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. 2021 Jul 23;16(7):e0254935. doi: 10.1371/journal.pone.0254935

Mothers’ utilization and associated factors of preconception care in Africa, a systematic review and meta-analysis

Tiwabwork Tekalign 1,*, Tesfanesh Lemma 2, Mulualem Silesh 2, Eyasu Alem Lake 1, Mistire Teshome 1, Tesfaye Yitna 1, Nefsu Awoke 1
Editor: Joseph Telfair3
PMCID: PMC8301666  PMID: 34297760

Abstract

Background

As the studies show, in every minute in the world, 380 women become pregnant and 190 face unplanned or unwanted pregnancies; 110 experience pregnancy-related complications, and one woman dies from a pregnancy-related cause. Preconception care is one of the proven strategies for the reduction in mortality and decreases the risk of adverse health effects for the woman, fetus, and neonate by optimizing maternal health services and improves woman’s health. Therefore, this study aimed to estimate the pooled prevalence of utilization of preconception of care and associated factors in Africa.

Methods

Systematic search of published studies done on PubMed, EMBASE, MEDLINE, Cochrane, Scopus, Web of Science CINAHL, and manually on Google Scholar. This meta-analysis follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The quality of studies was assessed by the modified Newcastle-Ottawa Scale (NOS). Meta-analysis was carried out using a random-effects method using the STATA™ Version 14 software.

Result

From 249,301 obtained studies, 28 studies from 3 African regions involving 13067 women included in this Meta-analysis. The overall pooled prevalence of utilization of preconception care among pregnant women in Africa was found to be 18.72% (95% CI: 14.44, 23.00). Knowledge of preconception care (P = <0.001), preexisting medical condition (P = 0.045), and pregnancy intention (P = 0.016) were significantly associated with the utilization of preconception care.

Conclusion

The results of this meta-analysis indicated, as one of best approaches to improve birth outcomes, the utilization of preconception care is significantly low among mothers in Africa. Therefore, health care organizations should work on strategies to improve preconception care utilization.

Introduction

According to the World Health Organization (WHO), preconception care (PCC) is, the provision of biomedical, behavioral, and social health interventions to women and couples before conception occurs, to improve their health status, and mitigating behaviors, individual and environmental factors that could contribute to poor maternal and child health outcomes [1, 2]. This is done through risk identification, health education, and promotion, and initiation of evidence-based interventions in the period before conception. The use of PCC in high- and low-income countries aims to improve maternal pregnancy and neonatal outcomes both in the short and long term [3]. PCC also includes the detection and optimal control of specific medical conditions to optimize pregnancy-related outcomes for the woman and her offspring as well as implemented to prevent pregnancies that are unplanned, too early, or too close [4, 5].

Now a day promoting and enhancing women’s health before pregnancy has a favorable outcome and highly reduces pregnancy and childbirth related complications [6], and also Preconception care can make a useful contribution to reducing maternal and childhood mortality and morbidity, and to improving maternal and child health in both high- and low-income countries [1]. In 2015, 303, 000 women in the world died from pregnancy and childbirth-related problems [7]. In Ethiopia, the pregnancy-related mortality ratio was 412 per 100,000 live births and the lifetime risk of pregnancy-related death is 21 in 1000 women [8]. Most of these complications develop during pregnancy, exist before, and worsened during pregnancy, especially if not managed as part of the PCC [2]. There is growing evidence that preconception care may have an important role in preventing short and long-term adverse health consequences for women and their offspring [9].

Besides PCC is very crucial for women with underlying chronic diseases, according to global statistics, non-communicable diseases (NCDs) are the cause of more than 53% of diseases. Moreover, it is predicted that NCDs will be the cause of 73% of deaths worldwide and 80% of deaths in developing countries [10, 11]. Researchers reported in their studies that 17.5% and 32% of pregnant mothers who were referred to healthcare centers had received pre-pregnancy care. Similarly, the findings of the studies conducted by Asresu and Betra 18.2% and 29.7% of people seek pre-pregnancy care programs [12–15]. In another study conducted by Frey and Files in Mayo clinic [16] found that only 39% of the women received PCC from their primary care physicians compared to 98.6% who believed in its importance.

There has been an increasing burden of maternal, newborn, and child mortality globally. Worldwide, 400/100000 women of childbearing age die every year due to complications of pregnancy and childbirth and 7 million infants die each year between birth to 12 months [17]. According to statistics, every minute in the world, 380 women become pregnant and 190 faces unplanned or unwanted pregnancies; 110 experiences a pregnancy-related complication; 40 have an unsafe abortion; and one woman dies from a pregnancy-related cause. Implementation of evidence-based preconception interventions improves infant and maternal pregnancy outcomes [18]. This review will contribute to the integration of preconception care with other existing health programs, assignment of the task of pre-pregnancy health promotion to the healthcare workers, improvement or promotion of preconception services, engagement of the media, usage of healthcare information technology, maximizing demand for and uptake of preconception interventions, especially by adolescents.

Objectives of the review

  • To determine the prevalence of utilization of Preconception care in Africa

  • To identify the associated factors of utilization Preconception care in Africa

Methods and materials

Study design and search strategy

We registered the protocol in PROSPERO (ID: CRD42020209551). This systematic review and meta-analysis was conducted under the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement [19, 20].

A three-step search strategy was utilized in this review. An initial limited search of PubMed was undertaken followed by the analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search was done by using all identified keywords and index terms across all included databases. Thirdly, the reference list of all identified reports and articles was searched for additional studies. Studies published in English language up to May 2021 were taken from EMBASE, MEDLINE, Cochrane, Scopus, Web of Science, CINAHL, and manually on Google Scholar. The search for unpublished studies included Google and institutional repositories. The search was performed using key terms such as preconception care, PCC, Pre-pregnancy care, prenatal care, folic acid, multi-vitamin, foliate supplement, folic acid intake, Iron–folic acid, IFA, Mother, reproductive age group, pregnant women, utilization, and uptake.

Study selection and eligibility criteria

  • Participants in the studies should be mothers.

  • Both published and unpublished studies conducted in Africa were included.

  • Studies that reported the prevalence of utilization of preconception care among mothers regardless of study design

Study extraction and quality appraisal

The data were extracted by three independent authors (TT, MT, and T.L) using a data extraction format prepared in a Microsoft Excel 2010 spreadsheet. The extracted data were: the first author’s name, publication year, country, design, sample size, sampling method, utilization of preconception care, and associated factors with their odds ratio. The quality of each study was assessed using the modified Newcastle-Ottawa Scale (NOS) for cross-sectional studies [21, 22] Studies were included with a score of 5 and more on the NOS [23]. The quality of each study was evaluated independently by four authors (TT, NA, MT, and T.L) and ay disagreements were resolved by discussion and consensus.

Publication bias and heterogeneity

To assess the existence of publication bias, funnel plots were used and Egger’s test was computed. A p-value< 0.05 was used to declare the statistical significance of publication bias. I2 test statistics were used to check the heterogeneity of studies. I2 test statistics of < 50, 50–75% and > 75% was declared as low, moderate and high heterogeneity respectively [24].

Outcome measure

The primary outcome of this review was the prevalence of utilization of preconception care. The second outcome of this review was the associated factors of preconception care utilization. The only factor identified as a significant factor in the two and above studies was included in this review and meta-analysis.

Data synthesis and analysis

STATA™ Version 14 software was used to conduct the analysis. The heterogeneity test was conducted by using I-squared (I2) statistics. The pooled prevalence of utilization of preconception care was carried out using a random-effects (DerSimonian and Laird) method. To minimize the potential random variations between studies; the sources of heterogeneity were analyzed using subgroup analysis, and meta-regression. A sensitivity analysis was also conducted.

Results

Study selection

Initially, a total of 249,301 studies were retrieved from the databases and manual searching. From this, 17195 duplicates were found and removed. The remaining 232,106 articles were screened by their title and abstract and 231378 irrelevant studies were removed. 728 full-text articles were assessed for eligibility and 700 of them were excluded due to not reporting the outcome of interest, which doesn’t report the computed value of the outcome of interest. Finally, a total of 28 studies was fulfilled the inclusion criteria and enrolled in the study (Fig 1).

Fig 1. PRISMA flow diagram of study selection.

Fig 1

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Study characteristics

The 28 studies [25–51] included 13067 participants. All of the included studies were cross-sectional studies and the sample size ranged from 50 [31] to 1331 [43]. Most studies were conducted in Ethiopia. Among the included studies, utilization of preconception care among mothers were ranged from 2.5 [40] to 86.8 [31] (Table 1).

Table 1. Characteristics of the included studies in the systematic review and meta-analysis.

Authors Name Publication Year Study setting Country Study design sample prevalence%(95%CI)
Goshu, Y. A., et al 2018 Adet town Ethiopia Cross-sectional 229 9.6(5.78–13.41)
Asresu, T. T., et al 2019 Mekelle City Ethiopia Cross-sectional 561 18.2(15.0–21.39)
Demisse, T. L., et al 2019 Debre Birhan Town Ethiopia Cross-sectional 410 13.4(10.10–16.69)
Okemo, J., 2020 Aga Khan University Hospital & Maragua Level Four Hospital Kenya Cross-sectional 194 25.8(19.64–31.95)
Fekene, D. B., et al 2020 west shoa Ethiopia Cross-sectional 669 14.5(11.83–17.16)
Metasebia Getachew Unpublished Debre Berhan Ethiopia Cross-sectional 413 16.5(12.92–20.07)
Olowokere, A.E et al 2015 Osun State Nigeria Cross-sectional 375 34.1(29.30–38.89)
Akinajo, O. R et al 2020 Lagos Nigeria Cross-sectional 50 86.8(77.41–96.18)
Gezahegn, A. (2016) Unpublished west Shoa Zon Ethiopia Cross-sectional 634 38.2(34.41–41.98)
Napoleon N. Ekem, et al 2018 teaching hospital Abakaliki Nigeria Cross-sectional 453 10.3(7.50–13.09)
Adeyemo, A. A., & Bello, O. O. 2021 University College Hospital, Ibadan Nigeria Cross-sectional 414 18.8(15.03–22.56)
Taddese F. Unpublished St. Paul’s Millennium Medical College Ethiopia Cross-sectional 280 18.1(13.59–22.6)
Setegn M. 2021 Mizan Aman Ethiopia Cross-sectional 605 16.2(13.26–19.13)
Teshome F, 2021 Manna District Ethiopia Cross-sectional 623 6.3(4.39–8.20)
Lawal TA, Adeleye AO. 2014 Ibadan Nigeria Cross-sectional 602 2.5(1.25–3.74)
Alsammani MA, et al 2017 Sudan Sudan Cross-sectional 1000 3.2(2.10–4.29)
Boakye-Yiadom AK, et al 2020 Tamale west hospital Ghana Cross-sectional 200 15(10.05–19.94)
Ahmed K, et al 2015 Sudan Sudan Cross-sectional 100 40(30.39–49.6)
Ezegwui HU, 2008 Nigeria Nigeria Cross-sectional 1331 47.7(45.01–50.38)
Al Darzi W, et al 2014 Ain Shams University Hospital Egypt Cross-sectional 660 8.8(6.63–10.96)
Dessie MA, et al 2017 Adama hospital medical college Ethiopia Cross-sectional 417 3.5(1.73–5.26)
Okon UA, et al 2020 Benue State Nigeria Cross-sectional 586 27.6(23.98–31.21)
Abdulmalek LJ. 2017 Benghazi Libya Cross-sectional 131 6(1.93–10.06)
Senoga I. Unpublished KCCA health centers, Kampala. Uganda Cross-sectional 423 16.5(12.96–20.03)
Adebo OO, et al 2017 Nigeria Nigeria Cross-sectional 300 3(1.06–4.93)
Anzaku AS. 2013 Jos Nigeria Cross-sectional 543 7.4(5.19–9.60)
C A. ENUKU, & FO. Adeyemo 2019 delta state Nigeria Cross-sectional 273 24.2(19.11–29.28)
Habte A, et al 2020 Southern state Ethiopia Cross-sectional 591 6.4(4.42–8.37)
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Utilization of preconception care among mothers

By including the twenty-eight published research articles we had estimated the pooled prevalence utilization of preconception care among mothers in Africa. Accordingly, the overall estimated pooled prevalence of utilization of preconception care among mothers with a random-effects model was 18.72% (95% CI: 14.44, 23.00) with a heterogeneity index (I2) of 98.7% (p = 0.000) (Fig 2).

Fig 2. Forest plot showing pooled prevalence of utilization of preconception care among women in Africa.

Fig 2

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Subgroup analysis

Subgroup analyses revealed a marked variation across regions. Based on the subgroup analysis result, the highest (24.81%; 95% CI: 14.80, 34.82), I2 = 99.3%) seen in western region and the lowest (15.90%; 95% CI: 11.54, 20.26), I2 = 97.6%) seen in eastern region (Fig 3).

Fig 3. Subgroup analysis of utilization of preconception care among mother by country in Africa.

Fig 3

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Heterogeneity and publication bias

Meta-regression was conducted to identify the source of heterogeneity using sample size as a covariate (Table 2). It was indicated that there is no effect of sample size on heterogeneity between studies. The presence of publication bias was checked using the Egger’s test, and graphical by Funnel plot, the result egger’s test was found significant (p<0.000), as a result to estimating the number of missing studies that might exist in a meta-analysis we conducted Duval and Tweedie’s trim and fill analysis, but is not significant. Also, visual inspection of the funnel plot indicated asymmetrical distribution showing publication bias (Fig 4).

Table 2. Meta-regression analysis of factors affecting between-study heterogeneity.

Heterogeneity source Coefficients Std. Err. P-value
Sample size -0.0031257 .0052047 0.553
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Fig 4. Funnel plot to test the publication bias in 28 studies with 95% confidence limits.

Fig 4

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Sensitivity analysis

Sensitivity analysis was done by removing studies step by step to evaluate the effect of a single study on the overall effect estimate. The result indicated removing a single study did not have a significant influence on pooled prevalence (Fig 5).

Fig 5. Sensitivity analysis of pooled prevalence for each study being removed one at a time.

Fig 5

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Factors associated with utilization of preconception care

Six variables were extracted to identify factors affecting the utilization of preconception care among women. Of these, three variables (knowledge, Pre-existing medical condition, and pregnancy intention) were found to be significantly associated with utilization of preconception care (Table 3).

Table 3. Factors associated with utilization of preconception care among women in Africa.

Determinants Comparison Number of studies Sample size OR(95%CI) P- value I2 (%) Heterogeneity test (p value)
Knowledge Poor Vs Good Knowledge 7 3581 0.61(0.51–0.74) < 0.001 97.5 < 0.001
Educational status No formal education Vs Primary school and above 7 3475 0.68(0.44–1.05) 0.084 80.0 0.007
Marital status Single Vs others 3 1103 0.68(0.44–1.05) 0.084 80.0 0.007
Pre-existing medical condition Yes vs No 4 1615 0.71(0.51–0.99) 0.042 96.7 < 0.001
Adverse birth outcome Yes vs No 2 845 1.15(0.81–1.64) 0.416 98.7 < 0.001
Pregnancy intension Yes vs No 3 1247 2.47(1.74–3.52) 0.000 75.9 0.016
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Mothers having poor knowledge of preconception care were 39% less likely to utilize the care than those having good knowledge (OR: 0.61(95% CI 0.51–0.74), p = 0.000, I2: 97.5%, the heterogeneity test (p< 0.001). Those mothers who had pre-existing medical condition were 29% less likely to utilize preconception care than their counterparts (OR: 0.71(95% CI 0.51–0.99), P = 0.045, I2: 96.7%, the heterogeneity test (p< 0.001).

Mothers who had pregnancy intention were 2.5 times more likely to utilize preconception care than those who hadn’t have an intention (OR: 2.47(95% CI 1.74–3.52), P = 0.000, I2: 75.9%, the heterogeneity test (p = 0.016).

Discussion

Many medical conditions, personal behaviors, psychosocial risks, and environmental exposures associated with negative pregnancy outcomes can be identified and modified before conception through clinical interventions. For certain conditions, opportunities for preventive interventions occur only before conception, this is by preconception care. PCC is one way believed to improve pregnancy outcomes and is considered important by health care workers and the general population [52, 53].

A systematic review of tools to assess the quality of observational studies examining incidence or prevalence concluded that there is no consensus exists as to which individual criteria should be assessed to establish methodological quality [54].

The Cochrane Collaboration advises assessing the risk of bias on a subjective basis using domain-based evaluation [55], so we used the Newcastle-Ottawa Quality Assessment Scale (adapted for cross-sectional studies) [22] and authors independently reviewed with minimal disagreement between reviewers.

According to this systematic review and meta-analysis, the estimated pooled prevalence of utilization of preconception care among mothers was 18.72% (95% CI: 14.44, 23.00). It was believed that preconception care helps to fill the gap in the existing continuum of maternal and child healthcare [56]. Different randomized controlled trials also showed that one of PCC component folate supplementation (alone, or in combination with other vitamins and minerals) reduces the prevalence of neural tube defect [57–59].

Every woman of reproductive age who is capable of becoming pregnant is a candidate for preconception care, regardless of whether she is planning to conceive [60]. But PCC implementation is in the infant stage in low and middle-income countries [61].

Based on the subgroup analysis result, the highest (24.81%; 95% CI: 14.80, 34.82), I2 = 99.3%) seen in western region and the lowest (15.90%; 95% CI: 11.54, 20.26), I2 = 97.6%) seen in eastern region. The difference might be because of the difference in sample size, socioeconomic status of the countries, and the number of included studies in this meta-analysis.

Among the extracted factors preconception care knowledge, pre-existing medical condition, and pregnancy intention were found to be significantly associated with utilization of preconception care.

Seven studies revealed that having adequate knowledge about PCC was strongly associated with the utilization of PCC. Mothers having poor knowledge of preconception care were 39% less likely to utilize the care than those having good knowledge (OR: 0.61(95% CI 0.51–0.74); this is consistent with a systematic review conducted in Ethiopia [62]. knowing enhances the utilization of any health-related service.

Having pre-existing medical conditions has an impact on the utilization of PCC. In this study, those mothers who had pre-existing medical conditions were 29% less likely to utilize preconception care than their counterparts (OR: 0.71(95% CI 0.51–0.99). this might be explained as those having pre-existing medical conditions entirely worry about their medical condition than using preconception care service. Also, a study conducted in Nigeria showed that none of the participants with pre-existing medical conditions had awareness of PCC [63].

Pregnancy intention is one of the means which facilitates using of preconception care service. According to this study, mothers who had pregnancy intention were 2.5 times more likely to utilize preconception care than those who hadn’t have the intention (OR: 2.47(95% CI 1.74–3.52). If women had the intention to have a healthy baby, the probability of using PCC will increase.

Conclusion

The results of this meta-analysis indicated as one of best approaches to improve birth outcomes, the utilization of preconception care is significantly low among mothers in Africa. Therefore, health care organizations should work on strategies to improve preconception care utilization.

Limitation of the study

This systematic review and meta-analysis presented the prevalence of preconception care utilization in Africa; it might have faced the following limitations. First, the lack of studies from southern and middle Africa may affect the generalizability of the finding to Africa. Secondly, due to the presence of significant heterogeneity and presence of publication bias, the result should be interpreted cautiously. Finally, we have faced difficulties in comparing our findings due to the lack of regional and worldwide systematic reviews and meta-analysis.

Supporting information

S1 Checklist. PRISMA 2009 checklist.

(DOC)

Click here for additional data file. (63.5KB, doc)
S1 Data. Raw data.

(XLSX)

Click here for additional data file. (47KB, xlsx)

Acknowledgments

We would like to thank all authors of studies included in this systematic review and meta-analysis.

Abbreviations

CI

Confidence Interval

NCD

Non Communicable Disease

NOS

Newcastle Ottawa Scale

OR

Odds Ratio

PCC

Preconception care

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

WHO

World Health Organization

Data Availability

The data analyzed during the current systematic review and meta-analysis is available as Supporting information files.

Funding Statement

The authors received no specific funding for this work.

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Decision Letter 0

Joseph Telfair

20 May 2021

PONE-D-21-05218

Mothers’ utilization and associated factors of preconception care in Africa, a systematic review and meta-analysis

PLOS ONE

Dear Dr. Tefesse,

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.

The academic editor has served as the second reviewer on this manuscript and agree with the assessment that major revisions are needed. 

Please submit your revised manuscript by Jul 02 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're 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.

Please include the following items when submitting your revised manuscript:

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Joseph Telfair, DrPH, MSW, MPH

Academic Editor

PLOS ONE

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At this time, please address the following queries:

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- https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241226

The text that needs to be addressed involves the Results section.

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

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Comments to the Author

1. 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: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

**********

3. 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

**********

4. 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

**********

5. 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: The authors conducted a systematic review and meta-analysis focusing on an important topic: the prevalence and factors associated with preconception care utilization in Africa. I commend the efforts of the authors to provide a sound evidence to improve the maternal and child health in the African continents. However, at the present state, I believe the manuscript must be further improved in order to be accepted for publication. Please find my comments, which would hopefully help to improve the manuscript as follows:

1) The search terms used are not specified in the manuscript and the term “Africa” is too vague. How do you define the countries included in Africa.

2) Another major concern is the narrow focus placed on the term preconception care. Preconception care covers many different services such as genetic screening, nutritional advice, violence prevention etc. and by just using the term “preconception care” in the search strategy, I am afraid this would provide a false picture of the actual situation in Africa. For example, the authors got 240551 hits from the database search and in the final analyses, the authors included only 11 studies and I noticed that these studies specifically included the term “preconception care” in their titles.

I suggest the authors to define “preconception care” carefully and not relying only on the titles as I believe many programs that would come under the umbrella of preconception care have already been conducted in many sub-Saharan African countries.

3) In the study selection, I do not understand by the authors only included “observational” studies. For example, an RCT could also report the prevalence of utilization of preconception care. By excluding other types of studies without proper justification would really lead the authors to arrive at a wrong conclusion.

4) How were the factors associated with utilization of preconception care is not clear. The authors wrote that factors reported in two or more studies were included but I believe this is not a convincing justification.

5) The conclusion states that “preconception care is low among mothers in Africa”. After reviewing the manuscript and the methods employed, I am not at all convinced with this conclusion as only three countries were included (Ethiopia, Nigeria, and Kenya). The results from these three countries might not represent the true picture of the African continent.

I would suggest the authors to consider the above points and probably reanalyze the results to arrive at a more trustworthy conclusion, which would hopefully be an important evidence to improve the lives of mothers and children in Africa.

**********

6. 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

[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.]

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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2021 Jul 23;16(7):e0254935. doi: 10.1371/journal.pone.0254935.r002

Author response to Decision Letter 0

3 Jun 2021

Response to reviewers

Review Comments to the Author

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates

Response – corrected

2. Please confirm that you have included all items recommended in the PRISMA checklist including the full electronic search strategy used to identify studies with all search terms and limits for at least one database

Response – we confirm that we followed recommended PRISMA checklis

3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available.

Response – corrected

4. Thank you for stating the following financial disclosure: "not applicable"

At this time, please address the following queries:

a. Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b. State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c. If any authors received a salary from any of your funders, please state which authors and which funders.

d. If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Response – corrected

5. Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

Response – corrected

6. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information

Response – corrected

7. We noticed you have some minor occurrence of overlapping text with the following previous publication, which needs to be addressed:

- https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241226

The text that needs to be addressed involves the Results section.

In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

Response – corrected

Reviewer #1: The authors conducted a systematic review and meta-analysis focusing on an important topic: the prevalence and factors associated with preconception care utilization in Africa. I commend the efforts of the authors to provide a sound evidence to improve the maternal and child health in the African continents. However, at the present state, I believe the manuscript must be further improved in order to be accepted for publication. Please find my comments, which would hopefully help to improve the manuscript as follows:

8. The search terms used are not specified in the manuscript and the term “Africa” is too vague. How do you define the countries included in Africa

Response – yes you wright, we just removed the word Africa

9. Another major concern is the narrow focus placed on the term preconception care. Preconception care covers many different services such as genetic screening, nutritional advice, violence prevention etc. and by just using the term “preconception care” in the search strategy, I am afraid this would provide a false picture of the actual situation in Africa. For example, the authors got 240551 hits from the database search and in the final analyses, the authors included only 11 studies and I noticed that these studies specifically included the term “preconception care” in their titles. I suggest the authors to define “preconception care” carefully and not relying only on the titles as I believe many programs that would come under the umbrella of preconception care have already been conducted in many sub-Saharan African countries.

Response – corrected

10. In the study selection, I do not understand by the authors only included “observational” studies. For example, an RCT could also report the prevalence of utilization of preconception care. By excluding other types of studies without proper justification would really lead the authors to arrive at a wrong conclusion.

Response – yes of course , you are right, we corrected on the revised version

11. How were the factors associated with utilization of preconception care is not clear. The authors wrote that factors reported in two or more studies were included but I believe this is not a convincing justification.

Response – we said the above statement because we are trying to identify associated factors, similar to multivariate analysis which needs to have more than two variables, in our case one variable should be identified as significant factor at least for two different articles. Also in case meta-analysis heterogeneity score is important which can be observed for articles conducted in at least two similar region ,(similarly for associated factors)

12. The conclusion states that “preconception care is low among mothers in Africa”. After reviewing the manuscript and the methods employed, I am not at all convinced with this conclusion as only three countries were included (Ethiopia, Nigeria, and Kenya). The results from these three countries might not represent the true picture of the African continent.

Response- in this version, we added studies from other parts of Africa and mentioned as a limitation.

Decision Letter 1

Joseph Telfair

16 Jun 2021

PONE-D-21-05218R1

Mothers’ utilization and associated factors of preconception care in Africa, a systematic review and meta-analysis

PLOS ONE

Dear Dr. Tefesse,

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.

==============================

ACADEMIC EDITOR: Before consideration for publication to be finally considered, the authors are asked to submit the manuscript to an editor to address grammatical errors, specifically English language usage. 

==============================

Please submit your revised manuscript by Jul 31 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're 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.

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). You should upload this letter as a separate file labeled 'Response to Reviewers'.

  • A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

  • An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Joseph Telfair, DrPH, MSW, MPH

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Before consideration for publication to be finally considered, the authors are asked to submit the manuscript to an editor to address grammatical errors, specifically English language usage.

[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

**********

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: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: 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

**********

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

**********

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 think the revisions and responses are reasonable.

However, I find many typos throughout the manuscript.

I would strongly suggest the authors to submit this manuscript for extensive English editing.

**********

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

[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.]

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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2021 Jul 23;16(7):e0254935. doi: 10.1371/journal.pone.0254935.r004

Author response to Decision Letter 1

20 Jun 2021

Thank you for all constructive comments

Response to reviewers

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response – revised

1. Is the manuscript technically sound, and do the data support the conclusions?

Response – corrected

2. Is the manuscript presented in an intelligible fashion and written in standard English?

Response – corrected

Attachment

Submitted filename: Response to reviewers 2.docx

Click here for additional data file. (14.6KB, docx)

Decision Letter 2

Joseph Telfair

29 Jun 2021

PONE-D-21-05218R2

Mothers’ utilization and associated factors of preconception care in Africa, a systematic review and meta-analysis

PLOS ONE

Dear Dr. Tefesse,

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.

==============================

ACADEMIC EDITOR: The Academic Editor served as the second reviewer on this manuscript.

Please attend to or clarify the requested correction in your results section in order to move forward for further publication consideration.

==============================

Please submit your revised manuscript by Aug 13 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're 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.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Joseph Telfair, DrPH, MSW, MPH

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Please attend to or clarify the requested correction in your results section in order to move forward for further publication consideration.

[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

**********

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

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: 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

**********

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

**********

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: Thank you for your revisions and this will be my final comment.

The result presentation in the abstract is not correct.

Please check carefully before publication as this would affect the quality of your paper.

"Knowledge of preconception care (P=0. 61), preexisting medical condition (P=0.71), and

pregnancy intention (p =2.47) were significantly associated with the utilization of preconception

care"

If "P" refers to the p-value, they are not significant. I believe you are referring to the odds ratio.

**********

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

[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.]

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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2021 Jul 23;16(7):e0254935. doi: 10.1371/journal.pone.0254935.r006

Author response to Decision Letter 2

29 Jun 2021

Response to reviewers

Thank you for the comments

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Response - all references were corrected with the help of google scholar but reference number 9, was cited by the way authors suggestion, due to we are unable to got in google scholar , it is not retracted

� About reference number, 22 , 57 – we used citation suggested in the journal but it differs in google scholar- so we corrected I accordingly

Review Comments to the Author

Reviewer #1: Thank you for your revisions and this will be my final comment.

The result presentation in the abstract is not correct.

Please check carefully before publication as this would affect the quality of your paper.

"Knowledge of preconception care (P=0. 61), preexisting medical condition (P=0.71), and

pregnancy intention (p =2.47) were significantly associated with the utilization of preconception

care"

If "P" refers to the p-value, they are not significant. I believe you are referring to the odds ratio.

Response- corrected

Attachment

Submitted filename: Response to reviewers 3.docx

Click here for additional data file. (16.1KB, docx)

Decision Letter 3

Joseph Telfair

7 Jul 2021

Mothers’ utilization and associated factors of preconception care in Africa, a systematic review and meta-analysis

PONE-D-21-05218R3

Dear Dr. Tefesse,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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 help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- 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.

Kind regards,

Joseph Telfair, DrPH, MSW, MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The academic editor served as the second and final reviewer for this revision and agree its should be  accepted for publication.

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

**********

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

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: 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

**********

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

**********

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: (No Response)

**********

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

Acceptance letter

Joseph Telfair

14 Jul 2021

PONE-D-21-05218R3

Mothers’ utilization and associated factors of preconception care in Africa, a systematic review and meta-analysis

Dear Dr. Tekalign:

I'm 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 let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, 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.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Joseph Telfair

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Checklist. PRISMA 2009 checklist.

    (DOC)

    Click here for additional data file. (63.5KB, doc)
    S1 Data. Raw data.

    (XLSX)

    Click here for additional data file. (47KB, xlsx)
    Attachment

    Submitted filename: Response to reviewers 2.docx

    Click here for additional data file. (14.6KB, docx)
    Attachment

    Submitted filename: Response to reviewers 3.docx

    Click here for additional data file. (16.1KB, docx)

    Data Availability Statement

    The data analyzed during the current systematic review and meta-analysis is available as Supporting information files.

    Articles from PLoS ONE are provided here courtesy of PLOS

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