Strategies to Reduce Maternal Death Rate and Improve the Provision of Quality Healthcare Services in Selected Hospitals of Vhembe District Limpopo Province

Round 1

Reviewer 1 Report

The topic has a relevant importance, since it addresses maternal death and how it can be reduced in the context studied, being able to design an Action Plan to reduce the MMR rate. It is a very well written and methodologically correct document.

Although it is understood, in line 42 it should correctly indicate the meaning of the acronym SA. Similarly, in line 49 the same happens with the acronym ESMOE.

In Table 3 it is not necessary to indicate the sex of the participants, since it is understood that they are all women.

It indicates that nurses have a "negative attitude towards patients", that their "Language is not very empathetic" and that there is "Mistreatment of patients by frustrated midwives", it would be good for them to find out why they act this way, frequent are the reasons for the lack of adequate quality and humane care.

They should correct reference 1.

 

Author Response

All comments raised were corrected.

Reviewer 2 Report

Thank you for the opportunity to review this manuscript. It addresses an important issue. Having said that, some issues need the attention of the authors. 

Introduction: The introduction needs to be structured to distinguish global issues on maternal health from local South Africa issues. There needs to be a sub-section in the introduction that discusses the issue of maternal health in South Africa and the strategies in place. For instance, why were strategies such as BANC, ESMOE etc implemented in SA, when was it implemented, and has it been evaluated before this research? Another reason for having a sub-section that discusses the local issues in South Africa is that the readers want to know the place of Limpopo among other South African provinces. How many provinces does South Africa have?

Use of acronyms and decimals: There are so many acronyms, such as MHC, SA, ESMOE etc, that need to be spelt out on first usage. Also, use points instead of commas when presenting data in percentages. See line 65 on page 2.

Design: the rationale for phenomenological design was unclear, considering the expansive number of objectives. It needed to be clarified what the phenomenon was. Is it the existing strategies against maternal death or the perceptions of doctors, midwives and patients about it? Is this a descriptive or interpretive phenomenological design? What is the phenomenological essence in this study, and how are the issues of bracketing, and reflectivity addressed in this study? 

Methods: What informed the selection of the four sub-districts in Vhembe? Participant recruitment should be in a separate sub-section for better clarity. The explanation that the sample size was determined by saturation could have been more convincing, especially since seven participants were recruited from each sub-districts. Did recruitment continue even after saturation was reached to achieve this uniformity, and why?

Data collection: The interview guide needs to reflect that their knowledge of existing strategies was obtained, and was this considered during recruitment? What criteria were used for purposive sampling? Who were the interview guide pre-tested with, and what changed because of this pre-testing? The needs to be more transparency about the research process.

Data analysis: What informed the use of IPA? How was quality achieved in the analysis? What roles did the co-authors play in the credibility of the analysis? Were the transcripts hand-coded, or did you use a software? The trustworthiness section needs more information to help readers understand the research process more.

Results: The resonance between the Donabedian framework and the study findings is unclear and seems forced. There are some issues with the theme and subthemes, which will be described below:

Theme 1: There are many overlaps between the themes, especially those that describe negative interactions between patients and midwives. In light of these, consider these three subthemes as opposed to the current five: Neglectful care and illtreatment, Unprofessional communication and unempathetic care. The theme itself can be negative interactions with midwives.

Theme 2: The theme would convey a more straightforward message if it is written as 'factors influencing poor maternal health outcomes. Theme 3.2.3 should be removed because the quotes do not support the assessment of incompetence among the nursing staff. In quote one, a doctor says a midwife does not respect or follow their instructions. Midwives are not supposed to be subservient to doctors. Rather, they need to collaborate and mutually earn each other's respect. The second quote also concludes that midwives are incompetent due to a delay in attending to the patient. This could be due to many factors, some of which you have outlined that might be outside the midwives' control. 3.2.2 should be moved and merged with 3.2.1 because it is about shortage. 

3.1.1 : Nurses or midwives? The lack of consistency in the use of nurses and midwives needs to be addressed. The opening sentence under 3.1.1 'to answer an open-ended question' needs to be clarified. 

The manuscript needs another round of proofreading and editing.

 

Author Response

All comments raised were corrected.

Author Response File: Author Response.pdf

Reviewer 3 Report

Congratulations to the authors. This is a well-written and constructed manuscript. I enjoyed learning about the study. I believe it is worthy of publication.

Some minor changes:

1. Introduction

-      Line 42: define SA.

-      Line 49: define ESMOE.

-      Line 53: define MHC.

- Line 74: I suggest discerning between general objective and specific objectives.

3. Materials and Methods

-      Line 96-102: Summarize.

-      Line 110: Tables’ enumeration should be reviewed.

-   It is recommended to include Tables 1,2 and 3 as appendix.

-  Line 117: ‘The first author (an MPH student on research training) conducted the interviews.’ In line 102 it is included that interviews were conducted in a quiet room occupied by one participant and the first author. It should be unified.

-     Line 140: ‘Data saturation…’. This sentence should be included in ‘Results’ section.

 

4. Results

-    Line 165: Table’s enumeration.

-      Line 165-169: The wording is not clear.

- Table 9: It is recommended to include the abbreviations and its definitions on footers. Please, Table’s enumeration should be reviewed.

-  Figure 1: The colors which have been used make reading difficult.

- Line 369 and line 419: In Table 1 and 2, 16 professionals are described.

 

5. Discussion

-   The use of verbal tenses should be reviewed.

- Line 552: The use of capital letters should be reviewed.

-      Line 559-562: Cite.

-      Line 571-572: Cite.

-  Line 712 and 715: The sentence ‘that comprises routine intrapartum care and antenatal care’ appears twice.

-  It is suggested to stablish possible underlying mechanisms which could respond to the findings of this study, as well as proposing new further research areas.  

Author Response

All comments raised were corrected.

Author Response File: Author Response.docx

Reviewer 4 Report

Excellent research. Commend the authors. Recommend reducing length of article substantially. Recommend using active voice whenever possible. 

Evaluate active vs passive verbs. Use active when possible.

Author Response

All comments raised were corrected.

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

Thank you for the opportunity to re-review this article. Kindly find my comments below:

1. 

2. Page 1, line 38: consider low and middle-income country as opposed to poor and middle poorer countries.

3. The citation order in unclear. In page 1, it went from 1 to 2 to 19. 

3. Page 2, line 46 - it is unclear what this uncited sentence means: "10% of millions...

Second paragraph on page 2 is an illustration of the writing challenges that plagued this article.

A study conducted in University of Maryland: Haiti (United States), discovered that regardless of introduced strategies such as community-based care and shifting tasks strategy for maternal care, there are still high reported rates of maternal mortality in Haritis [12]. Maternal mortality ratio is 380 deaths per 100,000 live births. Moreover, the lifetime risk of passing away from pregnancy-related problems is 1 in 83%. Despite implemented frameworks such as the Donabedian framework in Kenya, there is no improvement in MHC (maternal health care) [48]. It was also revealed that pregnant women wait for an extended period in ques, and this is associated with lower client satisfaction [11]. The situation is similar in Namibia because approximately every pregnant woman has limited access to MHC services, reducing access to emergency obstetric care and thus contributes to higher MMR [48].

What is Haritis? Is Haiti US/? The article used to support the first sentence in the paragraph above does not align with the content.

Aim and objectives: There objectives are not well linked to the aim and needs to be revised. 

Methodology: It is not convincing that phenomenology is the right approach for this study and the research question posed. Approaching it from an evaluative perspective might be more appropriate. It is still not clear what the phenomenon is.

Why Vhembe: The reasons given "Hospitals in Vhembe district were selected because they are mainly used by rural villagers who cannot afford private health care services. Moreover, they were selected because they cater for large populations from different areas. A non-probability purposive sampling technique was utilized to sample hospitals" are vague and does not link with the aims of the research.

Recruitment: It is unclear how and the decision around continuing recruitment is not soundly presented.

 

This article is poorly written. There is no coherence within and between paragraphs. Most of the references were incorrect due to incorrect numbering and missing referencing in some instances. For instance, after 1 and 2, the next citation was 29 and 12 was a mis-attribution. 

A professional editor should recommended for publication in this journal

Author Response

All comments raised were attended to, see attached..

Author Response File: Author Response.docx