Examining inequalities in access to delivery by caesarean section in Nigeria

Boniface Ayanbekongshie Ushie; Ekerette Emmanuel Udoh; Anthony Idowu Ajayi

doi:10.1371/journal.pone.0221778

Peer Review History

Original SubmissionMay 31, 2019
13 Jun 2019 Decision Letter - Charles A. Ameh, Editor PONE-D-19-15544 Examining inequalities in access to delivery by caesarean section in Nigeria PLOS ONE Dear Dr Ajayi, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. We would appreciate receiving your revised manuscript by Jul 28 2019 11:59PM. When you are 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. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Charles A. Ameh, PhD, MPH, FWACS (OBGYN), FRCOG Academic Editor PLOS ONE Journal Requirements: 1. When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf Additional Editor Comments Dear Authors, I think this is a very relevant topic, inequity of in the availability of CS and in a country that makes a significant contribution to global maternal mortality. Given that the 2018 Nigeria DHS report and data sets are available, it makes your paper based on data related to 5 years preceding 2013 NDHS less relevant. What about running a similar analysis using DHS 2018 data set and comparing both results? If you can do this, I will be happy to send your revised manuscript for review. Best wishes [Note: HTML markup is below. Please do not edit.] Reviewers' comments: [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0221778.r001
Revision 1
15 Jun 2019 Author Response Comment I think this is a very relevant topic, inequity of in the availability of CS and in a country that makes a significant contribution to global maternal mortality. Given that the 2018 Nigeria DHS report and data sets are available, it makes your paper based on data related to 5 years preceding 2013 NDHS less relevant. What about running a similar analysis using DHS 2018 data set and comparing both results? If you can do this, I will be happy to send your revised manuscript for review. Response The comments are important and we made effort to use the latest nationally representative data available. We have now contacted DHS and were informed that the NDHS 2018 data is not available to the public at the moment and were also told that only the preliminary result is publicly available. The full report is not yet out. Given the paucity of studies on this important topic, we believe that our paper will contribute to the literature and serve as reference point to future studies. We have however noted the comments and added it as one of our future papers to be written once the NDHS 2018 dataset is finally released. Attachments Attachment Submitted filename: Dear Editor.docx https://doi.org/10.1371/journal.pone.0221778.r002
2 Jul 2019 Decision Letter - Charles A. Ameh, Editor PONE-D-19-15544R1 Examining inequalities in access to delivery by caesarean section in Nigeria PLOS ONE Dear Dr Ajayi, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. We would appreciate receiving your revised manuscript by Aug 16 2019 11:59PM. When you are 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. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Charles A. Ameh, PhD, MPH, FWACS (OBGYN), FRCOG Academic Editor PLOS ONE Additional Editor Comments (if provided): Thanks for submitting to PLOS One. After careful review, we have concluded that the article does not contribute new knowledge unless significantly revised. A recent article using the same DHS 2013 data set https://bmjopen.bmj.com/content/bmjopen/9/6/e027273.full.pdf may be of interest as you repackage your manuscript. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed Reviewer #2: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: 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. Reviewer #1: No Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: No Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: i commend the authors for reviewing an important topic and their ambitious plans to effect a positive change ( improvement in women healthcare in Nigeria) from their findings. The large data set and parameters reviewed gives strength to this research work. However, there is new and important reference survey from Nigeria DHS 2018 report which makes the research work outdated as it was based on the old NDHS 2013 report. I appreciate the fact that authors have made an attempt to request the data from the 2018 report which is not fully available to the general public. Perhaps this research can be delayed and new analysis done based on the new report Based on this submission, he conclusion does not add anything new to what is already known about this topic. Linking the disparity to maternity outcome variables within the data set might actually provide strong evidence and attract interest to effect change as intended. Reviewer #2: There are numerous grammatical errors throughout the text, albeit they do not detract from the meaning. However, they should be addressed. The main issue however is that of the depth of the discussion. That there is inequity across the continuum of care is well addressed in Countdown 2030, and Nigeria remains a Countdown country. Caesarean section rates may be seen to some extent as a surrogate for the accessibility and availability of obstetric care, but there are other important factors to consider, both on the supply and demand sides, that have relevance to the rate of caesarean sections in real life situations. Whereas the authors have focused briefly on some demand side issues that may contribute to women declining a caesarean delivery there are many supply side issues too. I would have been interested to see more of a discussion as to why better educated women in the top wealth quintile have a higher rate of caesarean deliveries as compared to those with the same wealth but less education. Also the issue of whether the woman has health insurance also plays a part. A considered discussion of the influence of these factors on possible decision making processes by doctors is of relevance. Another complicating factor is that not all caesareans are done for good reasons even when the underlying rate is low. There are many reasons for this, but one factor is that doctors with insufficient experience are left unsupported to make crucial obstetric decisions, resulting in some women being subjected to all the present and future risks of surgery to be delivered by a caesarean that wasn't even necessary. This is a limitation of choosing caesarean rates as a surrogate for quality care provision, and should be mentioned. I feel therefore that if caesarean section rate is the measure to be considered in this important discourse on equity than the discussion would greatly benefit from a re-write to look in greater depth at the possible "why" questions that lie behind the inequities. We already know from looking at both Countdown and the DHS that inequity is a big issue, but it is not likely that meaningful change will occur until the "why" questions are addressed more forensically. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0221778.r003
Revision 2
11 Jul 2019 Author Response Dear Editor We are to submit the revised version of our manuscript. The comments provided during the review process have further enabled to strengthen our manuscript. We trust you will find that our manuscript has improved significantly during this process. Our responses to the comments raised by the reviewers are found below. Best regards Anthony Ajayi On behalf of all authors. Reviewer #1: I commend the authors for reviewing an important topic and their ambitious plans to effect a positive change (improvement in women healthcare in Nigeria) from their findings. The large data set and parameters reviewed gives strength to this research work. However, there is new and important reference survey from Nigeria DHS 2018 report which makes the research work outdated as it was based on the old NDHS 2013 report. Response We thank the reviewer for the constructive and positive feedback. I appreciate the fact that authors have made an attempt to request the data from the 2018 report which is not fully available to the general public. Perhaps this research can be delayed and new analysis done based on the new report. Based on this submission, the conclusion does not add anything new to what is already known about this topic. Linking the disparity to maternity outcome variables within the data set might actually provide strong evidence and attract interest to effect change as intended. Response: We thank the reviewer for the insightful comments. As we said previously, we intend to write a second paper examining the change in inequality in access to birth by caesarean section when the recently completed 2018 DHS data is released and becomes publicly available. We believe our paper fills an important gap given our focus on this important issue that affects the lives of many women in Nigeria as over 58, 000 maternal deaths are recorded annually. Our paper further contributes to the evidence base for understanding the reason for the high burden of maternal deaths in Nigeria. We outline inequality in access to caesarean section as a contributing factor to adverse maternal outcomes in Nigeria, thus, contributing to knowledge on why maternal deaths are prevalent in Nigeria. We hope to build on this study in the future utilizing datasets from previous as well as the 2018 DHS to perform trend analysis to show changes in caesarean section utilization as an emergency obstetric care and hopefully will lead to the desired changes in supply and demand aspect of maternal health delivery in Nigeria. Reviewer #2: There are numerous grammatical errors throughout the text, albeit they do not detract from the meaning. However, they should be addressed. Response: We have extensively proofread our manuscript and also engaged a language editor. Reviewer #2: The main issue, however, is that of the depth of the discussion. That there is inequity across the continuum of care is well addressed in Countdown 2030, and Nigeria remains a Countdown country. Caesarean section rates may be seen to some extent as a surrogate for the accessibility and availability of obstetric care, but there are other important factors to consider, both on the supply and demand sides, that have relevance to the rate of caesarean sections in real life situations. Whereas the authors have focused briefly on some demand side issues that may contribute to women declining a caesarean delivery there are many supply side issues too. I would have been interested to see more of a discussion as to why better educated women in the top wealth quintile have a higher rate of caesarean deliveries as compared to those with the same wealth but less education. Also the issue of whether the woman has health insurance also plays a part. A considered discussion of the influence of these factors on possible decision making processes by doctors is of relevance. Another complicating factor is that not all caesareans are done for good reasons even when the underlying rate is low. There are many reasons for this, but one factor is that doctors with insufficient experience are left unsupported to make crucial obstetric decisions, resulting in some women being subjected to all the present and future risks of surgery to be delivered by a caesarean that wasn't even necessary. This is a limitation of choosing caesarean rates as a surrogate for quality care provision, and should be mentioned. I feel therefore that if caesarean section rate is the measure to be considered in this important discourse on equity than the discussion would greatly benefit from a re-write to look in greater depth at the possible "why" questions that lie behind the inequities. We already know from looking at both Countdown and the DHS that inequity is a big issue, but it is not likely that meaningful change will occur until the "why" questions are addressed more forensically. Response: We agree with the points highlighted and thank the reviewer for these insightful comments, which have enabled us to significantly improve on the discussion section of our paper. We have revised our discussion to better focus on both supply and demand sides of the caesarean section. Also, we have discussed the effect of health insurance coverage in birth by caesarean section. The countdown 2030 is an enormous piece of work that monitors and measure women’s, children’s, and adolescents’ health in the 81 countries that account for 95% of maternal and 90% of all child deaths worldwide. We have read several publications from the countdown work to gain more insight into the issue of inequity in health outcomes. We have benefited from the insight and experience of the reviewer. https://doi.org/10.1371/journal.pone.0221778.r004
12 Aug 2019 Decision Letter - Charles A. Ameh, Editor PONE-D-19-15544R2 Examining inequalities in access to delivery by caesarean section in Nigeria PLOS ONE Dear Dr Ajayi, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. We would appreciate receiving your revised manuscript by Sep 26 2019 11:59PM. When you are 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. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'. Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out. We look forward to receiving your revised manuscript. Kind regards, Charles A. Ameh, PhD, MPH, FWACS (OBGYN), FRCOG Academic Editor PLOS ONE Additional Editor Comments (if provided): Thanks for making significant improvements to this manuscript. There are minor comments to address before it can be accepted for publication. Thanks [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: (No Response) Reviewer #2: (No Response) ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: 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. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Many thanks to the authors for the revisions made. However, this topic which is based on the old data set (Nigeria DHS 2013) has been covered extensively in some recently published articles therefore adds no new information to what is already known on this topic. Reviewer #2: This paper has been greatly improved. My only additional comment is that I feel the paragraph in the discussion starting "anecdotal evidence suggests..." where the authors go on to discuss longer hospital stays following caesarean section should have some reference for the assertions made regarding hospital stay. Otherwise, the discussion is much richer and of wider interest as a result. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0221778.r005
Revision 3
13 Aug 2019 Author Response Dear Editor, We want to thank you and the reviewers for the constructive criticism and suggestions that have helped us to improve our manuscript. We have now addressed the comments raised, and we trust you will find our manuscript acceptable for publication. Below we provide a point-by-point response to the comments. Best Regards Anthony On behalf of all authors. Additional Editor Comments (if provided): Thanks for making significant improvements to this manuscript. There are minor comments to address before it can be accepted for publication. Thanks Response: We thank the Editor for providing us with constructive feedback that has helped us to improve our manuscript. Reviewer #1: Many thanks to the authors for the revisions made. However, this topic which is based on the old data set (Nigeria DHS 2013) has been covered extensively in some recently published articles, therefore, adds no new information to what is already known on this topic. Response: We believe our paper addresses an important topic, and our work is unique by focusing on inequality in access to caesarean section in Nigeria, a country that contributes 19% of global maternal deaths. While the 2013 NDHS may appear to the old in the context of the 2018 NDHS data, the fact is that the 2013 data is still the most recent publicly available. As indicated in our earlier response, when the 2018 data set becomes available, we hope to build on this work to undertake trend analysis on the caesarean section utilization. Reviewer #2: This paper has been greatly improved. My only additional comment is that I feel the paragraph in the discussion starting "anecdotal evidence suggests..." where the authors go on to discuss longer hospital stays following caesarean section should have some reference for the assertions made regarding hospital stay. Otherwise, the discussion is much richer and of wider interest as a result. Response: We appreciate the reviewer’s comments that have enabled us to revise our discussion section significantly. We have now referenced the paragraph as suggested. https://doi.org/10.1371/journal.pone.0221778.r006
15 Aug 2019 Decision Letter - Charles A. Ameh, Editor Examining inequalities in access to delivery by caesarean section in Nigeria PONE-D-19-15544R3 Dear Dr. Ajayi, We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements. Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication. Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and 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. With kind regards, Charles A. Ameh, PhD, MPH, FWACS (OBGYN), FRCOG Academic Editor PLOS ONE Additional Editor Comments (optional): Thanks for addressing all comments, I am pleased to recommend this manuscript for publication. Reviewers' comments: https://doi.org/10.1371/journal.pone.0221778.r007
Formally Accepted
22 Aug 2019 Acceptance Letter - Charles A. Ameh, Editor PONE-D-19-15544R3 Examining inequalities in access to delivery by caesarean section in Nigeria Dear Dr. Ajayi: I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. 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. For any other questions or concerns, please email plosone@plos.org. Thank you for submitting your work to PLOS ONE. With kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Charles A. Ameh Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0221778.r008

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