Dear Dr. Sia,

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Additional Editor Comments:

Thank you for submitting your manuscript. The topic is timely and important; however, the manuscript requires substantial revision before it can be considered further. In addition to addressing the external reviewer comments, please carefully consider and respond to the points outlined below. These relate primarily to clarity, internal consistency, methodological rigor, and alignment between the aims, methods, results, and discussion.

Intro

- Please provide references for assertions made throughout. For example: “Four out of five uninsured pregnant women received inadequate prenatal care. More than half of these women received insufficient prenatal care, and 6.5% received no prenatal care at all.” – What are the references for these?

- “Insurance status was also linked to the type of health care provider, reasons for caesarean section, neonatal resuscitation rates, and the length of maternal hospital stay.” Was linked in what study? In what country? More transparent information required here.

- The argument in the intro is also confusing as contradictory in parts. For example, you assert: “…many migrant women in Canada and the United States often receive care that falls below recommended standards due to a lack of public health insurance coverage (6)”, but then immediately after (lines 11-15) you note that in Canada most immigrants and resettled refugees do have universal coverage comparable to citizens. Without qualification, those two claims directly clash.

- The population of interest is not clearly defined and appears inconsistent across the title and background. While the title and text refer broadly to “migrant women,” the background indicates that immigrants and resettled refugees in Canada have universal health coverage, whereas lack of insurance applies specifically to undocumented migrants and certain temporary visa holders. These groups are not interchangeable.

- The authors should clearly specify which migrant subgroups are the focus of the review, ensure alignment between the title, aims, and background, and avoid using “migrant women” as a blanket term if the focus is on uninsured subpopulations.

- There is also inconsistency in the use of “perinatal care.” While the review claims to examine perinatal interventions, the background and epidemiological data presented relate almost exclusively to antenatal care. If postnatal and intrapartum care are within scope, this should be reflected in the background and rationale. Otherwise, terminology should be tightened and used consistently from the outset.

Materials and Methods

- The sentence “This study utilized the Arksey and O’Malley” is incomplete as written and should be revised for clarity.

- The research questions and overarching aim should be presented at the end of the Introduction, not in the Methods section.

- The research questions require clarification. Research question 2 combines multiple distinct elements (impacts, strengths, weaknesses, and costs), which reduces conceptual clarity. The authors should consider streamlining or separating this question. In addition, “policies” should be clearly positioned within the scope of the review, for example as a type of intervention, and the terminology used consistently.

- For the inclusion criteria, please clarify whether a cut-off period was applied for the postpartum period.

- The inclusion criteria are unclear and partially redundant. The perinatal period is already defined by pregnancy, labour, and postpartum; the subsequent sentence referring again to “articles addressing the perinatal period” adds no additional clarification and creates ambiguity. Please streamline and clearly define the perinatal timeframe used for study inclusion.

- Lines 75-85 under “Population”: This material is conceptual and definitional and would be more appropriately located in the Introduction. Clarification of who is encompassed by the term “migrant” (and which subgroups are within scope) is necessary for framing the review, rather than being embedded in the Methods section. The population of interest should be clearly defined upfront and aligned with the title and aims.

- The content presented under “Interventions” primarily describes the population and perinatal timeframe rather than defining the intervention concept. This section should clearly specify what was considered an intervention (including policy-level interventions), what was excluded, and the rationale for these decisions. Population and timeframe definitions should be addressed in the intro and briefly in “Population” and kept distinct from intervention eligibility.

- In PICO, the comparator would be another intervention, usual care, or explicitly “no comparator”. The existing content presented under “Comparator” is not appropriate. This section describes study design, language, and publication eligibility rather than a comparator.

- The Outcomes section is incorrectly framed. Rather than describing what the review reported, this section should specify the outcome domains considered for study inclusion. So, studies were included if..

- The search strategy requires clarification. The section refers to “eleven electronic databases” but then lists journals, reference lists, and organisational websites, which are not databases. In addition, the inclusion of NGO and organisational websites appears inconsistent with the stated eligibility criteria limiting inclusion to empirical scientific studies, unless reports or grey literature were also included. The authors should clearly distinguish between databases and other sources, clarify what types of records were eligible, and ensure consistency with the stated inclusion criteria.

- Importantly: The authors note that the search was last updated in December 2024. Given that more than 12 months have elapsed, the search should be updated to ensure the review reflects the current evidence base.

- The PICO elements should be presented within the Study selection section, rather than preceding it.

- The data analysis section lacks methodological clarity. The authors describe general activities (e.g. categorising studies, summarising findings) rather than specifying the analytic approach used. Please clarify the analytical method applied (e.g. descriptive mapping, thematic synthesis, framework-based analysis), including how data were compared and synthesised.

Results

- The Results section should begin with a clear descriptive numerical summary of the included studies (e.g. total number of studies, countries, study designs, populations), consistent with scoping review reporting standards. Currently, the section opens with an interpretive statement rather than a structured overview.

- The rationale for the organisation of results under the current headings (e.g. “Interventions in favor of access…”, “Actors involved…”) is unclear. The authors should explicitly state the basis for this structure (e.g. analytic framework, thematic synthesis, a priori categories) and ensure it aligns with the described data analysis approach.

- Overall, the Results section lacks coherence and a clear analytic logic. The basis for organising results under the current headings is not specified and does not clearly align with a stated analytical framework or method. It is unclear whether findings are being grouped by intervention type, policy level, actor, outcome, or study focus, and the structure appears to shift across sections without justification.

- the section titled “Strengths and weaknesses of these interventions” is unclear. It is not specified whether this refers to the strengths and weaknesses of the interventions themselves, the policies, or the quality of the included studies. As presented, this section conflates empirical findings with interpretation and lacks methodological clarity.

- The authors should:

– Clearly state the analytic approach used to structure and synthesise results;

– Ensure that section headings are conceptually precise and consistently applied;

– Distinguish clearly between results, interpretation, and discussion-level critique.

Discussion

- The Discussion section requires tighter alignment with the aims, research questions, and findings of the review. Several sections (e.g. ethical implications, economic theory, policy agility) introduce themes that were not clearly framed in the Introduction nor explicitly examined in the Results. As written, it is often unclear whether these points are derived from the included studies or represent broader commentary.

- The authors should refocus the Discussion on interpreting the review’s findings, clearly link all discussion points to the included evidence, and avoid introducing new conceptual themes that fall outside the stated scope of the review.

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Reviewers’ comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: N/A

Reviewer #3: Yes

Reviewer #4: N/A

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: 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

Reviewer #3: Yes

Reviewer #4: No

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Reviewer #1: The manuscript presents a comprehensive scoping review examining interventions and policies that influence access to perinatal care for pregnant migrant women without medical insurance (PMWMIs). It follows a clearly structured methodology guided by the PICO framework and adheres to PRISMA-ScR standards, which strengthens its methodological transparency. The inclusion and exclusion criteria are well-articulated, and the authors demonstrate thoroughness in defining “migrant” and related population subgroups, acknowledging heterogeneity across migrant statuses.

For the strengths, the use of multiple databases, grey literature, NGO websites, and hand-searching increases the review’s breadth. The involvement of an experienced librarian adds rigor to the search strategy. Furthermore, the selection process is clear with a well-structured data extraction strategy.

However, some aspects need improvement:

- Lines two to five should have a reference

- From line 11 to 31 is such a long paragraph, can be made two paragraphs

- The review is heavily dominated by studies from the USA and Canada (85%), limiting the generalizability to global migrant contexts especially low and middle-income countries where migration dynamics differ. Hence, they authors could indicate interpretation with cognisance of this

- The acronym PMWMIs is used for “pregnant migrant women without medical insurance,” but later appears to refer to postpartum women with mental illness on line 254—this should be corrected for consistency.

Reviewer #2: Thank you. This was an interesting read. The work aligned with global public health priorities, and was quite timely. This reviewer only has some minor comments.

1. Limiting to English and French would, undoubtedly, limit generalizability. There would need to be a stronger justification, and preferably a sensitivity analysis.

2. With a rather limited number of existing evidence, the authors could also consider expanind to the grey literature.

3. What was the screening process? Was there a reliability count? How exactly was the "discussion" done - the conflicts may best be quantified.

4. Was there any quality appraisal for the included studies?

5. Was it possible to deepend the synthesis and analysis? Like a thematic analysis?

6. The consultation process was mentioned, but more details should be reported.

7. Uncritically presented cost-benefit claims may not be the best way forward. Please consider applying more critial discussions, like inflation adjustments or generalizability.

8. There seemed to be some minor formatting and typo issues.

9. "First of its kind" was rather a strong claim. Please consider citing prior reviews on migrant maternal health and differentiate.

10. Please discuss more on implications on local and global policies.

Reviewer #3: This manuscript presents a well-conducted and timely scoping review addressing a critically important and underexplored area of maternal and public health: access to perinatal care for migrant women without medical insurance. The topic is highly relevant in the context of increasing global migration and persistent health inequities affecting undocumented migrants and asylum seekers.

The authors have applied the Arksey and O’Malley framework appropriately and transparently, ensuring methodological rigor throughout the scoping review process. The inclusion of both peer-reviewed literature and grey literature strengthens the comprehensiveness of the findings and enhances the policy relevance of the study. The clear description of search strategies, inclusion criteria, and study selection adds to the credibility and reproducibility of the review.

The synthesis of evidence across multiple national contexts (Canada, the United States, Iran, and Thailand) is a notable strength, as it allows for meaningful cross-country comparisons and highlights how different health system structures influence access to perinatal care. The discussion effectively links policy changes to their short-, medium-, and long-term economic and health consequences, offering valuable insights into how restrictive policies may inadvertently increase healthcare costs and worsen health outcomes.

The manuscript is clearly written, logically structured, and accessible to a broad readership, including researchers, clinicians, and policymakers. The conclusions are well supported by the presented evidence and successfully underscore the public health and ethical implications of excluding migrant women from perinatal care. Importantly, the authors’ emphasis on political drivers of policy decisions adds depth to the analysis and contributes to ongoing discussions around health equity and social justice.

Reviewer #4: Dear Authors,

Abstract:

a. Materials and Methods: Kindly include the rationale for using the Arksey and O’Malley (2005) framework in the Abstract.

b. Results: While the Results section highlights the quality of the interventions, it does not specify what “existing interventions and policies” were identified or how many were found. Please indicate your findings in the Results section.

Introduction:

a. The section would benefit from improved organization and paragraph restructuring to enhance coherence. For example, the introductory statistics presented in lines 1-8 are not sufficiently contextualized. Additionally, in lines 8- 10, it is unclear what is being contrasted, and the information on the absence of access to prenatal services appears disjointed. In line 17, kindly expand on the phrase “the restrictive measures” to clarify or highlight the potential reasons for inadequate prenatal care to strengthen the argument regarding “the growing concerns surrounding healthcare access for PMWMIS”(line 42) and “facilitate the implementation of context -appropriate intervention…” (lines 46-47). Finally, there appears to be some repetition in lines 45 to 46 and 52.

Materials and Methods:

a. Line 89: The phrase “newborn’s first months” is ambiguous. Please define the exact age range to improve clarity.

b. Lines 89 to 90: There appears to be a repetition of information that could be streamlined.

c. Lines 95 to 97. Please provide a justification for the design inclusion and exclusion criteria.

d. Additionally, consider reporting the number of articles initially identified and selected to improve transparency of the review process.

Discussion:

a. Although the acronym PMWMI is defined at first use (Line 36), the Discussion section, lines 252 to 254, appears to refer to a different study population. Additionally, it is unclear whether the acronym PMWMI applies to pregnant migrant women without medical insurance (line 360) or to pregnant and postpartum women with mental Illnesses( Line 254). Please clarify and ensure the consistent use of acronyms and study population terminology throughout the manuscript.

b. Lines 302 to 304: Is this phrase supported by verified data? If so, please provide appropriate references.

General comment: There are concerns regarding punctuation, spelling, repetition, and incomplete sentences. Please carefully reread the manuscript and make the necessary corrections. A few examples have been highlighted:

Line 349: Implantation?

Line 17: Per se?

Line 57: incomplete

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: Dr. Neha Asif

Reviewer #4: No

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Interventions facilitating access to perinatal care for migrant women without medical insurance: a scoping review

PONE-D-25-57301R1

Dear Drissa Sia,

Thank you all for your hard work and commitment during the revision process. Your efforts have successfully addressed all concerns and suggestions raised by the reviewers, and I am pleased to inform you that the manuscript has now been accepted for publication once it meets all outstanding technical requirements. This is an excellent outcome, and I truly appreciate the collective effort that has brought us to this stage. I look forward to the next steps in the production process and to seeing the final version published.

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Academic Editor

PLOS One