Intervention Strategies to Reduce Maternal Mortality in the Context of the Sustainable Development Goals: A Scoping Review

Round 1

Reviewer 1 Report (New Reviewer)

Comments and Suggestions for Authors

This is a systematic review of a highly topical subject, due to its importance and the suffering it causes. Maternal mortality is a scourge in the 21st century that should disappear.

For the introduction

1.      What are the trends in maternal mortality in the world? Is it increasing or decreasing? What trends are there in the various continents?

2.      From the text of the article, it appears that disparities in maternal mortality occur only in developed countries, but there are also large disparities in some African countries between MM in urban and rural areas. Comment on this aspect and introduce references.

MATERIAL AND METHODS

3.      Include a bibliographic reference AMSTAR 2 checklist, and explain what it consists of. Include a bibliographic reference Appraisal of 151 Guidelines for Research & Evaluation (AGREE) II instrument.

4.      The authors calculated the Kappa, indicate which program was used for its calculation, for example OpenEpi, IBM SPSS, Stata, etc.

5.      In line 159, reference is made to the WHO definition of maternal mortality, a bibliographic reference should be included.

RESULTS

1.      In figure 1 there is a typo  “sesarching”  it should be “database searching

2.      Please include in Figure 1Records identified through databases searching

3.      (n=976) the data of table 2, (Data base name, and number of records in each one)

 

4.      You should analyze, the country and the region where the studies were conducted.

5.      In my opinion, the results section is to short, and schematic. The authors should expand it, speaking of each of the studies.

6.      What does it mean in line 246 “locally” all the other studies international.

7.      Lines 246  write between brackets in which country is located Andalusia.

 

DISCUSION

8.      In the introduction the authors should introduce more bibliography, and comment on their findings

 

9.      What is the main message for the decision maker, what considerations should be taken at the local, regional, national and international level?

Author Response

Comments 1: What are the trends in maternal mortality in the world? Is it increasing or decreasing? What trends are there in the various continents?

Response 1: We have added a paragraph in which this statements are described:

The MMR is defined as the proportion of mothers who do not survive childbirth compared to those who do, per 100,000 live births (1) . The Millennium Development Goals (MDGs) achieved a 37% reduction in global MMR from 385 to 216 deaths per 100,000 live births between 1990 and 2015 [2 ]. However, according to the United Nations Population Fund (UNFPA), approximately 830 women still die each day worldwide due to pregnancy or birth-related reasons, which means that every two minutes a woman dies [3 ]. The global MMR in 2020 was estimated at 223 maternal deaths per 100 000 live births (UI 202 to 255), down from 227 in 2015 (Uncertainty interval 211 to 246) and from 339 in 2000 (UI 319 to 360) – a reduction of one third (34.3%) over the full 20-year period. On current trends, more than one million additional maternal deaths will occur by 2030. The average annual rate of reduction (ARR) in the global MMR from 2000 to 2020 was 2.1% (UI 1.3% to 2.6%), meaning that on average, the global MMR declined by 2.1% every year between 2000 and 2020, although progress was uneven throughout this period n 2020, sub-Saharan Africa was the only region with a very high4 MMR – estimated at 545 maternal deaths per 100 000 live births (UI 477 to 654). This is 136 times higher than the MMR in Australia and New Zealand (4; UI 3 to 4) where MMR was lowest. From lowest to highest, the regions of Europe and Northern America (13), Eastern and South-Eastern Asia (74), Northern Africa and Western Asia (84), and Latin America and the Caribbean (88) all had low MMRs (below 100) in 2020. Sub-Saharan Africa alone accounted for approximately 70% of global maternal deaths in 2020, followed by Central and Southern Asia which accounted for almost 17%. These regional differences in the MMR correspond to substantial differences in the lifetime risk of dying from a maternal cause.

Comments 2:   From the text of the article, it appears that disparities in maternal mortality occur only in developed countries, but there are also large disparities in some African countries between MM in urban and rural areas. Comment on this aspect and introduce references.

Response 2: This information is introduced in the precedent paragraph related to Comment 1.

Comments 3: Include a bibliographic reference AMSTAR 2 checklist, and explain what it consists of. Include a bibliographic reference Appraisal of 151 Guidelines for Research & Evaluation (AGREE) II instrument.

Response 3:  A bibliographic reference has been included: 

AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017;358:j4008

And also an explanation:

 The quality of the included systematic reviews was assessed using the AMSTAR 2 checklist to identify high quality of systematic reviews, including those based on non-randomised studies of healthcare interventions.

 A bibliographic reference has been included for AGREE II Instrument:

Brouwers, Melissa C., et al. "AGREE II: advancing guideline development, reporting and evaluation in health care." Cmaj182.18 (2010): E839-E842.  

Comments 4: The authors calculated the Kappa, indicate which program was used for its calculation, for example OpenEpi, IBM SPSS, Stata, etc.

Response 4: IBM SPSS has been used to calculate kappa statistic

Comments 5: In line 159, reference is made to the WHO definition of maternal mortality, a bibliographic reference should be included.

Response 5:  A bibliographic reference has been included:

Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO.

Comments 6:   In figure 1 there is a typo  “sesarching”  it should be “database searching

Response 6: It has been corrected.

Comments 7: Please include in Figure 1Records identified through databases searching

Response 7: It has been included.

Comments 8: (n=976) the data of table 2, (Data base name, and number of records in each one)

Response 8: These changes have been included.

 

Comments 9: You should analyze, the country and the region where the studies were conducted.

Response 9: Most of the studies included in the Scoping review are systematic reviews, meta-analysis, narrative reviews, and consensus documents in which many countries are included. The original papers do not refer to a specific country but describe circumstances related to maternal mortality, such as initiatives to reduce it, actions to improve delivery assistance, and other issues related to maternal mortality.  For this reason, it is not possible to indicate a specific country in each of the studies.

Comments 10: In my opinion, the results section is to short, and schematic. The authors should expand it, speaking of each of the studies.

Response 10: The synthesis of each of the articles included in this Scoping review can be found in Table 3. For this reason, comments on each of the studies have not been included in the section on writing up the results and they have been grouped according to the objectives of the article.

Comments 11:What does it mean in line 246 “locally” all the other studies international.

Response 11: The term “locally” refers to strategies promoted by local governments through triangular cooperation and fostering municipal international action. As an example, information has been included in this regard, related to the strategies developed by the Andalusian government (southern Spain) in relation to SGD 3.

Comments 12:    Lines 246  write between brackets in which country is located Andalusia

Response 12: Andalusian: In the South of Spain.

Comments 13:  In the introduction the authors should introduce more bibliography, and comment on their findings

Response 13: Some references have been introduced.

Comments 14: What is the main message for the decision maker, what considerations should be taken at the local, regional, national and international level?

Response 14: A new paragraph has been included:

Effective connections among the various SDGs are necessary to accelerate the achievement of reducing MM. Substantial shifts in focus and investment are needed now if the SDG target to achieve a global MMR below 70 is to be met. If the 2016–2020 pace of progress continues, by 2030, the global MMR would still be 222 maternal deaths per 100 000 live births – the same as estimated for 2020 – due to the stagnation in the ARRs observed during the first years of the SDG era.

With half of the SDG period remaining, the time is now to intensity efforts and renew the commitment to end preventable maternal mortality, and to ensure women not only simply survive a pregnancy but are healthy and thrive.

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

Abstract:
Lines 12-14: “According to the United Nations Population Fund, approximately every two minutes a woman dies, totaling approximately 830 deaths per day for reasons related to her pregnancy or childbirth.” Please review this phrase to ensure that it clearly indicates that these deaths are due to complications associated with pregnancy or childbirth. Right now, it is unclear.
Line 22: Please provide examples of these barriers.
Line 23: “The strategy...” - please indicate of what? Currently the transition between the barriers and the strategy is abrupt.

Introduction:
Line 33 and line 44: The authors mention association of Maternal Mortality and “health.”. It is unclear to what type (mental, somatic?) of health, and to whose health (of the females who passed away) the authors are referring. Please reconsider.

The Introduction covers a wide range of factors affecting MM. Organization of the ideas (e.g., grouping the related ideas; creating separate paragraphs for the mentioned factors etc.), as well as transition between ideas could be smoother to improve readability and coherence. Moreover, some of the phrases are lengthy and complex and could be simplified.

2. Material and Methods:
2.1. Methodology
Line 111: Which are these countries?

2.1.1. Search Strategy
Please mention the terms used for the research (for the time being, the MeSH are provided in the table only).
Line 123: The authors mention English and Spanish Languages. Further on, in the Inclusion/ Exclusion criteria, as well as in the Table 1 (Filters) there is information of studies in English, Spanish and Portuguese. Please clarify.

2.1.2. Inclusion/Exclusion Criteria
Some of the exclusion criteria (e.g., line 138: “The exclusion criteria were articles that did not relate MM to the SDGs”) appear redundant. Please reconsider.

2.1.3. Data Collection
Line 145: The phrase "The two authors (I.C-G & L.M.O-R) carried out the search in pairs" is somewhat redundant, as "two authors" implies a pair. Please reconsider.

 

3.1.2. Main Results
3.1.2.1. Main Barriers to Implementation
I find this section not specific enough. For instance, it feels that some barriers are mentioned without much explanation (e.g., "lack of records" - what types of records are missing?).

3.1.2.2. Interventions Aimed at Reducing MM
The interventions listed by the authors are important. Providing wider context, or more specific examples would however strengthen the argumentation and help the reader understand the interventions more deeply.

 

Discussion:
The Discussion section seems to be somewhat dense in ideas, superficial and lacks balance (e.g., the authors emphasize the training, while put less focus on other elements). The topic of the article as relevant, and therefore providing shorter and more specific paragraphs related to the discussed elements, would be beneficial. Not only it would strengthen the paper, by giving clarity but also would improve the readers experience.

Comments on the Quality of English Language

See the review.

Author Response

Comments 1: Lines 12-14: “According to the United Nations Population Fund, approximately every two minutes a woman dies, totaling approximately 830 deaths per day for reasons related to her pregnancy or childbirth.” Please review this phrase to ensure that it clearly indicates that these deaths are due to complications associated with pregnancy or childbirth. Right now, it is unclear.

 

Response 1: These data have been checked according to the information about this in the estimate that WHO, UNICEF, UNFPA, Word bank group, and UNDESA in their publication “Trends in maternal mortality 2000 to 2020” and we have updated these data with this paragraph in the introduction as well as in the Abstract:

In 2020, an estimated 287 000 women worldwide died from a maternal cause, equivalent to almost 800 maternal deaths every day and approximately one every two minutes. This is more than a third lower than in 2000 when there were estimated 446 000 maternal deaths.

Comments 2: Line 22: Please provide examples of these barriers.

Response 2: We have included in the abstract: Social and structural barriers.

Comments 3: Line 23: “The strategy...” - please indicate of what? Currently the transition between the barriers and the strategy is abrupt. 

Response 3:  We have included examples of strategies in the abstract:  Strategies to protect maternal health, especially in the most at-risk populations, and improve health system.

Introduction: 
Comments 4: Line 33 and line 44: The authors mention association of Maternal Mortality and “health.”. It is unclear to what type (mental, somatic?) of health, and to whose health (of the females who passed away) the authors are referring. Please reconsider.

Response 4: We have introduced specifications related to this regard.

Comments 5: The Introduction covers a wide range of factors affecting MM. Organization of the ideas (e.g., grouping the related ideas; creating separate paragraphs for the mentioned factors etc.), as well as transition between ideas could be smoother to improve readability and coherence. Moreover, some of the phrases are lengthy and complex and could be simplified.

Response 5: We have modified the paragraphs so that the reading can be easily done.

2. Material and Methods: 
2.1. Methodology
Comments 6: Line 111: Which are these countries? 

Response 6: Most of the studies included in the Scoping review are systematic reviews, meta-analysis, narrative reviews, and consensus documents in which many countries are included. The original papers do not refer to a specific country but describe circumstances related to maternal mortality, such as initiatives to reduce it, actions to improve delivery assistance, and other issues related to maternal mortality.  For this reason, it is not possible to indicate a specific country in each of the studies. We have included “Countries where strategies have been analysed to reduce MM have been evaluated” as the PICO question in general.

2.1.1. Search Strategy

Comments 7:  Please mention the terms used for the research (for the time being, the MeSH are provided in the table only).

Response 7: MeSH are included in the text

Comments 8: Line 123: The authors mention English and Spanish Languages. Further on, in the Inclusion/ Exclusion criteria, as well as in the Table 1 (Filters) there is information of studies in English, Spanish and Portuguese. Please clarify.

Response 8: We have used these MeSH, described in the precedent comment, in English or Spanish to define the search profile. Another thing is that the inclusion and the exclusion criteria included articles in Spanish, English or Portuguese.

2.1.2. Inclusion/Exclusion Criteria
Comments 9: Some of the exclusion criteria (e.g., line 138: “The exclusion criteria were articles that did not relate MM to the SDGs”) appear redundant. Please reconsider. 

Response 9: We have kept this sentence because we want to emphasize this circumstance.

2.1.3. Data Collection
Comments 10: Line 145: The phrase "The two authors (I.C-G & L.M.O-R) carried out the search in pairs" is somewhat redundant, as "two authors" implies a pair. Please reconsider.

Response 10: We have eliminated “in pairs”

 

3.1.2. Main Results
3.1.2.1. Main Barriers to Implementation
Comments 11: I find this section not specific enough. For instance, it feels that some barriers are mentioned without much explanation (e.g., "lack of records" - what types of records are missing?).

Response 11: We have included the records that can be missing to clarify the appropriate magnitude of MM: medical records, police records, surveillance systems, national registries, death certificates, censuses, medical autopsies and administrative reviews to estimate the true number of maternal deaths in a specified geographic area.

3.1.2.2. Interventions Aimed at Reducing MM

Comment 12: 
The interventions listed by the authors are important. Providing wider context, or more specific examples would however strengthen the argumentation and help the reader understand the interventions more deeply.

Response 12: We have included a paragraph listing some of these specific examples: Multisectoral action is needed to target the distal determinants of maternal mortality – including health system failures, social determinants that put some subpopulations at greater risk, harmful gender norms and biases, and both humanitarian and climate crises that lead to health system fragility.

Discussion:
Comments 13: The Discussion section seems to be somewhat dense in ideas, superficial and lacks balance (e.g., the authors emphasize the training, while put less focus on other elements). The topic of the article as relevant, and therefore providing shorter and more specific paragraphs related to the discussed elements, would be beneficial. Not only it would strengthen the paper, by giving clarity but also would improve the readers experience.

Response 13: We have restructured the Discussion section to make it more readable. We have included one paragraph to enhance other elements:

Member States must intensify efforts to address health system failures that erode the provision of safe, affordable and quality sexual and reproductive health care. Efforts must be made to reduce health inequities by addressing the needs of populations in vulnerable and marginalized situations. These inequities can lead to mistreatment within the health system, erode trust and impede service utilization.

 

Round 2

Reviewer 1 Report (New Reviewer)

Comments and Suggestions for Authors

The authors have incorporated all my remarks in the manuscript or answer adequately.

 There is a minor question: The authors should include the version of the software used. They just said IBM SPSS, and they should include the version of the program. 

Author Response

Comments 1: There is a minor question: The authors should include the version of the software used. They just said IBM SPSS, and they should include the version of the program. 

Response 1: Thank you for this suggestion. We have added version: 

SPSS v. 28.1 for Windows (IBM Corp. 2018, Armonk, NY, USA)

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

Overall, I find the work done within the revisions insufficient, with only some elements added. The discussion seems to be unspecific, without clear ideas, strategies, implementation, recommendations etc. Please add subsections related to specific strategies or recommendations, providing a more clear structure of the review.

A better option is to synthesise the information: Please present all these in a form of a table, making the results more visible.

Please also indicate the quality assessment of the studies included.

Moreover, the authors indicated that this was a scoping review in the title, but at the same time they indicate that this is a systematic review in the abstract and in the other parts of the paper. 

Author Response

Comments 1:Overall, I find the work done within the revisions insufficient, with only some elements added. The discussion seems to be unspecific, without clear ideas, strategies, implementation, recommendations etc. Please add subsections related to specific strategies or recommendations, providing a more clear structure of the review.

Response 2:  A new structure has been included in the discussion to clarify its structure.

Comments 2: Please also indicate the quality assessment of the studies included.

Response 2: We have included this paragraph in the Method section to clarify the quality assessment: 

The quality of the included systematic reviews was assessed using the AMSTAR 2 checklist to identify high quality of systematic reviews, including those based on non-randomised studies of healthcare interventions. The methodological quality of consensus documents  was assessed using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument. They were indentified as “High quality” articles when they met more than 75% of the standard criteria proposal, as “Medium-Low quality” if the percentage was between 50% and 75% of the criteria, and as “Low quality” if the percentage was below 50%.   And also the quality assessment of each study is included in table 3 in the Categorization column.

Comments 3: Moreover, the authors indicated that this was a scoping review in the title, but at the same time they indicate that this is a systematic review in the abstract and in the other parts of the paper.

Response 3: We have included Scoping review when needed.

Round 3

Reviewer 2 Report (New Reviewer)

Comments and Suggestions for Authors

The paper has been improved satisfactorily.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript is scientifically written. However, the abbreviations must be avoided in the abstract. Objective: To understand strategies to reduce maternal mortality within the context of SDGs, the verb understand is not measurable, it must be replaced.

Author Response

Dear reviewer, 

Thank you for your suggestions. The abbreviations have been eliminated and we have substituted understand for analyse.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors:

Thank you for allowing me to review this manuscript. I believe that this work has virtues and positive aspects, but it has serious methodological problems that require very deep changes, so unfortunately my recommendation is rejection. Even so, I am going to make some comments with the aim of trying to improve this work,

-Introduction: Correct. Line 74 refers to an old statistic (68% of births attended by trained personnel). It would be perhaps convenient to put more recent data (and check if it is the correct reference).

-Methods:

-Line 91 should explain the acronyms of the UN, UNFPA, and Cooperanda. It would be useful to cite these websites.

-The search dates for each database should be included (according to PRISMA standards).

-Inclusion/Exclusion Criteria: This is the most problematic aspect of your review and justifies my rejection. My opinion is that you should have excluded observational studies from your review, as this type of study is not in line with the PICO question posed and it was also the most appropriate thing to do if you subsequently intended to perform a meta-analysis. I would like to point out that for reviews of observational studies there are other standards, the MOOSE (Meta-Analysis Of Observational Studies in Epidemiology guidelines). But you also include in your results systematic reviews (with or without meta-analysis), as well as including studies where the design is not indicated (you even include ecological studies). This indicates that there is no concordance in the methodology used and the results obtained. It is not possible to mix so many different designs in a systematic review. For this there are other designs (exploratory reviews, umbrella reviews...).

On the other hand, a record for which the full text has not been obtained should not be considered as an exclusion criterion. You indicate that records with low quality were excluded, but only explain how quality was determined in observational studies.

Another aspect is that it is not explained what system was used when there was a discrepancy between the two authors regarding the inclusion of a record.

In the methodology you state that you have used Kappa statistic to assess the degree of agreement. Where are these results? The same applies to the use of Review Manager software to determine the bias of the included studies. These results are not available.

Finally at no point do you state which variables were going to be extracted.

Results:

The flow chart does not follow the PRISMA scheme. The reasons for rejections are not stated. According to this scheme, you only included studies with free open access, which is such an important bias that by itself determines the rejection. Moreover, it does not identify the interventions that reduce maternal mortality, which in the end is what answers the PICO question.

I regret to reject this manuscript, because the subject is important (although there are already many systematic reviews published on the subject), but methodologically it has serious problems that make rejection advisable.

Author Response

Comments 1: Correct. Line 74 refers to an old statistic (68% of births attended by trained personnel). It would be perhaps convenient to put more recent data (and check if it is the correct reference).

Response 1: Thank you for your recommendation. A new reference has been introduced with updated information regarding this issue from the World Health Organization. This new information has been included in the article.

Comments 2: Line 91 should explain the acronyms of the UN, UNFPA, and Cooperanda. It would be useful to cite these websites.

Response 2: Thank you for this comment. These acronyms have been already introduced in the abstract (lines 22-23).  Also, a description of these sources of information has been introduced in Method section.

Comments 3: -The search dates for each database should be included (according to PRISMA standards).

Response 3:Thank you for the comment. These dates have been introduced in table 2 and also in Method section.

Comments 4: Inclusion/Exclusion Criteria: This is the most problematic aspect of your review and justifies my rejection. My opinion is that you should have excluded observational studies from your review, as this type of study is not in line with the PICO question posed and it was also the most appropriate thing to do if you subsequently intended to perform a meta-analysis. I would like to point out that for reviews of observational studies there are other standards, the MOOSE (Meta-Analysis Of Observational Studies in Epidemiology guidelines). But you also include in your results systematic reviews (with or without meta-analysis), as well as including studies where the design is not indicated (you even include ecological studies). This indicates that there is no concordance in the methodology used and the results obtained. It is not possible to mix so many different designs in a systematic review. For this there are other designs (exploratory reviews, umbrella reviews...).

Response 4: Thank you for this important comment. The research team has reflected on this circumstance and, in order to adapt the article to the reviewer's recommendations, has decided to modify the type of study to "scoping review". Thus, the work carried out can be adapted to the very pertinent recommendations of the reviewer. Therefore, we have changed the title to: 

"Intervention strategies to reduce maternal mortality in the context of the sustainable development goals: a scoping review."

Comments 5: On the other hand, a record for which the full text has not been obtained should not be considered as an exclusion criterion. You indicate that records with low quality were excluded, but only explain how quality was determined in observational studies.

Response 5: Thank you again for this comment. We have not included these articles (without the full text is not available), because the quality of these articles is low. We have used multiples resources in order to obtain these full text such as: interlibrary loan, university library repositories... but we found many difficulties in obtaining the full text of these articles. However, the total number of articles for which the full text could not be obtained was very low (n=6).

Comments 6: Another aspect is that it is not explained what system was used when there was a discrepancy between the two authors regarding the inclusion of a record.

Response 6: To assess the methodological quality of the articles, the Enhancing the QUality and Transparency Of health Research (EQUATOR). For the assessment of experimental studies, the CONsolidated Standards of Reporting Trials (CONSORT). We have included figure 1 to explain the discrepancy.

Comment 7: In the methodology you state that you have used Kappa statistic to assess the degree of agreement. Where are these results? The same applies to the use of Review Manager software to determine the bias of the included studies. These results are not available.

Response 7: The Kappa statistic is 0.79 and it is included in the subheading 2.1.3 Data Collection in lines 165-166

Comments 8: Finally at no point do you state which variables were going to be extracted.

Response 8: We have included one section related to the variables extracted.

Comments 9: The flow chart does not follow the PRISMA scheme. The reasons for rejections are not stated. According to this scheme, you only included studies with free open access, which is such an important bias that by itself determines the rejection. Moreover, it does not identify the interventions that reduce maternal mortality, which in the end is what answers the PICO question.

Response 9: We have adapted the Flow diagram of the selection of articles according to PRISMA. As we have already explained we have included not only articles with free open access, but also articles that we could obtain the full text. There were only 6 articles in which we could not obtain the full text, probably because their low quality. (6 articles out of 651 screened is not an important bias).

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors, congratulations on a dense and interesting manuscript.

I have a few comments:

In lines 89-90, is it relevant to inform the period of application of PRISMA? I believe that there may be some confusion at first reading with the historical period of the review.

In Table 2 there is a selection filter mentioning 2025-2024, which is not clear.

In lines 147-148, it is also unclear why 651 articles were discarded after using the reference manager.

And last but not least, what surprised me is that there was no research that cited the implementation of a public health system, such as the English NHS or the Brazilian SUS, as an important policy intervention.

Author Response

Dear reviewer,

Thank you for your comments. We attach the responses for your suggestions:

Comment 1:  In lines 89-90, is it relevant to inform the period of application of PRISMA? I believe that there may be some confusion at first reading with the historical period of the review.

Response 1: We have included the period of application of PRISMA to avoid confusion.

Comment 2: In Table 2 there is a selection filter mentioning 2025-2024, which is not clear.

We have modified the mistake. Thank you.

Comment 3: In lines 147-148, it is also unclear why 651 articles were discarded after using the reference manager.

Response:  Articles were discarded once added to the reference manager because of duplicity, not related with the aim of the revision abstracts for which we could not find the full reports and studies with low quality assessments. We have included this statement in the article.

Comment 4: And last but not least, what surprised me is that there was no research that cited the implementation of a public health system, such as the English NHS or the Brazilian SUS, as an important policy intervention.

Thank you for the suggestion. We have included this information in the intruduction section : 

Within the health policies of public health systems, we should highlight those implemented by the English NHS and the Brazilian SUS. Although they have been effective and aligned with the sustainable development objectives, there is still a long way to go as there are still differences in maternal mortality between Black ethnic backgrounds compared to White women and women living in the most deprived areas

Reviewer 4 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you so much for this timely article titled "Intervention Strategies to reduce maternal mortality in the Context of the Sustainable Development Goals: a systematic review."

I have read through your work and I must say this is a well-crafted piece that flows seamlessly. However, there are a few issues you need to attend to, these suggestions may strengthen your argument and make the article clearer.

-Sustainable development goals should be one of the keywords in the abstract.

-In the introduction, the first two lines in the introduction should have a citation.

-In line 56, kindly add a statement to highlight that the 3-Delay models vary from one context to another.

-Line 57 delete 'they'

-As a major issue, a sub-heading for strengths and limitations of this review should be provided rather than being embedded in the discussion section. This will quickly show the readers why the systematic review was important and if there are striking findings.

-Generally, proofread your manuscript to expunge redundant sentences and punctuations.

-Lastly, I will be glad to read this manuscript if it makes it to publication.

 

 

 

Comments on the Quality of English Language

None

Author Response

Dear reviewer,

Thank you for your feedback and suggestions.  We follow your recommendations and comments.

Comments 1 : -Sustainable development goals should be one of the keywords in the abstract.

Response 1: Sustainable development goals has been included as a keyword.

Comments 2: -In the introduction, the first two lines in the introduction should have a citation.

Response 2: We have added a citation related to maternal mortality and Sustainable development goals 

Comments 3: -In line 56, kindly add a statement to highlight that the 3-Delay models vary from one context to another.

Response 3: We have introduced the 3 model delay described by Thaddeus and Maine with a discussion in the variation due to different contexts.

Comments 4: -As a major issue, a sub-heading for strengths and limitations of this review should be provided rather than being embedded in the discussion section. This will quickly show the readers why the systematic review was important and if there are striking findings.

Response 4: We have introduced one subheading within the discussion section with the strengths and limitations of this review.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors:

Thank you for allowing me to revise this manuscript again. Thank the authors for the changes implemented in the manuscript. While some aspects have been improved, other questions have not been satisfactorily answered. I indicate some of the most important aspects:

-You indicate that after reflection of the research team you have considered that a scoping review is better adapted to your work. However, you indicate that you have carried out the risk of Bias across studies. This is not applicable to this type of review, according to item 15 of PRISMA. -Recruitment: Who recruited the participants? Did the researchers know the participants? How many participants refused to participate? If so, explain the possible reasons. All these questions are very important in qualitative studies and should be reflected in the study.

Item 15 (Not Applicable): Risk of Bias Across Studies

This item from the original PRISMA is not applicable for scoping reviews because the scoping review method is not intended to be used to critically appraise (or appraise the risk of bias of) a cumulative body of evidence.

Furthermore, in figure 1, it does not appear which studies have been assessed for bias. This is possible to check, as the results table does not identify which studies are experimental studies (many studies are referred to as original papers, which is not a study design).

- Scoping reviews can be conducted to meet various objectives. They may examine the extent (that is, size), range (variety), and nature (characteristics) of the evidence on a topic or question; determine the value of undertaking a systematic review; summarize findings from a body of knowledge that is heterogeneous in methods or discipline; or identify gaps in the literature to aid the planning and commissioning of future research. But this does not mean that a disparity of studies or designs can be mixed. For example, it does not make sense to include systematic reviews in a scoping review (that is what the umbrella review design is for). This review aims to analyse intervention strategies to reduce maternal mortality, but in the results it is not clear which interventions are included. (item 21: Synthesis of Results Summarize or present the charting results as you relate to the review questions and objectives.)

-The search dates for each database do not appear. I am not referring to the years of origin of the records included, but you should indicate the dates on which each database was searched.

-You indicate that you did not access some records because the relevance was low, but these are concepts that should not be confused. How was this supposedly low relevance assessed?

-They have not answered how possible discrepancies between the two researchers were resolved.

-The flow chart is not described according to the Prisma recommendations (e.g. the reasons for exclusion are not explained, the arrows do not follow the right direction).

-It remains unclear how the methodological quality of certain included records such as systematic reviews and consensus documents was assessed.

I am sorry. In my opinion, this review has serious methodological problems that make its rejection advisable. I hope that these comments will help you to improve your future work. Best regards

Author Response

Comments 1:

-You indicate that after reflection of the research team you have considered that a scoping review is better adapted to your work. However, you indicate that you have carried out the risk of Bias across studies. This is not applicable to this type of review, according to item 15 of PRISMA. -Recruitment: Who recruited the participants? Did the researchers know the participants? How many participants refused to participate? If so, explain the possible reasons. All these questions are very important in qualitative studies and should be reflected in the study.

Item 15 (Not Applicable): Risk of Bias Across Studies

This item from the original PRISMA is not applicable for scoping reviews because the scoping review method is not intended to be used to critically appraise (or appraise the risk of bias of) a cumulative body of evidence.

Furthermore, in figure 1, it does not appear which studies have been assessed for bias. This is possible to check, as the results table does not identify which studies are experimental studies (many studies are referred to as original papers, which is not a study design).

Response 1: Thank you for this clarification. Figure 1 has been removed.

Comments 2: Scoping reviews can be conducted to meet various objectives. They may examine the extent (that is, size), range (variety), and nature (characteristics) of the evidence on a topic or question; determine the value of undertaking a systematic review; summarize findings from a body of knowledge that is heterogeneous in methods or discipline; or identify gaps in the literature to aid the planning and commissioning of future research. But this does not mean that a disparity of studies or designs can be mixed. For example, it does not make sense to include systematic reviews in a scoping review (that is what the umbrella review design is for). This review aims to analyse intervention strategies to reduce maternal mortality, but in the results it is not clear which interventions are included. (item 21: Synthesis of Results Summarize or present the charting results as you relate to the review questions and objectives.)

Response 2: Thank you for this comments.  The results related to the review questions and objectives have been included in Table 3. Note that not only have interventions been included but also identified barriers to avoid them, both are objectives of the study.

Comments 3: The search dates for each database do not appear. I am not referring to the years of origin of the records included, but you should indicate the dates on which each database was searched.

Response 3: These dates have been included in Table 2. There were introduced in lines 111-112.

Comments 4: You indicate that you did not access some records because the relevance was low, but these are concepts that should not be confused. How was this supposedly low relevance assessed?

Response 4: The exclusion criteria were articles that did not relate MM to the SDGs, as well as those from which the full document could not be obtained (because the relevance was low due to the low impact factor)and those of low quality (not included in Journal Citation Ranking and gray literature).

Comments 5: -They have not answered how possible discrepancies between the two researchers were resolved.

Response 5: Any discrepancies between the authors were resolved through discussion, until consensus was reached.

Comments 6: -The flow chart is not described according to the Prisma recommendations (e.g. the reasons for exclusion are not explained, the arrows do not follow the right direction).

Response 6: The flow chart has been modified according to PRISMA recommendations.

Comments 7: -It remains unclear how the methodological quality of certain included records such as systematic reviews and consensus documents was assessed.

Response 6:  The quality of the included Systematic reviews was assessed using the AMSTAR 2 checklist.  The methodological quality of consensus documents  was assessed using the Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument.

 

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors, I can see that the recommendations have been followed, which has contributed to making the manuscript even more consistent as an important reference in the field.

 

Author Response

Comments 1: Dear authors, I can see that the recommendations have been followed, which has contributed to making the manuscript even more consistent as an important reference in the field.

Response 1: Thank you for your review.

Reviewer 4 Report

Comments and Suggestions for Authors

Dear Authors

Thank you for addressing the review comments comprehensively. Looking forward to reading this article.

 

All the best in other processes.

 

Author Response

Comments 1: Thank you for addressing the review comments comprehensively. Looking forward to reading this article.

Response 1: Thank you for your review and your kind words.