Maternal Healthcare Access and Childbirth Outcomes in Rural, Resource-Limited Settings: Evidence from the Eastern Cape, South Africa

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Based on the article the original contributions, relevance, and the specific gap addressed can be summarized as follows. Based on the methods and results described in the manuscript, several methodological improvements and additional controls could strengthen the study’s validity and interpretation of findings.

1. The study included 213 participants with only 26 unfavorable outcomes (12%). This small number of outcome events likely reduced statistical power in the logistic regression models, which may explain why no variables reached statistical significance. Conduct a power calculation to determine the required sample size. Increase the sample or combine data from multiple facilities.
2. Participants were recruited only from St Elizabeth Hospital, which may introduce bias. Include participants from primary clinics, community settings, home births. Use multisite recruitment.

In summary, while the study is methodologically solid with its prospective, controlled, and randomized design, integrating these improvements would significantly enhance the internal and external validity, reduce bias, and provide stronger evidence for clinical recommendations.

Author Response

Please find attached a point-by-point response to the comments.

 

Thank You !!.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review thia article.

First dot point under public health significance is inconsistent with what is reported under public health implications. 

How long after childbirth were the women recruited. What about the accuracy of recall in these women for what happened at birth. Need to mention that information was obtained from health records and what this was. How were women recruited.

2.3 is not clear.

Results - what was included in unhealthy outcomes - provide examples here or list what they included.

Suggest consistency with use of birth or delivery.

What was the outcomes of those women who attended less than 4 visits and how did this compare to those that attended more.

Usually refer to tables in the text.

Add references to discussion where literature is referred to.

Line 273 - but about delayed access to services.

What about limitations.

There are two discussion sections.

Discussion needs developing more and taking back to the literature. It lacks the 'so what' of this research.

 

 

 

 

Author Response

Please find attached the point-by-point response to the comments. 

 

Thank You !!. 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Abstract: The abstract could be improved by adding measured outcomes in the objectives and also results.  

Introduction: It presents the situation in East Cape Town and the need to conduct this study. In order for the manuscript to flow easier, remove “Study aims” since the sentence starts with “ this study aimed.” Additionally, provide the outcomes measured.  

Material and Methods: This section has major flaws. Specify whether the study was prospective or retrospective to ensure readers fully understand the methodology.  

Please specify the inclusion and exclusion criteria for the study and explain the rationale for selecting the specific age range. Additionally, report the study's power calculation. Move any sample composition details from the methods section to the results section for proper organization.  

Clarify whether data collection was conducted through interviews or questionnaires. If a questionnaire was used, describe its development process, the usage of a framework, indicate if it was a validated instrument, and specify the number of items analyzed. Include appropriate references. Also, detail the statistical analyses performed in the study regarding the outcomes studied.  

Results: There are major flaws in this section. Please provide a few paragraphs that contain the significance of your results. Then provide the measured outcomes and indicate whether they were statistically significant.  

Discussion: It has major flaws. Since the results section does not provide enough details and it is difficult to understand the measured outcomes and their significance, the discussion section must be reformatted. It is appalling that the discussion section has no references and fails to discuss the results. There is a section that highlights the implications of a working hypothesis; however, the manuscript has not presented one. Additionally, the discussion section was added twice.  

Conclusion: Since the results section was poorly presented, the conclusion is unsubstantiated.

Author Response

Please find attached the point-by-point response to the comments. 

 

Thank You!!. 

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

The authors addressed all my suggestions. The manuscript has increased.