Factors Associated with Late Antenatal Initiation among Women in Malawi

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Comments for author File: Comments.pdf

Comments on the Quality of English Language

Minor English revision needed.

Author Response

 

	Comments	Action Taken
	In the Introduction section the first paragraph – perhaps it would be better to end the image of mortality and morbidity with newer statistical data, not 2023 but at least 2019 or 2020, perhaps using WHO statistics.	WHO statistics included
	Add in the second paragraph mortality and morbidity as high indicators. Same comment as above, if you have newer data available please use.	This sentence has been revised to refer to the first paragraph which has the necessary indicators
	MDHS – please add the abbreviation in the abstract section, to latter use it.	This is include
	“Late initiation of ANC is not only associated with such negative health outcomes as premature birth, still birth, low birth weight, and increased complications during pregnancy and childbirth, but also leads to poor use of other services like delivering in health facilities and use of skilled attendants during delivery. The World Health Organisation (WHO) has revised the recommended minim number of the ANC visits from four to eight with the first visit in the first trimester.” – repetitive paragraph – please delete the ono with no references and leave the one that has references.	The repeated paragraph was deleted   Although WHO has revised the recommended minimum number, four ANC visits was still relevant/applicable at the time of 2015-16 MADHS. Elsewhere I have argued  that eight ANC visits is too much for resource poor countries like Malawi (though ideal)
	Be more clear in presenting the aim of the study and the clinical impact, the justification, its importance.   Rethink and redo figure 1. The three above mentioned factors contribute to the frequency of ANC, they do not have a unidirectional link between them they participate in modelling the number of ANC visits, so no arrows between the three factors; previous C section you said, positively influences the number of ANC, so it is associated with higher number of ANC or not?	I have reworked the figure and removed arrows between the three factors
	Capitalize the letter from the title of Figure 1.	This was done as suggested.   Figure 1. Modified Conceptual Framework for Late ANC Initiation.
	ICF Macro – explain the abbreviation.	The abbreviation is explained.
	2.3.2 independent variables section – “ever use of family” – it’s meaning is not clear “wanted last child (1=wanted then, 2=wanted later, 3=wanted no more” – please rephrase to enhance clarity	Changed as suggested. “ ever use of family planning
	“Similar percentages from earlier DHSs are 90.2% in 1992, 92.9% in 2000, 92.0% in 2004 and 87.6% in 2010” – the phrase needs to be moved in the discussion section, in the results section you only present the results you have obtained.	Moved to discussion as suggested
	Figure 3 needs to be moved in the discussion section also.	Moved to discussion as suggested
	Results section; 3.2; last paragraph - “The percentage initiating ANC late is negatively to education level and wealth status.” – add the verb Results;	The sentence has been revised. It now reads: The results indicate that late initiation of  ANC  is negatively to education level and wealth status.
	3.3 section “The odds ratio decreased with the increasing age of the woman up to age group 30–34 and then increases as age of the women increases.”	Rephrased as follows:   The results show that the odds ratios decreased with the increasing age of the woman up to age group 30–34 and then increased as age of the women increases.
	Rephrase Discussion section “In addition, studies in other countries have reported regional differences in the initiation of ANC” perhaps it would be better to state in which countries/continents are these regional differences mentioned.	The sentence has been rephrased as follows:   In addition, studies conducted in Burkina Faso [53], Ethiopia [11, 45], Ghana [25], Nigeria [30, 54] and Sierra Leone[55] have reported regional differences in the initiation of ANC.
	Conclusion section “and last birth by caesarean section” is associated with late ANC or with early ANC as in discussion section. It is not clear.	The paragraph has been revised
	The abstract states late onset ANC in those without C section last birth, in the results section C section is associated with late ANC as in Table 1 (66% with last birth by c section have late ANC)	Changed accordingly

 

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

Firstly, the authors should provide a clear rationale for the chosen sample size, taking into consideration the statistical power required to detect meaningful effects. 

Secondly, the method of data collection is not clearly described. 

 

Additionally, the statistical analysis methods used in the study are not well-explained

 

Furthermore, the study design is not clearly articulated. The authors should provide more information on the research design

 

     

Author Response

	comments	Action taken
	Firstly, the authors should provide a clear rationale for the chosen sample size, taking into consideration the statistical power required to detect meaningful effects.	The paper is based on the secondary analysis of data that was collected by the National Statistical Office. It is difficult for the author to justify the sample size. That is the problem of using secondary data.
	Secondly, the method of data collection is not clearly described.	I have improved the section to make it clear
	Additionally, the statistical analysis methods used in the study are not well-explained	The presentation of the analysis was modified
	Furthermore, the study design is not clearly articulated. The authors should provide more information on the research design	I have improved the section to make it clear

Reviewer 3 Report

Comments and Suggestions for Authors

Factors associated with late antenatal visits among women in Malawi.

Abstract

• The abstract provides a concise yet informative overview of the study's objectives, methods, key findings, and implications.
• It effectively communicates the relevance of the study's results for informing ANC policies in Malawi.
• The identified factors associated with late ANC initiation contribute valuable insights for public health interventions.

Introduction

The introduction provides a thorough overview of the health situation in Malawi, contextualizing the persistently high maternal and child morbidity and mortality rates. It effectively introduces the rationale for the study, emphasizing the significance of ANC and the specific focus on the timing of the first ANC visit. The incorporation of historical data, global comparisons, and the WHO's recommendations enhances the depth of the introduction. Additionally, it sets the stage for the subsequent sections by highlighting the gaps in existing research and the use of a large-scale dataset.

Methodology

The methods section is adequately described. It provides a clear understanding of the data source, study population, and the variables used in the analysis. The inclusion of a reference to the detailed report of the 2015–16 MDHS enhances the transparency of the study's methodology. The methods of analysis are well-selected and suitable for the research questions. Ethical considerations are clearly outlined, demonstrating a commitment to ethical standards in both the original data collection and the secondary data analysis.

Results

The results are presented clearly, with well-organized information on the characteristics of the study population and factors associated with late ANC initiation. The use of percentages, logistic regression, and odds ratios enhances the clarity of the findings. The information is succinctly summarized, making it accessible to readers. The figures and statistics provided offer a comprehensive understanding of the study outcomes.

Discussion

Overall, the discussion effectively synthesizes the study's findings, providing a comprehensive overview of the factors associated with late ANC initiation in Malawi, while also acknowledging the study's strengths and limitations. The recommendations offer practical insights for policy and program development in the context of maternal healthcare.

Suggestions for Improvement

1. Clarity and Conciseness:
• Consider rephrasing sentences for greater clarity and conciseness. For instance, in the first sentence of the conclusion, you could say, "The study found that ANC initiation in Malawi is often delayed, with most first visits occurring after the first trimester."
2. Consistent Terminology:
• Ensure consistency in the use of terms. For example, you referred to "late initiation" in the title, but in the conclusion, you mentioned "late ANC association." Consistency in terminology will enhance clarity.
3. Data Presentation:
• Consider presenting some key descriptive statistics in the abstract to give readers a quick overview of the demographic characteristics of the study population. This could include the mean age, distribution of education levels, and other relevant details.
4. Abbreviations:
• Introduce and define any abbreviations at the first instance of use. For example, ANC could be introduced as "antenatal care (ANC)" upon first mention.
5. Highlighting Significance:
• Emphasize the significance of the findings. Why is it important to know the factors associated with late initiation of ANC in Malawi? How could this information be used to improve maternal health outcomes?
6. Avoid Repetition:
• Some information, such as the prevalence rate, is mentioned multiple times. While repetition is important for emphasis, consider avoiding redundancy and ensuring that each detail serves a specific purpose.
7. Future Directions:
• Consider adding a brief sentence at the end of the abstract to suggest potential future directions for research or implications for policy and practice based on the study's findings.

Here's a revised example considering some of the points mentioned:

"Late initiation of antenatal care (ANC) is a prevalent issue in Malawi, with 75.6% of women initiating ANC after the first trimester, as revealed by the 2015–16 Malawi Demographic and Health Survey. Factors associated with late ANC initiation include region, place of residence, marital status, and age. Notably, the study highlights the need for targeted interventions and policy adjustments to promote early ANC initiation and improve maternal health outcomes in Malawi."

 

 

 

 

 

 

Comments on the Quality of English Language

Factors associated with late antenatal visits among women in Malawi.

Abstract

• The abstract provides a concise yet informative overview of the study's objectives, methods, key findings, and implications.
• It effectively communicates the relevance of the study's results for informing ANC policies in Malawi.
• The identified factors associated with late ANC initiation contribute valuable insights for public health interventions.

Introduction

The introduction provides a thorough overview of the health situation in Malawi, contextualizing the persistently high maternal and child morbidity and mortality rates. It effectively introduces the rationale for the study, emphasizing the significance of ANC and the specific focus on the timing of the first ANC visit. The incorporation of historical data, global comparisons, and the WHO's recommendations enhances the depth of the introduction. Additionally, it sets the stage for the subsequent sections by highlighting the gaps in existing research and the use of a large-scale dataset.

Methodology

The methods section is adequately described. It provides a clear understanding of the data source, study population, and the variables used in the analysis. The inclusion of a reference to the detailed report of the 2015–16 MDHS enhances the transparency of the study's methodology. The methods of analysis are well-selected and suitable for the research questions. Ethical considerations are clearly outlined, demonstrating a commitment to ethical standards in both the original data collection and the secondary data analysis.

Results

The results are presented clearly, with well-organized information on the characteristics of the study population and factors associated with late ANC initiation. The use of percentages, logistic regression, and odds ratios enhances the clarity of the findings. The information is succinctly summarized, making it accessible to readers. The figures and statistics provided offer a comprehensive understanding of the study outcomes.

Discussion

Overall, the discussion effectively synthesizes the study's findings, providing a comprehensive overview of the factors associated with late ANC initiation in Malawi, while also acknowledging the study's strengths and limitations. The recommendations offer practical insights for policy and program development in the context of maternal healthcare.

Suggestions for Improvement

1. Clarity and Conciseness:
• Consider rephrasing sentences for greater clarity and conciseness. For instance, in the first sentence of the conclusion, you could say, "The study found that ANC initiation in Malawi is often delayed, with most first visits occurring after the first trimester."
2. Consistent Terminology:
• Ensure consistency in the use of terms. For example, you referred to "late initiation" in the title, but in the conclusion, you mentioned "late ANC association." Consistency in terminology will enhance clarity.
3. Data Presentation:
• Consider presenting some key descriptive statistics in the abstract to give readers a quick overview of the demographic characteristics of the study population. This could include the mean age, distribution of education levels, and other relevant details.
4. Abbreviations:
• Introduce and define any abbreviations at the first instance of use. For example, ANC could be introduced as "antenatal care (ANC)" upon first mention.
5. Highlighting Significance:
• Emphasize the significance of the findings. Why is it important to know the factors associated with late initiation of ANC in Malawi? How could this information be used to improve maternal health outcomes?
6. Avoid Repetition:
• Some information, such as the prevalence rate, is mentioned multiple times. While repetition is important for emphasis, consider avoiding redundancy and ensuring that each detail serves a specific purpose.
7. Future Directions:
• Consider adding a brief sentence at the end of the abstract to suggest potential future directions for research or implications for policy and practice based on the study's findings.

Here's a revised example considering some of the points mentioned:

"Late initiation of antenatal care (ANC) is a prevalent issue in Malawi, with 75.6% of women initiating ANC after the first trimester, as revealed by the 2015–16 Malawi Demographic and Health Survey. Factors associated with late ANC initiation include region, place of residence, marital status, and age. Notably, the study highlights the need for targeted interventions and policy adjustments to promote early ANC initiation and improve maternal health outcomes in Malawi."

 

 

 

 

 

 

Author Response

 

	Clarity and Conciseness: Consider rephrasing sentences for greater clarity and conciseness. For instance, in the first sentence of the conclusion, you could say, "The study found that ANC initiation in Malawi is often delayed, with most first visits occurring after the first trimester."	Changed as suggested
	Consistent Terminology: Ensure consistency in the use of terms. For example, you referred to "late initiation" in the title, but in the conclusion, you mentioned "late ANC association." Consistency in terminology will enhance clarity.	Noted. Revised as suggested.   I have decided to use late ANC initiation throughout.   Based on this I have also changed the title by replacing “visits” with initiation.
	Data Presentation: Consider presenting some key descriptive statistics in the abstract to give readers a quick overview of the demographic characteristics of the study population. This could include the mean age, distribution of education levels, and other relevant details.	Noted. Based on this a section on setting has been added in the methodology
	Abbreviations: Introduce and define any abbreviations at the first instance of use. For example, ANC could be introduced as "antenatal care (ANC)" upon first mention.	Done
	Highlighting Significance: Emphasize the significance of the findings. Why is it important to know the factors associated with late initiation of ANC in Malawi? How could this information be used to improve maternal health outcomes?	This was done. The following was added:   Encouraging early initiation of ANC among Malawian women can improve maternal and child health situation. Therefore, government policies and interventions should target women residing in rural areas, women with no or little education and other modifiable risk factors, such as young unmarried women and women’s autonomy
	Avoid Repetition: Some information, such as the prevalence rate, is mentioned multiple times. While repetition is important for emphasis, consider avoiding redundancy and ensuring that each detail serves a specific purpose	Removed the information that is repeated.
	Future Directions: Consider adding a brief sentence at the end of the abstract to suggest potential future directions for research or implications for policy and practice based on the study's findings.	Have included the following     Encouraging early initiation of ANC among Malawian women can improve maternal and child health situation. Therefore, government policies and interventions should target women residing in rural areas, women with no or little education and other modifiable risk factors, such as young unmarried women and women’s autonomy.
	Here's a revised example considering some of the points mentioned: "Late initiation of antenatal care (ANC) is a prevalent issue in Malawi, with 75.6% of women initiating ANC after the first trimester, as revealed by the 2015–16 Malawi Demographic and Health Survey. Factors associated with late ANC initiation include region, place of residence, marital status, and age. Notably, the study highlights the need for targeted interventions and policy adjustments to promote early ANC initiation and improve maternal health outcomes in Malawi."	This was revised as suggested.

 

Reviewer 4 Report

Comments and Suggestions for Authors

Dear Editor, many thanks for allowing me to review this interesting manuscript. The research idea is very interesting, but it requires a revision to improve its quality. The details are provided below.

Abstract: 

1. In the abstract, what makes your study different from other published papers? So, the gap in the study should be explicitly stated.

Introduction:

1. (DHS) This abbreviation wasn't mentioned in the abbreviations list, although it was used more than 10 times. 

2. The fifth paragraph, which starts with "Late initiation of ANC is not only associated with such negative health outcomes as premature birth, stillbirth, low birth weight, and increased complications………" is repeated in the sixth paragraph; therefore, it must be deleted.

3. In some cases, the author used these brackets [ ]; others used these brackets ( ). Please adhere to the style of the journal.

1. Some sentences are very long. Break them up into smaller, more manageable sentences.

Methods:

1. Although I am not convinced by the methodology on which the research was conducted, which is the use of data collected more than seven years ago on non-pregnant participants, at the least, only pregnant women should have been included in the study, not those who gave birth within the previous five years and the study design should be clarified in the title and method section. Please justify. 
2. In 2.3.2. There are a lot of redundancies in independent variables. It's enough to mention the theme without its categorization.
3. In 2.4. Analysis: Please clearly show how the model is fitted. How are the assumptions tested? How multicollinearity is checked? If you have done all those things, you need to report all findings.

Discussion 

         The discussion section is well written.

  Conclusion 

Please divide it into conclusion and clinical implication 

Reference 

Needs to be checked according to the journal's style 

Grammar 

The manuscript contains numerous grammatical errors; therefore, it needs English editing.

Comments on the Quality of English Language

The manuscript contains numerous grammatical errors; therefore, it needs English editing.

Author Response

 

	Comments	Action taken
	Abstract:  1. In the abstract, what makes your study different from other published papers? So, the gap in the study should be explicitly stated.	No study conducted has looked at this subject using DHS data.
	(DHS) This abbreviation wasn't mentioned in the abbreviations list, although it was used more than 10 times.	Included
	The fifth paragraph, which starts with "Late initiation of ANC is not only associated with such negative health outcomes as premature birth, stillbirth, low birth weight, and increased complications………" is repeated in the sixth paragraph; therefore, it must be deleted.	The fifth paragraph is removed. Sixth paragraph is maintained.
	In some cases, the author used these brackets [ ]; others used these brackets ( ). Please adhere to the style of the journal.	This was corrected
	Some sentences are very long. Break them up into smaller, more manageable sentences.	This was done. The language editor also assisted in this regards.
	Methods: Although I am not convinced by the methodology on which the research was conducted,   which is the use of data collected more than seven years ago on non-pregnant participants, at the least,   only pregnant women should have been included in the study, not those who gave birth within the previous five years and the study design should be clarified in the title and method section. Please justify.	Noted . However, this common in demographic studies of this nature.     This is true the data is old. But it is the most recent DHS in the country.     Noted. Studies that are clinic/hospital based tend to use pregnant women. Studies using DHS data usually use “women who gave birth within the previous five years”.
	In 2.3.2. There are a lot of redundancies in independent variables. It's enough to mention the theme without its categorization.	Noted. This is a matter of style. Some do mention categorisation others do not (this is what is being suggested). However, in my experience categorisation may affect the outcome of the results ie the statistical significance. That is why it is important to mention it.   In view of the above, to remove duplication, I have removed the following paragraph   age of the respondent, region, place of residence, education, sex of head of household, wealth status, work status, marital status, parity, frequency of listening to the radio or watching television or reading newspaper/magazine, knowledge of family planning, ever use of family planning, wanted last child, last birth by caesarean section. The independent variables were categorised as follows.
	In 2.4. Analysis: Please clearly show how the model is fitted. How are the assumptions tested? How multicollinearity is checked? If you have done all those things, you need to report all findings.	Multicollinearity was tested. A paragraph has been added
	Discussion           The discussion section is well written.	Noted with thanks.
	Conclusion  Please divide it into conclusion and clinical implication	This was done
	Reference  Needs to be checked according to the journal's style	I corrected the mistake and checked all references in line with journal format.
	Grammar  The manuscript contains numerous grammatical errors; therefore, it needs English editing.   Comments on the Quality of English Language The manuscript contains numerous grammatical errors; therefore, it needs English editing.	The corrected version was sent to the language editor.