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. 2022 Nov 21;17(11):e0277075. doi: 10.1371/journal.pone.0277075

Challenges in antenatal care utilization in Kandahar, Afghanistan: A cross-sectional analytical study

Bilal Ahmad Rahimi 1,2,*, Enayatullah Mohamadi 3, Muhibullah Maku 3, Mohammad Dawood Hemat 3, Khushhal Farooqi 4, Bashir Ahmad Mahboobi 1, Ghulam Mohayuddin Mudaser 5, Walter R Taylor 6
Editor: Monalisha Sahu7
PMCID: PMC9678260  PMID: 36409670

Abstract

Background

Quality antenatal care (ANC) is one of the four pillars of safe motherhood initiatives and improves the survival and health of mother and neonate. The main objective of this study was to assess the barriers in the utilization of ANC services in Kandahar, Afghanistan.

Methods

This was a cross-sectional analytical study conducted over one year from December 2018–November 2019. Data were analyzed by descriptive statistics, Chi squared, and binary logistic regression.

Results

A total of 1524 women were recruited in this study with mean age of 30.3 years. Of these women, 848 (55.6%) were rural dwellers, 1450/1510 (96.0%) were illiterate, 438/608 (72.0%) belonged to low-income families, 1112/1508 (73.7%) lived in joint families, 1420/1484 (95.7%) lived in a house of >10 inhabitants, while 388/1494 (26.0%) had attended had at least one ANC visit during their last pregnancy. On univariate analysis, the main barriers in the utilization of ANC services were living in rural areas, being illiterate, having lower socio-economic status, remoteness of the health facility from home, bad behavior of clinic personnel, and unplanned pregnancy. Only lower socio-economic status and bad behavior of clinic personnel were independent explanatory variables in the regression model.

Conclusions

Utilization of ANC services is inadequate in Kandahar province. Improving clinic staff professional behavior and status of women by expanding educational opportunities, and enhancing community awareness of the value of ANC are recommended.

Introduction

Globally, maternal mortality is one of the main public health issues [1]. It has been shown that better antenatal care (ANC) services improve the survival and health of both mothers and newborns [2]. World Health Organization (WHO) recommends at least eight ANC visits during pregnancy starting with the first visit at 12 weeks of gestational age (GA), then at 20, 26, 30, 34, 36, 38 and 40 weeks [3]. Afghanistan is among the top ten countries that contribute to more than half of the global maternal deaths [4,5]. In 2015 survey, only 59% of the pregnant women in Afghanistan attended at least one ANC visit [6].

In 2014, only 52% of the pregnant women attended four ANC visits in developing countries, where the mean MMR of 230/100,000 live births is 14 times greater than in developed countries [7]. Data show that when pregnant women in low- and middle-income countries (LMICs) receive better ANC from health facilities, most of the maternal and newborn deaths and pregnancy-related complications are prevented [8–11], e.g., neonatal deaths were 55% lower in women who had attended four ANC visits [12]. Moreover, ANC visits may detect early previously undiagnosed maternal morbidity as well as pregnancy related complications like eclampsia, small pelvis, and placenta previa [13,14]. ANC visits also provide a good opportunity for educating pregnant women about the warning symptoms and signs of common problems during pregnancy, healthy nutrition for the mother and newborn, and contraception for family planning [15].

Several factors affect ANC utilization in LMICs, including access to ANC, quality of ANC, socio-economic status, maternal education, demographic factors (e.g., maternal age and occupation), beliefs/knowledge about ANC, cultural beliefs, and previous obstetric history like unplanned pregnancy and parity [16–18].

Afghanistan is a low-income country and has been at war for several decades. As a result, the country faces significant challenges such as increasing poverty, continued political instability, and a devastated health infrastructure [5]. Afghanistan’s challenges have been unique in consideration of ongoing conflicts for the last 45 years. These conflicts have severely affected not only the capacity of the health services to deliver quality ANC but also the broader disruption to the social determinants of health. Nevertheless, all public health facilities continue to offer free medical care, including ANC visits. According to the WHO, Afghanistan is one of the worst countries for pregnant women with a maternal mortality ratio (MMR) of 638 deaths/100,000 live births in 2017 [19]. Comparatively, in 2017, Somalia and Yemen which are also countries with devastating civil war, MMR was 829 and 164 deaths/100,000 live births, respectively [19]. The 2002 Reproductive Age Mortality Survey (RAMOS) conducted in Afghanistan estimated the MMR to be 1,600 deaths/100,000 live births [20]. Although The 2010 Afghanistan Mortality Survey (AMS) estimated the MMR to be 327/100,000 live births [21], the result of this survey was controversial and not acceptable [22]. Finally, the Afghanistan Demographic and Health Survey (AfDHS) 2015 reported that the pregnancy related mortality ratio (all maternal deaths during pregnancy, child birth, or within two months after pregnancy) was 1,291 maternal deaths per 100,000 live births.[6]. According to AfDHS data, Afghanistan has the highest MMR in the world. Unfortunately, Afghanistan did not achieve the goal 5 of the Millennium Development Goals (MDGs) which was to reduce MMR to 75% by the year 2015 [23]. Also, the target 3.1 of the Sustainable Development Goals (SDGs) does not seem to be achieved which was to decreased MMR to <70/100,000 live births by the year 2030 [24]. In Afghanistan, ANC services are free at all public healthcare facilities. These facilities are provided by skilled healthcare staff including doctors, midwives, nurses, auxiliary midwives, and community health workers. Contrary, similar ANC services at private healthcare facilities are chargeable to the patients [6,25].

Studies from different parts of Afghanistan have revealed that the main factors affecting ANC utilization were level of maternal education, place of residence, previous health education on safe motherhood, media exposure, socio-economic status, availability of transport, and the behavior of healthcare personnel when seeing pregnant women [26–30]. There are very little published data regarding ANC utilization from Kandahar province which are solely limited to Kandahar city only [31,32]. We, therefore, investigated barriers in the ANC utilization in Kandahar city and Daman district located outside Kandahar city.

Materials and methods

Study design and period

This was a cross-sectional study questionnaire-based study that took place over 12 months from December 2018–November 2019.

Study site and population

Kandahar province was selected for research due to the fact that it is one of the most unsecure provinces of Afghanistan. This study was conducted in four public health clinics in Kandahar city (Amir Jan comprehensive health center [CHC], Shams-ul-Haq Kakar CHC, Al-Khidmat CHC, and Nazo Ana CHC) and two public health clinics in Daman district (Mandisar CHC and Khoshab sub-health center). These health clinics were randomly selected using lottery-method. Daman district is a rural area adjoining Kandahar city. The sampling population consisted of all married women who attended any of the above-mentioned clinics for any reason (not only women attending ANC visit) and reported a pregnancy in the last one year.

Primary objective

To assess the barriers in the utilization of ANC services in Kandahar Province, Afghanistan.

Inclusion criteria

  • Married women who had given birth in the past one year prior to the study.

  • Permanent residents for more than five years.

Exclusion criteria

  • Unmarried pregnant female. These females are excluded due to the facts that extramarital pregnancies are rare and also considered very big sin in the Afghan society. If the family members get information of extramarital pregnancy, there is a fear that the female can be tortured or even killed.

  • Patients who refused to take part in the study.

Sample size calculations

The sample size was based on the precision method and was calculated using Stata 15 (College Station, Texas, USA). Assuming an 85% response to a given question with a precision of 2%, the calculated sample size was 1440 females; in the event we analyzed 1524 females.

Ethical considerations

Written informed consent was obtained from all the participants prior to the study. Ethical approval was taken from Kandahar University Ethics Committee with the approval number of 244/1397.

Data collection and analysis

Data were collected from the respondents in a structured questionnaire developed based on relevant literature in a face-to-face interview. Initially, the questionnaire was drafted in English language. Later, it was translated into the local language (Pashto) by experts. Before the study, the questionnaire was pretested on 15 pregnant women attending ANC services in Shams-ul-Haq Kakar CHC with the aim of revising the poorly structured questions. The data were collected by trained female doctors and nurses using an exit interview with pregnant women. To ensure consistency, the data collection process was strictly supervised by principal investigator.

Data were analyzed with SPSS version 22 (Chicago, IL, USA) by descriptive statistics (proportions, means, and standard deviations). Chi squared (using crude odd ratio [COR]) was used to compare proportional data and ‘t’ tests and their nonparametric equivalents were used to analyze continuous data. All variables that were statistically significant in univariate analyses were assessed for independence in a binary logistic regression (using adjusted odd ratio [AOR]) to determine the factors affecting the utilization of ANC services. A P-value of <0.05 was considered statistically significant.

Receiving antenatal care was defined as a pregnant woman having at least one antenatal care check-up during their last pregnancy from health facility [33].

Distance to the nearby health facility was defined according to the history the mothers gave: near if mothers accessed the clinic < 30 minutes while “remote or far away” was defined as ≥30 minutes [34].

Study variables and their indicators

  • Socio-demographic characteristics included age, socio-economic status, employment, literacy level, residence, parity (number of babies delivered), and number of family members living in the same house.

  • Attitudes and practice included clinic staff behavior, at least one ANC visit done during last pregnancy, number of ANC visits during last pregnancy, and reason of not attending ANC visit.

These above-mentioned variables have been reported to be the barriers in the utilization of ANC services in Afghanistan [31] and other parts of the world [16–18].

Definitions

Socio-economic status [31,35]

Low income = < 2500 Afghanis (< 30 USD) per month.

Middle income = 2500–20,000 Afghanis (30–250 USD) per month.

High income = > 20,000 Afghanis (> 250 USD) per month.

Negative clinic staff behavior

Presence of one or more of the following behaviors: hostility, aggressiveness, rudeness, disrespect, physical abuse or bullying toward the patients [25,26,36,37].

Results

Of the 1610 pregnant women who had visited their local ANC within 1 year, 1524 married women agreed to participate in the study. Their mean age was 30.3 years (range 16 to 50). More than half of them, 62.3% (950/1524) were aged between 21–30 years and 848 (55.6%) were rural dwellers.

Almost all, 1520/1524 (99.7%), were housewives, 1450/1510 (96.0%) were illiterate and 438/608 (72.0%) came from low-income families. The majority, 1112/1508 (73.7%), lived with extended families and 1420/1484 (95.7%) lived in households of >10 inhabitants (Table 1). Only 388/1494 (26.0%) attended the ANC at least once and main reason (511/1106 [46.2%]) for poor attendance was remoteness of the health facility from their home (Table 2).

Table 1. Socio-demographic characteristics of the study participants.

Variable Number (n = 1524) Percentage (%)
Age (years)
    ≤20
    21–30s
    31–40
    >40
92
950
406
76
6.0
62.3
26.7
5.0
Socio-economic status (n = 1516)
    Low income
    Middle income
    High income
528
782
206
34.8
51.6
13.6
Employment
    Employed
    Housewife
4
1520
0.3
99.7
Literacy level (n = 1510)
    Literate
    Illiterate
60
1450
4.0
96.0
Number of babies delivered (n = 1450)
    1
    2–5
    >5
152
876
422
10.5
60.4
29.1
Number of children (n = 1400)
    1
    2–5
    >5
90
810
500
6.4
57.9
35.7
Age of last child (n = 1352)
    ≤1 year
    >1 year
286
1066
21.2
78.8
Type of family (n = 1508)
    Nuclear
    Joint
396
1112
26.3
73.7
Number of family members living in the same house (n = 1484)
    <5
    5–10
    >10
18
46
1420
1.2
3.1
95.7
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Table 2. ANC-related and other variables in study participants.

Variable Number (n) Percentage (%)
At least one ANC visit done during last pregnancy (n = 1494)
    Yes
    No
388
1106
26.0
74.0
Number of ANC visits during last pregnancy (n = 388)
    Once
    2–4 times
    >4 times
35
225
128
9.0
58.1
32.9
Reason for not attending ANC visit (n = 1106)
    Clinic is far away
    No medicine in clinic
    No night duty staffs in clinic
    Clinic staff do not have good behavior
    Family does not allow
511
362
57
22
154
46.2
32.7
5.2
2.0
13.9
Clinic present near home (n = 1510)
    Yes
    No
1100
410
72.8
27.2
Distance from house to clinic (walking) (n = 1488)
    <30 minutes
    30–60 minutes
    61 minutes–2 hours
    >2 hours
448
660
348
32
30.1
44.4
23.4
2.2
Clinic staff behavior (n = 1476)
    Good
    Negative (not good)
1114
362
75.5
24.5
Planned pregnancy (n = 1000)
    Yes
    No
804
196
80.4
19.6
Method used to make drinking water safe (n = 1472)
    Boil
    Add bleach/chlorine
    Strain through a cloth
    Use water filter
1106
160
128
78
75.1
10.9
8.7
5.3
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ANC, Ante-natal care; n, number.

In the univariate analysis, significant barriers in the utilization of ANC services were living in rural areas (COR 1.4), being illiterate (COR 2.4), low socio-economic status (COR 1.5), remoteness of health facility from home (COR 1.8), bad behavior of clinic personnel (COR 3.2), and an unplanned pregnancy (COR 1.5). By logistic regression only two statistically significant barriers to ANC utilization remained: bad behavior of clinic personnel (AOR 9.4) and low socio-economic status (AOR 2.3). A higher literacy level was associated with greater utilization of ANC (Table 3).

Table 3. Univariate analyses and logistic regression of barriers to the utilization of ante natal care services.

Variable Total, n (%) ANC visit(s) done COR (95% CI) P-value AOR (95% CI) P-value
Yes, n (%) No, n (%)
Age (years) (n = 1494)
    >30
    ≤ 30
476 (31.9)
1018 (68.1)
134 (28.2)
254 (25.0)
342 (71.8)
764 (75.0)
1
0.8 (0.7–1.1)		 0.189
Place of living (n = 1494)
    Urban
    Rural
666 (44.6)
828 (55.4)
198 (29.7)
190 (22.9)
468 (70.3)
638 (77.1)
1
1.4 (1.1–1.8)		 0.003
1
2.3 (0.8–6.4)		 0.105
Literacy level (n = 1480)
    Literate
    Illiterate
60 (4.0)
1420 (96.0)
27 (45.0)
359 (25.3)
33 (55.0)
1061 (74.7)
1
2.4 (1.1–5.0)		 0.022
1
0.1 (0.0–0.4)		 0.002
Number of children (n = 1380)
    >5
    ≤5
492 (35.7)
888 (64.3)
120 (24.4)
256 (28.8)
372 (75.6)
632 (71.2)
1
1.3 (1.0–1.6)		 0.076
Age of last child (n = 1344)
    ≤1 year
    >1 year
284 (21.1)
1060 (78.9)
48 (16.9)
310 (29.2)
236 (83.1)
750 (70.8)
1
0.5 (0.4–0.7)		 <0.001
Type of family (n = 1478)
    Nuclear
    Joint
384 (26.0)
1094 (74.0)
80 (20.8)
306 (28.0)
304 (79.2)
788 (72.0)
1
0.7 (0.5–0.9)		 0.006
Number of family members living in the same house (n = 116)
    <5
    ≥ 5
18 (15.5)
98 (84.5)
2 (11.1)
28 (28.6)
16 (88.9)
70 (71.4)
1
0.3 (0.1–1.4)		 0.120
Socio-economic status (n = 1488)
    Low income
    Middle/High income
514 (34.5)
974 (65.5)
114 (22.2)
272 (27.9)
400 (77.8)
702 (72.1)
1
1.5 (1.2–1.9)		 0.001
1
2.3 (1.0–5.4)		 0.044
Clinic present near home (n = 1480)
    No
    Yes
404 (27.3)
1076 (72.7)
74 (18.3)
314 (29.2)
330 (81.7)
762 (70.8)
1
1.8 (1.4–2.4)		 <0.001
1
0.5 (0.2–1.4)		 0.213
Distance from house to clinic (n = 1460)
    <30 minutes
    ≥30 minutes
440 (30.1)
1020 (69.9)
116 (26.4)
270 (26.5)
324 (73.6)
750 (73.5)
1
1.0 (0.8–1.3)		 0.966
Clinic staff behavior (n = 1458)
    Not good
    Good
354 (24.3)
1104 (75.7)
44 (12.4)
342 (31.0)
310 (87.6)
762 (69.0)
1
3.2 (2.2–4.4)		 <0.001
1
9.4 (2.4–36.7)		 0.001
Planned pregnancy (n = 986)
    No
    Yes
194 (19.7)
792 (80.3)
34 (17.5)
194 (24.5)
160 (82.5)
598 (75.5)
1
1.5 (1.0–2.3)		 0.039
1
1.8 (0.6–5.2)		 0.274
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ANC, Ante-natal Care; AOR, Adjusted Odds Ratio; CI, Confidence Interval; COR, Crude Odds Ratio; n, number.

Discussion

In this large survey from Kandahar, we collected data from 1524 women and identified two key independent factors for poor ANC utilization: poor professional behavior by clinic staff and low socioeconomic status. By contrast, a higher level of literacy was associated with greater utilization.

Very few ANC studies have been conducted in Afghanistan. Most published articles are based on the retrospective survey data conducted by Afghanistan MoPH; they show several overlapping reasons for poor ANC utilization [5,25–27,30,38]. The main independent factors associated with no ANC visits were young maternal age (15–19 years), being a working mother, and the decision for healthcare being taken by the husband [25]. In Kabul and Ghazni (a province SW of Kabul), underuse of ANC services was associated with low maternal motivation, family decision, notably the mother-in-law and husband not consenting to the ANC visit, lower socio-economic status, and transportation challenges [26]. A recent community-based cross-sectional study in Kandahar city revealed that main determinants of underuse of ANC utilization were illiteracy, unplanned pregnancy, and living in poorer districts of the city [31].

The main factors determining ANC utilization from different developing countries include illiteracy, lower socio-economic status, remoteness of the health facility, transportation challenges, and living in rural areas [39–45]. A study based on the evidence from demographic health surveys in sub-Saharan Africa revealed that main barriers to the utilization of ANC services were decreased literacy level, living in rural areas, low socio-economic status, and not getting permission to visit the health facility [46]. A systematic review and meta-analysis of 15 observational studies in Ethiopia concluded that rural residence, illiteracy of woman or her husband, and unplanned pregnancy were the main barriers in ANC services utilization [2].

We showed that poor professional behavior of clinic staff was a more important factor than socioeconomic status leading to a reluctance of women to attend ANCs. Another study in Afghanistan also reported significant dissatisfaction with the behavior of health personnel, which included verbal and physical abuse [26]. Health care dissatisfaction is also reported from Ethiopia. In Jimma (central Ethiopia), 67.1%, 49.9%, and 37.8% of the pregnant women were dissatisfied with the physical environment of the ANC, quality of care, and organization of health care [36]. In Kuala Lumpur, Malaysia, 81.3%, 61.7%, and 51.3% of the ANC attendants were not satisfied with the continuity of care, accessibility, and convenience in the antenatal clinic [37] and most women (60.7%) attending ANCs specializing in the prevention of maternal to mother transmission of HIV in Benin city, Nigeria, were dissatisfied with the counselling service [47].

Although ANC is free of charge in all public health facilities in Afghanistan, women may seek care in the private sector to avoid the disadvantages of the public health system such as unprofessional staff behavior, poor infrastructure, absent ANC staff, and a shortage of medications, especially in rural areas.

In the univariate analysis, rural women were less likely to attend ANC visits than their urban counterparts but this was not significant in the regression model; this result may have been due to reduced power in the model. By contrast, several studies report rural dwellers are less likely to attend ANCs in India [48], Nepal [49], Indonesia [50,51], Ghana [52], Sudan [53], and Ethiopia [54]. We found that a higher level of maternal literacy was associated independently with good ANC attendance, similar to many other studies [16,39,51,55–57]. A higher level of maternal education may mean that such women should be better informed of the benefits of ANC and better able to decide for themselves. If they are urban dwellers, they will also have greater access to health information and have greater accessibility to clinics [58,59]. Although remoteness from the nearest ANC was not a significant factor in our regression model, it was a key factor in a range of studies from Kenya [45], Rwanda [60], Ethiopia [61], Haiti [62], and Indonesia [63]; however, one Indian study found it was not a significant factor [39].

Limitations of the study

Although large, our study had limitations. We interviewed women once and so did not take into account risk factors that may change over time in attending the ANC. Another limitation could be recall bias because questions to women were about events in the past. Moreover, we did not ascertain the clinical course and outcome of the pregnancy in question or the presence of comorbidities.

Conclusions

The utilization of ANC services is very poor in Kandahar province. Although several intuitive reasons were identified in the univariate analysis, only poor staff behavior and low socioeconomic status were independent factors. More research is needed to explore other factors affecting women’s decision to forego ANC attendance like a previously complicated pregnancy, the presence of comorbidities, and experience with the private sector. Ways to improve the professionalism of clinic staff is needed urgently. Assessing simple, low-tech interventions like health messaging and the acceptability of training ‘bush’ midwives (also known as traditional birth attendants) to carry out simple pregnancy assessments in the field should be conducted. Moreover, improving the status of women by expanding educational opportunities, strengthening promotion of antenatal and delivery care by enhancing community awareness of the importance of antenatal, natal, and post-natal care are recommended.

Supporting information

S1 File. Questionnaire used for the research.

(DOCX)

Click here for additional data file. (20.5KB, docx)
S2 File. SPSS file with a part of the research data.

(SAV)

Click here for additional data file. (37.9KB, sav)

Acknowledgments

We present our highest and sincere thanks to the authorities Faculty of Medicine, Kandahar University, Directorate of Public Health, and staff members of health facilities. We are also very thankful of all the women who consented to take part in our study.

Data Availability

All relevant data are within the paper and Supporting Information files.

Funding Statement

This study did not receive any specific funding. WRT is partially-funded by Wellcome under grant 220211. For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission.

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Decision Letter 0

Emily Chenette

26 Apr 2022

PONE-D-21-18840Title of the Article: Challenges in antenatal care utilization in Kandahar, Afghanistan: A cross-sectional analytical study.PLOS ONE

Dear Dr. Rahimi,

Thank you for submitting your manuscript to PLOS ONE. I sincerely apologise for the unusually delayed review timeframe. 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. (Please see attached report from the reviewer.) In addition to the concerns that the reviewer has raised, please address the following editorial concerns:- In the Methods section, please provide detailed information about how the questionnaire was developed, and how or whether it was pre-tested and validated.- Please provide the method by which the sample size was calculated.

Please note that we have only been able to secure a single reviewer to assess your manuscript. We are issuing a decision on your manuscript at this point to prevent further delays in the evaluation of your manuscript. Please be aware that the editor who handles your revised manuscript might find it necessary to invite additional reviewers to assess this work once the revised manuscript is submitted. However, we will aim to proceed on the basis of this single review if possible.

Please submit your revised manuscript by Jun 09 2022 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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We look forward to receiving your revised manuscript.

Kind regards,

Emily Chenette

Editor in Chief

PLOS ONE

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https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed the survey or questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If the questionnaire is published, please provide a citation to the (1) questionnaire and/or (2) original publication associated with the questionnaire.

3. Please revise the title of your manuscript to remove "Title of the Article:" in the submission system.

4. Thank you for stating the following financial disclosure: "There was no financial support for this research from any source."

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.”

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

5. Thank you for stating the following in your Competing Interests section:  "There are no competing interests."

Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now 

 This information should be included in your cover letter; we will change the online submission form on your behalf.

6. 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. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

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We will update your Data Availability statement to reflect the information you provide in your cover letter.

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

Reviewers' comments:

Reviewer's Responses to Questions

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: Partly

**********

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

Reviewer #1: Yes

**********

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: No

**********

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

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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: I was pleased to read this important paper from a high maternal burden country. The authors are provided enclosed comments for a chance to improve the paper. The paper has potential to be published but key areas where the authors may like to focus are:formatting, background context and presentation of information.

**********

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Reviewer #1: Yes: Dr Danish Ahmad

[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.]

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Attachment

Submitted filename: Review.pdf

Click here for additional data file. (74.5KB, pdf)
PLoS One. 2022 Nov 21;17(11):e0277075. doi: 10.1371/journal.pone.0277075.r002

Author response to Decision Letter 0

3 Jun 2022

PONE-D-21-18840R1

Title of the Article: Challenges in antenatal care utilization in Kandahar, Afghanistan: A cross-sectional analytical study.

Bilal Ahmad Rahimi

Dear Dr. Rahimi,

We've checked your submission and before we can proceed, we need you to address the following issues:

1. Please upload a Response to Reviewers letter which should include a point by point response to each of the points made by the Editor and / or Reviewers. (This should be uploaded as a 'Response to Reviewers' file type.) Please follow this link for more information: http://blogs.PLOS.org/everyone/2011/05/10/how-to-submit-your-revised-manuscript/

Answer: A "Response to reviewers" file has been uploaded.

2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed the survey or questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. If the questionnaire is published, please provide a citation to the (1) questionnaire and/or (2) original publication associated with the questionnaire.

Answer: OK. Now questionnaire has been uploaded as Supporting Information.

3. Please revise the title of your manuscript to remove "Title of the Article:" in the submission system.

Answer: Now "Title of the Article:" is removed in the submission system.

4. Thank you for stating the following financial disclosure: "There was no financial support for this research from any source."

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.”

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

Answer: We did not have any funding sources for our study. The publication fee for our article will be provided by MORU (Mahidol-Oxford Tropical Medicine Research Unit), Bangkok. MORU will pay only if the journal put the following statement in the funding part of the article:

“This study did not receive any specific funding. WR Taylor is part funded by Wellcome under grant 220211. For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission.”

I have mentioned this in the Cover letter too.

5. Thank you for stating the following in your Competing Interests section: "There are no competing interests."

Please complete your Competing Interests on the online submission form to state any Competing Interests. If you have no competing interests, please state "The authors have declared that no competing interests exist.", as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now

This information should be included in your cover letter; we will change the online submission form on your behalf.

Answer: We have added the following sentence in the Cover letter:

“The authors have declared that no competing interests exist.”.

6. 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. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

Answer: As the data file is the property of Kandahar University Research Center, we are not allowed to share the data file with anyone. For this we contacted the research center. They provided a part of the data from the main SPSS data file. Now have uploaded it as the Supporting Information file.

Also, we mentioned this information in the Cover letter.

Thank you for submitting your work to PLOS ONE and supporting our mission of Open Science.

Kind regards,

Richard Ibañez Dilla

PLOS ONE

Many thanks

Bilal

Attachment

Submitted filename: Response to the Reviewers.docx

Click here for additional data file. (17.9KB, docx)

Decision Letter 1

Hanna Landenmark

10 Jul 2022

PONE-D-21-18840R1

Challenges in antenatal care utilization in Kandahar, Afghanistan: A cross-sectional analytical study.

PLOS ONE

Dear Dr. Rahimi,

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 reviewer from the first round has reassessed the manuscript. Whilst they are overall happy with the amendments made, they have provided some additional suggestions, which can be found below.

Please also amend your Methods section to include details of how the questionnaire was developed, tested and validated.

Please submit your revised manuscript by Aug 22 2022 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.

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Hanna Landenmark

Staff 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.

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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: (No Response)

********** 

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: Dear Authors,

Thank you for submitting an improved version

The response to my previous comments has been attempted but has not been satisfactorily completed. The background section for example starts with a summary of MDG's and the SDG goal' which is not needed and does not add value to the paper. Rather,Afghanistan's MMR progress in the SDG and MDG is important to highlight. Similarily, the study variables on page 8 lines 193 need better explanation of why they were chosen with links to the litertaure. The definitions sections in page 9 also needs work-Please provide narrative explanation of these definitions along with links to the litertaure. Formatting of table 3 remains an issue .I would encourage the authors to make these changes in depth as the paper provides important findings

********** 

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: Yes: Dr Danish Ahmad

**********

[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. 2022 Nov 21;17(11):e0277075. doi: 10.1371/journal.pone.0277075.r004

Author response to Decision Letter 1

3 Aug 2022

PONE-D-21-18840R1

Title of the Article: Challenges in antenatal care utilization in Kandahar, Afghanistan: A cross-sectional analytical study.

Bilal Ahmad Rahimi

• Please also amend your Methods section to include details of how the questionnaire was developed, tested and validated.

Answer: Now details have been added in the “Materials and methods” section (lines 181-189) to clarify how the questionnaire was developed, tested and validated.

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: Dear Authors,

Thank you for submitting an improved version.

The response to my previous comments has been attempted but has not been satisfactorily completed.

1. The background section for example starts with a summary of MDG's and the SDG goal' which is not needed and does not add value to the paper. Rather, Afghanistan's MMR progress in the SDG and MDG is important to highlight.

Answer: Summary of MDGs and SDGs goals have been removed from the “Introduction” section. Afghanistan's MMR progress in the SDG and MDG is now added in the second last paragraph of the “Introduction”.

2. Similarly, the study variables on page 8 lines 193 need better explanation of why they were chosen with links to the literature.

Answer: Now the study variables on page 8 have explained why they were chosen and also liks to the literatures have been provided.

3. The definitions sections in page 9 also needs work-Please provide narrative explanation of these definitions along with links to the literature.

Answer: Now the definitions section has been explained narratively and links are provided.

4. Formatting of table 3 remains an issue. I would encourage the authors to make these changes in depth as the paper provides important findings.

Answer: I formatted table 3. To make table 3 clearer and easy to understand, I merged tables 3 and 4 as one table. Now this table contain both Chi-square analyses and logistic regression, making it very easy to understand.

Many thanks

Bilal

Attachment

Submitted filename: Response to the Reviewers.docx

Click here for additional data file. (16.6KB, docx)

Decision Letter 2

Monalisha Sahu

26 Sep 2022

PONE-D-21-18840R2Challenges in antenatal care utilization in Kandahar, Afghanistan: A cross-sectional analytical study.PLOS ONE

Dear Dr. Rahimi,

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.

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

While the paper provides important insights into challenges of ANC service utilization in Kandhar, Afghanistan; please address key issues mentioned below in your revised submission.

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

Please submit your revised manuscript by 10/10/2022. 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: https://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,

Monalisha Sahu

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):

Dear Authors,

Thanks for submitting your research with PLOS One. While the paper provides important insights to challenges of ANC service utilization in Kandhar, Afghanistan; there are certain key issues which must be addressed beforehand for possible publication.

Introductions:

• The first paragraph could be shortened and should be written more focussed on Afghanistan; the irrelevant information can be removed.

• 92 Generalized sentences like- ‘International community has always tried to reduce maternal mortality’ should be converted to more specific ones.

Methodology:

• 152.Study Design should be mentioned more specifically (almost all quantitative studies are questionnaire based)

• 156. Why these four clinics were chosen in Kandahar city should be explained properly.

• 160. Why Kandhar province was selected for the studyshould move up in the study methodology, probably to line No. 156.

• 170.Why unmarried female were excluded and how ethical consideration were met for them may be discussed briefly?

• 203. The Independent variable section n methodology does not mention Breastfeeding time of last child or any other variable related to ‘Using methods to make drinking water safe’; but they have been included in the result tables 2 &3. Also, how these variables can affect ANC services utilization can be briefly addressed for wide comprehension. If deemed not suitable these variables should be removed from the result tables.

Formatting of intext citation should be checked and corrected as per journal policy.

[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

Reviewer #2: (No Response)

**********

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

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: 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: (No Response)

Reviewer #2: 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

Reviewer #2: 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: Dear Authors,

Thank you for a much improved version. The paper reads better but still has formatting issues linked to intext references.For sequential references used intext such as1,2,3,4 please use [1-4]. I advice the authors to spend time reviewing the paper and checking for foramtting issues. As this is the only revision, the paper stands in a good place to be published if addressed and deemed by the editor

Reviewer #2: (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: Yes: Dr Danish Ahmad

Reviewer #2: 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. 2022 Nov 21;17(11):e0277075. doi: 10.1371/journal.pone.0277075.r006

Author response to Decision Letter 2

26 Sep 2022

PONE-D-21-18840R1

Title of the Article: Challenges in antenatal care utilization in Kandahar, Afghanistan: A cross-sectional analytical study.

Bilal Ahmad Rahimi

Review Comments to the Author

Dear Authors,

Thanks for submitting your research with PLOS One. While the paper provides important insights to challenges of ANC service utilization in Kandahar, Afghanistan; there are certain key issues which must be addressed beforehand for possible publication.

Introductions:

• The first paragraph could be shortened and should be written more focussed on Afghanistan; the irrelevant information can be removed.

• Answer: OK. Now the first paragraph has been shortened, irrelevant information has been removed, and now focussed on Afghanistan.

• 92 Generalized sentences like- ‘International community has always tried to reduce maternal mortality’ should be converted to more specific ones.

• Answer: OK. Now these generalized sentences have been removed and converted into more specific sentences.

Methodology:

• 152.Study Design should be mentioned more specifically (almost all quantitative studies are questionnaire based)

• Answer: OK. Thanks for the comment. To make it clearer and specific, now I changed it to “Cross-sectional questionnaire-based study” .

• 156. Why these four clinics were chosen in Kandahar city should be explained properly.

• Answer: OK. Now it is clearly explained. “These health clinics were randomly selected using lottery-method.”

• 160. Why Kandhar province was selected for the study should move up in the study methodology, probably to line No. 156.

• Answer: OK. As per reviewer comment, now this sentence is moved up to line 156.

• 170.Why unmarried female were excluded and how ethical consideration were met for them may be discussed briefly?

• Answer: Now the following sentences have been added in exclusion criteria after “unmarried females”:

“These females are excluded due to the facts that extramarital pregnancies are rare and also considered very big sin in the Afghan society. If the family members get information of extramarital pregnancy, there is a fear that the female can be tortured or even killed.”

• 203. The Independent variable section n methodology does not mention Breastfeeding time of last child or any other variable related to ‘Using methods to make drinking water safe’; but they have been included in the result tables 2 &3. Also, how these variables can affect ANC services utilization can be briefly addressed for wide comprehension. If deemed not suitable these variables should be removed from the result tables.

• Answer: OK. Thanks for the good point. As these 2 variables (i.e., “Breastfeeding time of last child” and “Using methods to make drinking water safe” do not affect ANC services utilization, now they have been removed from the tables.

Formatting of intext citation should be checked and corrected as per journal policy.

• Answer: OK. Thanks. Now the intext citation is thoroughly checked and corrected as per journal policy. For example, intext citation of 1,2,3,4 has been changed to 1-4.

Many thanks

Bilal

Attachment

Submitted filename: Response to the Reviewers.docx

Click here for additional data file. (17.6KB, docx)

Decision Letter 3

Monalisha Sahu

20 Oct 2022

Challenges in antenatal care utilization in Kandahar, Afghanistan: A cross-sectional analytical study.

PONE-D-21-18840R3

Dear Dr. Rahimi,

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,

Monalisha Sahu

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The in text citation still needs correction

Reviewers' comments:

Acceptance letter

Monalisha Sahu

11 Nov 2022

PONE-D-21-18840R3

Challenges in antenatal care utilization in Kandahar, Afghanistan: A cross-sectional analytical study.

Dear Dr. Rahimi:

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. Monalisha Sahu

Academic Editor

PLOS ONE

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