful integration of supporting references. Some sections are underdeveloped and require further elaboration to demonstrate the reliability and rigor of the data collection and analysis processes.

Results: The data presented are relevant, the section would benefit from clearer writing and a more logical flow. Examples of some phrasing and formatting that needs improvement, includes:

• “We analyzed and included in the final analysis…” (line 206) could be simplified for clarity, such as “We analyzed 680 ANC service records”;

• “almost two third” (line 208) should be “almost two-thirds”; also found in line 214

• line 212-214 could be rephrased, “More than half the women were multipara (56.8%), followed by grand multipara (17.8%)”

• the “distance from HF” row is missing a parenthesis after 14.1

• spacing between numbers and parenthesis should be consistent (e.g., Table 2 – some are presented with a space 85 (12.5) and some without 386(56.8)). This is found in the remaining tables.

• Data presentation should be consistent – most present 1 digit, but line 216 presents 2 digits (48.18%)

• Line 217 should read “obstetric complications” or perhaps better rewritten “Among women who experienced obstetric complications during pregnancy, nearly half (48.2%) had pregnancy-induced hypertension, followed by antepartum hemorrhage (32.1%)”

• Line 228-229 – select consistent capitalization for Hospital or hospital.

Similar suggestions are found throughout the remaining results section and should continue to check for this consistency in presentation, logical flow, and clarity of presentation.

Descriptions of the results presented in the tables could be improved. For example, in the description for Table 1, the text notes that 72.9% were in the age range 21-35 but the table shows groups 15-24, 25-34, and 35 or more. The description should match the way data is presented. If there is a reason for discussing results differently than how it is presented in the table, this should be explained.

The description for Table 4 of very unclear, as is why the CI is presented in text and not the table. Are these univariates among all 680 women who had four or more visits? It is also unclear where the description of “80% of mothers were diagnosed using ultrasound” is coming from (line 237-238).

The section around table 5, which presents findings from bi-variable and multivariable logistic regression, lacks clarity, consistency, and precision in language, which makes it a bit hard to follow. The opening sentence is overly long and awkwardly constructed. Phrases like “identified as a candidate variables” (line 246) contain both grammatical and pluralization errors. It would benefit from clearer subject-verb agreement and tighter phrasing. The use of "multiple logistic regression" should be replaced with the standard term "multivariable logistic regression" for accuracy.

Additionally, the narrative interpretation of odds ratios is not always intuitive or clearly explained. For example, stating that the "odds were 68% lower" when the AOR is 0.32 may confuse readers unfamiliar with interpreting odds ratios. This could be better framed as "women aged 25–34 had significantly lower odds of effective coverage compared to those aged 15–24."

There is also some repetition and awkward phrasing. For example, "those mothers who had no encountered previous gynecological complications" (lines 260-261) should be revised for grammatical accuracy ("those who had not experienced..."). Finally, references to “table 5” should ideally be integrated more naturally into the narrative or visually indicated in the formatting, especially when listing statistical results.

Overall, the results section communicates important findings but would benefit from clearer language, grammatical revision, and improved statistical interpretation.

Discussion: The discussion summarizes key findings but is weakened by problems in structure, logic, and writing quality. There is a lot of repeating of the results but no interpretation of those results is provided.

The opening paragraph contains an incomplete phrase - “The overall effective coverage of ANC services 25.9%” (line 270) and immediately compares results with previous studies without first interpreting their substantive meaning of the result found in this study. Comparisons to earlier Ethiopian and Pakistani studies are offered, yet the explanations (“differences in social backgrounds” or “where the study was done”) are speculative and unsupported by data. Citing concrete contextual factors from these comparative studies (e.g., sampling frame, facility type, survey year) would be more convincing and better ground your argument.

Throughout, percentages are repeated without context, interpretation, and discussion. For example, readers are told that SFH measurement was 100% (line 278) and that gestational diabetes screening was 8.2% (line 281). But what this means in the Ethiopian – or larger – context or the implications for maternal outcomes or service quality are not discussed. This fails to help the reader understand the significance of these findings.

Interpretations of odds ratios are sometimes inaccurate or poorly framed. For example, describing the adjusted odds ratio of 0.32 for women aged 25–34 as “68% lower” is mathematically correct (line 290), yet no rationale is provided for why younger women achieve higher effective coverage. Speculation about “active reproductive group level” (line 292) lacks clarity and evidence.

Similarly, attributing higher coverage among multiparous women to “more exercise about its follow up” (line 297) is vague and grammatically incorrect. The discussion routinely labels findings as “contralateral” or “contrast,” but it fails to explore potential explanations such as health seeking behavior, facility readiness, or cultural norms. Other grammatically confusing or incorrect sentences can be found throughout as well - (“this could be that this age group is active reproductive group level” (lines 291-292); “women who had multiparty have more exercise about its follow up” (line 293-294).

Overall, a more effective approach for the discussion section would be to highlight the most salient associations, relate them to existing literature, and consider programmatic implications. This section also requires clearer writing, stronger linkage between results and interpretation, and evidence based explanations for disparities.

Conclusion: The conclusion lacks a strong impact. It requires refinement to offer a more coherent and policy-relevant summary of the study’s implications.

Reviewer #5: Thank you for the opportunity to review your manuscript. This is an important topic and could have a major impact on maternal and perinatal mortality. The study estimated the effective coverage of antenatal care in women who had at least 4 AN appointments. The medical records of 680 women who attended antenatal care from 30 June 2023 to 30 July 2023 in one of 3 randomly selected hospitals out of the 8 in West Gojjam Northwest Ethiopia were reviewed by trained data collectors.

The study aims to address an important issue and provides valuable estimates of the rates of crude and effective coverage. However there are some significant limitations with the statistical analysis.

Abstract - I struggled to match the CIs in lines 37-40 with adjusted odds ratios presented in table 5.

Main text - Consideration of Selection bias - How well did the study population match the source population in terms of demographics? Did the criteria of requiring 4 ANC affect recruitment? One of the hospitals selected was the larger district hospital - are the women who attend this larger hospital comparable to those attending the 2 smaller local hospitals?

The tables and figure titles should be clearer eg Table 1: shows the demographics of pregnant women in the 3 hospitals in the study, not the region. Rather than referring to the region, these tables and figures should referring to 640 women with ante-natal care in 3 hospitals in the province, during one month June- July 2023

Effective coverage only shown in total and not by hospital, but there were clear differences in crude coverage across the 3 hospitals. I would recommend that hospital should be included in the regression modelling in separate models, as a fixed effect but also in a multilevel model as a random effect, to explore within and between hospital variance. This impact of this and confounding across variables mean the results of the multivariable regression presented are likely unstable. Was the likely confounding across many of the variables assessed? Of particular concern are estimates that have changed direction between the bivariate and multivariate analyses; not all of these variables are appropriate to be included in the same model. eg age is confounded with multiple variables including parity, planned pregnancy and marital status.

The discussion would benefit from expansion and should include reference to selection bias and limitations in the statistical analyses.

Reviewer #6: The authors present an interesting research question aimed at quantifying effective antenatal care and they propose to examine multiple variables that may impact care. Unfortunately, the manuscript lacks any sound conclusions, presents inconsistent data, and has numerous typographical and grammar errors making it unsuitable for publication at this time. The most concerning problem with this manuscript is that the data the authors present is inconsistent throughout, leaving the reader unclear what is truth and how that impacts their research question. For example, in the manuscript’s abstract the authors cite “Parity (multipara) (AOR: 1.74; 95 % CI:0.05- 0.55)” but that data is not repeated or presented anywhere in the paper that follows. The main source of this data is in Table 5, but the numbers in that table are different from what’s stated in the abstract. This happens for multiple of the key variables they explored.

Also, many of their AORs and CIs don’t make sense where the AOR does not fall within the 95% CI. This is seen in the “Parity (multipara)” example stated above, the “previous gynecological complication (AOR:3.98; 95% CI; 1.33-3.70)” cited in the abstract, and also in the manuscript’s Results and Discussion sections.

Finally, the conclusions reached in this manuscript aren’t actually conclusions, but statements about the data. It’s not meaningful to just state which variables are significantly associated with (in)effective coverage of ANC services, the authors should also explain if these variables positively or negatively impacted coverage. For example, did being married or divorced increase or decrease effective coverage? Both have positive AORs and highly variable CIs.

It is this reviewers recommendation to reject the manuscript in its current form. The authors need to revisit their data analysis and conclusions. Ideally, they would also have more editing done to remove the grammar and typographical mistakes make the writing easier to follow.

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Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

Reviewer #6: Yes: Samantha ByrnesSamantha ByrnesSamantha ByrnesSamantha Byrnes

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Dear Mr. Endalew,

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.

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Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #4: All comments have been addressed

Reviewer #6: (No Response)

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

Reviewer #4: Yes

Reviewer #6: Partly

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

Reviewer #4: Yes

Reviewer #6: 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.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 #4: Yes

Reviewer #6: Yes

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

Reviewer #4: Yes

Reviewer #6: Yes

**********

Reviewer #4: I appreciate the authors’ attention to responding effectively to the previous issues, resulting in a much-improved version of the manuscript. Despite these advancements, the paper is still hindered by grammatical errors, unclear sentence structures, and inconsistencies that detract from clarity and weaken its overall impact.

The Introduction effectively contextualizes the problem, defines key terms, and highlights the study’s relevance. While it is generally well-structured with a clear research gap and notable improvements in flow, it would benefit from minor polishing to address run-on sentences, redundancy, and enhance conciseness.

The Methods section is logically organized with adequate detail but requires further editing for grammar, formatting, and clarity. Addressing awkward phrasing, run-on sentences, and inconsistent tense usage will improve readability and academic rigor, ensuring the manuscript is publication-ready.

The Discussion is content-rich, appropriately identifies patterns, explains findings, and addresses limitations. However, it needs revision to improve grammar, sentence structure, and logical flow; eliminate redundancy; clarify contradictory points (notably regarding age versus parity); and strengthen the conclusion with actionable recommendations.

Overall, the manuscript demonstrates commendable attention to detail and effectively addresses the key issues previously raised. I commend the authors for their work and encourage a thorough final edit to resolve remaining grammatical issues, improve clarity, and ensure consistency for a polished, professional presentation.

Reviewer #6: The original reviewers note, correctly, that a 1 month study period is extremely short for a cross-sectional study design. The authors responded to this comment noting that the study period was actually 1 year and that detail was updated in the revised manuscript, however the abstract in the revised version clearly states only a 1 month study period from 30 June 2023 to 30 July 2023. Then in the Methods Section the authors note the longer time-period from 01 September 2021 - 30 August 2022, but it's unclear why they classify this as "secondary data" and how the data in the 1-month and 1-year study periods are related. Are all of these results included in the results section or only some? It's very unclear and should be updated.

The overall goal/conclusion of this study was to measure the effective ANC coverage for this population and the authors clearly define effective ANC coverage as "attended four or more antenatal care (ANC) visits, and they received all the WHO recommended interventions at least once during". Given this definition, it does not make sense that the authors conclude that the effective ANC coverage is 25.9%. How is this possible if Table 5 shows that only 8.2% of women received "Screening for gestational diabetes mellitus" which is one of the noted/required WHO interventions? Given this data and how the authors define effective coverage, wouldn't that mean only 8.2% met the standard for effective coverage? The breakdown in services and what is/isn't provided to pregnant individuals in this population is very interesting, but I think the data interpretation doesn't match what the authors themselves laid out as qualifying as effective coverage.

**********

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Reviewer #4: No

Reviewer #6: Yes: Samantha A ByrnesSamantha A ByrnesSamantha A ByrnesSamantha A Byrnes

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Dear Dr. Endalew,

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 April 5, 2026, 11:59. 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.. 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.. 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.. 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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• 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 . 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 . 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 . 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,

Agegnehu Bante

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 #7: All comments have been addressed

Reviewer #8: All comments have been addressed

**********

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

Reviewer #7: Yes

Reviewer #8: Yes

**********

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

Reviewer #7: Yes

Reviewer #8: Yes

**********

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.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 #7: Yes

Reviewer #8: Yes

**********

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

Reviewer #7: Yes

Reviewer #8: Yes

**********

Reviewer #7: Reviewer Comments for Manuscript PONE-D-24-45499R3

This manuscript contains grammatical errors, awkward phrasing, and inconsistent tense usage that reduce clarity and readability. Several sentences are overly long or redundant, which weakens the logical flow of the argument. I recommend a thorough language edit to:

• Correct grammar and typographical errors.

• Ensure consistent use of past tense in the Methods and Results sections, and present tense in the Introduction and Discussion…(e.g., “effective coverage,” “crude coverage”)

• Shorten or restructure overly long sentences to improve conciseness and readability. Minor typographical errors and redundancies should be carefully polished before publication.

Suggestion: The manuscript would benefit significantly from thorough proofreading by a native English speaker or professional editing service to improve clarity and adherence to academic writing standards.

2. Abstract

• The abstract is informative but needs refinement for clarity.

• The study period is confusing: the abstract mentions June–July 2023 (1 month), while the methods section refers to September 2021–August 2022 (1 year). This inconsistency must be corrected. You have to remove … “using secondary data of mothers who received antenatal care from September 01, 2021, to August 30, 2022”. You have also change design into “retrospective cross-sectional studies”. Change…”bi variable logistic regression” → “bivariable logistic regression”;

• The results section of the abstract should align with the operational definition of effective coverage. For example, if screening for gestational diabetes is required, how does the reported 25.9% coverage reconcile with only 8.2% receiving that service?

3. Introduction

• The introduction is well contextualized, but some sentences are repetitive and could be streamlined.

• The rationale for focusing on effective coverage rather than crude coverage is well stated, but the flow could be improved by reducing redundancy.

• Consider clarifying the conceptual framework of effective coverage (need, use, quality) more succinctly.

• Suggestion: Consider adding a sentence on why West Gojjam Zone specifically was chosen—e.g., known gaps in ANC quality, high maternal mortality, or representative setting.

• Question: The authors state that “none have examined EC of ANC in our region especially in my study setting.” Were there any sub-national or facility-based ANC quality assessments that could be referenced for context?

Methods

Study design and period

The description of the study design is somewhat confusing. The manuscript currently states: “A facility-based analytical cross-sectional study design was conducted in West Gojjam public hospitals from June 30 to July 30, 2023, utilizing secondary data from mothers who received antenatal care between September 1, 2021, and August 30, 2022.”

• Since the data were extracted retrospectively from ANC charts, the design would be more accurately described as a retrospective cross-sectional study rather than “analytical cross-sectional.”

• The phrase “utilizing secondary data from mothers who received antenatal care between September 1, 2021, and August 30, 2022” is redundant here, because the study population and source of data are already explained elsewhere.

• I recommend that the authors simplify this section to report only the study design and data collection period, while clearly noting that secondary data were used. For example: “A facility-based retrospective cross-sectional study was conducted in West Gojjam public hospitals. Data were collected between June 30 and July 30, 2023, from ANC charts covering the period September 1, 2021, to August 30, 2022.”

Sampling Size Calculation

I appreciate that the authors calculated the sample size for both objectives (coverage and associated factors). However, including the full formula in the manuscript is not necessary, since you have already stated that the single population proportion formula was used.

I recommend simplifying this section by:

• Clearly stating that the sample size was calculated for both objectives.

• Indicating that the largest sample size obtained was selected as the final sample size for the study.

• Removing the redundant formula presentation, while keeping the assumptions (confidence level, margin of error, prevalence, design effect, non-response rate) clearly described.

This will make the Methods section more concise and reader friendly, while still transparent about how the sample size was determined.

Study Design and Sampling:

• The multi-stage random sampling is appropriate, but the description of selecting 3 out of 8 hospitals (38%) by “lottery” is vague. Were all hospitals eligible? Was stratification considered?

• Suggestion: Clarify whether the selection was truly random or purposive, and justify the sample size allocation.

Why were only 3 hospitals selected? Was power considered at the hospital level?

Why was a design effect of 1.5 applied? Was clustering expected, and if so, at what level? Please justify this choice.

Measurement of Effective Coverage:

The definition aligns with WHO recommendations, but the operationalization—“received all the WHO recommended interventions at least once”—may overlook frequency and timing of interventions, which is acknowledged as a limitation.

Suggestion: Briefly note how missing data on intervention timing was handled.

How was “adequately trained human power” assessed? Was it based on presence per shift, or per patient load?

Clarify whether data were extracted only from charts or supplemented with interviews.

Line 181-182. Avoid----�remove…”The questionnaire was prepared in English and

182 pretested among 5% (34) of study population before the actual data collection”…this repetition/The author already included in data quality control.

Data Analysis:

The use of p<0.25 for inclusion in multivariable analysis is acceptable but should be justified given the sample size.

Suggestion: Consider also using variance inflation factors (VIF) to check multicollinearity, especially among obstetric/gynecological variables.

Question: Why were hospital-level factors (e.g., equipment, staffing) not included in the regression model?

Results:

Tables are comprehensive but could be better formatted. For example, Table 5 is split across pages Comment on Definition and Results of Effective Coverage

The manuscript defines effective coverage of ANC interventions as: pregnant women who attended four or more ANC visits and received all WHO recommended interventions at least once during their ANC follow up period.

However, the results presented raise important concerns:

• For several interventions, the proportion of women receiving them “at least once” is far below 25.9%. For example, only 8.2% received antenatal ultrasound and 8.2% were screened for gestational diabetes mellitus.

• If all WHO recommended interventions are required for effective coverage, then the reported 25.9% effective coverage seems inconsistent with these low uptake rates.

• The table also mixes “at each visit” and “at least once” indicators, which makes interpretation difficult. For example, gestational diabetes screening is reported as 25.9% “at each visit” but only 8.2% “at least once.” This needs clarification.

• The operational definition should be applied consistently: if “all WHO interventions at least once” is the criterion, then the effective coverage proportion should reflect the lowest uptake intervention (e.g., 8.2%).

Recommendations:

1. Clarify the operational definition of effective coverage — is it “all WHO interventions at least once” or “some interventions at least once”?

2. Ensure consistency between the definition and the reported results.

3. Revise the Results section to avoid contradictory figures (e.g., 25.9% vs. 8.2%).

4. Consider presenting both crude coverage (ANC 4+) and effective coverage (ANC 4+ plus all WHO interventions) separately, with clear explanation.

Discussion:

The discussion appropriately contextualizes findings within existing literature and offers plausible explanations for discrepancies.

To strengthen the impact of your manuscript, please revise the Discussion to move beyond restating the Results. Instead, focus on interpreting the clinical and public health significance of your key findings. For each major result, please address:

1. What does this mean for practice? (e.g., How should the very low rate of Gestational Diabetes Mellitus screening change clinical protocols or health worker training?)

2. What are the policy implications? (e.g., Does the finding that women with prior complications receive better coverage suggest a need to reallocate resources or change messaging to reach low-risk women?)

3. How can these findings inform action? Conclude with targeted, practical recommendations for health system managers and policymakers in your setting."

Question: The finding that prior complications increase effective coverage suggests that risk-based care is occurring. Does this imply that low-risk women are being neglected? This has important programmatic implications.

Reviewer #8: (No Response)

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

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Reviewer #7: No

Reviewer #8: No

**********

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<p>Effective Coverage and Associated Factors of Antenatal Care Service among Women Who Attended Antenatal Care at West Gojjam Zone Public Hospitals, Northwest Ethiopia

PONE-D-24-45499R4

Dear Mr. Enalew,

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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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,

Agegnehu Bante

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #7: All comments have been addressed

Reviewer #8: All comments have been addressed

**********

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

Reviewer #7: Yes

Reviewer #8: Yes

**********

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

Reviewer #7: Yes

Reviewer #8: 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.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 #7: Yes

Reviewer #8: Yes

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

Reviewer #7: Yes

Reviewer #8: Yes

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Reviewer #7: (No Response)

Reviewer #8: (No Response)

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Reviewer #7: No

Reviewer #8: No

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