Intention to use maternity waiting home and associated factors among pregnant women in Gamo Gofa zone, Southern Ethiopia, 2019.

BACKGROUND: A maternity waiting home is a temporary residence in which pregnant women from remote areas wait for their childbirth. It is an approach targeted to advance access to emergency obstetric care services especially, in hard-to-reach areas to escalate institutional delivery to reduce complications that occur during childbirth. Apart from the availability of this service, the intention of pregnant women to utilize the existing service is very important to achieve its goals. Thus, this study aimed to assess the intention to use maternity waiting homes and associated factors among pregnant women.
METHODS: Community-based cross-sectional study was conducted among 605 pregnant women using a multistage sampling technique from March 10 to April 10, 2019, by using a structured questionnaire through a face-to-face interview. The collected data was entered into Epi-Data version 3.1 and analyzed using the SPSS version 24 statistical package. Logistic regression analysis was used to test the association. All variables at p-value < 0.25 in bivariate analysis were entered into multivariate analysis. Lastly, a significant association was declared at a P-value of < 0.05 with 95% CI.
RESULTS: In this study, the intention to use maternity waiting homes was 295(48.8%, 95%CI: 47%-55%)). Occupation (government employee) (AOR:2.87,95%CI: 1.54-5.36), previous childbirth history (AOR:2.1,95%CI:1.22-3.57), past experience in maternity waiting home use AOR:4.35,95%CI:2.63-7.18), direct (AOR:1.57,95%CI:1.01-2.47) and indirect (AOR: 2.18, 1.38,3.44) subject norms and direct (AOR:3.00,95%CI:2.03-4.43), and indirect (AOR = 1.84,95%CI:1.25-2.71) perceived behavioral control of respondents were significantly associated variables with intention to use maternity waiting home.
CONCLUSION: The magnitude of intention to use maternity waiting homes among pregnant women is low. Community disapproval, low self-efficacy, maternal employment, history of previous birth, and past experiences of MWHs utilization are predictors of intention to use MWHs, and intervention programs, such as health education, strengthening and integration of community in health system programs need to be provided.

Introduction

The World Health Organization (WHO) defined Maternity Waiting Home (MWH) as a temporary housing service nearby health facilities, in which pregnant women wait for childbirth [1]. Endorsing MWH near health facilities is a strategy that can reduce inequity, by improving poorer women’s access to health facilities that enable advanced management of childbirth complications. It is a highly profitable and cheap approach to decrease maternal morbidity and mortality as well as it is a low-cost solution to access skilled birth attendants in remote areas [1-4]. Besides, it is a life-changing innovative approach, which was established as one of the three institutional innovations (existence of community-based health insurances, the establishment of maternal waiting homes, and strengthening of health facilities and personnel) that have substantially contributed to accelerating progress on maternal health in Africa [5]. Even if there are certain challenges to utilize MWH, it is important to educate, and counsel the women about pregnancy, childbirth, newborn and infant care, and family planning, and it offers the opportunity for women to come closer to the health institutions before labor starts which helps to avoid reluctance to walk a long distance after labor begins [6-10].

Globally, about 10.7 million women died in a year between 1990 and 2015 due to maternal causes. This catastrophic event is coarsely 20 folds higher in developing regions than developed regions. Approximately 99% of the estimated global maternal deaths occurred in developing regions in 2015. Of this sub-Saharan Africa alone accounted for roughly 66% of maternal deaths followed by Southern Asia [11]. According to the United Nations sustainable development goal (SDG) three target one plan, the global maternal mortality ratio will be less than 70 per 100,000 live births by 2030 and thus, each country in the world will be required to reduce MMR by at least 7.5% each year between 2016 and 2030 to achieve this target [12].

Access to comprehensive emergency obstetric care is limited in Ethiopia; and due to lack of modern transport, people use a locally made stretcher to carry laboring mothers to the health facility by community members [13]. In Ethiopia, a maternal mortality ratio remains high; which is 412 per 100,000 live births as per the 2016 EDHS report [14]. According to the mini EDHS 2019 survey report, institutional delivery is only 48%, which indicated that home delivery is still common, and as a result of distance, inaccessibility, and lack of appropriate facilities, lack of access to health facilities in rural areas (primarily in hard-to-reach areas), and in rural Ethiopia, only 43%, and 40% of women delivered by skilled birth attendants, and in health facilities respectively as per the 2019 EDHS report [15]. In the Southern Nations, Nationalities, and Peoples’ Region of Ethiopia, more than three fourth (78.6%) of women gave birth without a skilled birth attendant, and this region has a high MMR [14, 16]. Though escalating institutional deliveries is vital to reduce maternal and neonatal mortality and building and using maternal waiting homes is one of the solutions [3, 17, 18]. In Ethiopia, the first MWH was built in 1976 [13], and currently, the Amhara region is the top in MWHs coverage with 72% followed by Southern Nations, Nationalities, and Peoples’ Region(SNNPR) (57%), and Oromia region (56%); and least (8%) in the Gambella region [19].

In the developing world, the probability of death among MWH users is 80% less than in non-users and 73% less occurrence of stillbirth among users, and also 98.8% of MWH users delivered with a low proportion of bad obstetric outcomes than non-users [20-23]. The health-seeking behavior of the mothers, inadequate progressive planning for delivery; the women’s perception of service benefits (attitude); women’s perception about social pressure from important others (normative beliefs); the previous history of obstetric complications, and the availability of MWH at health institutions are factors that are related to the willingness of the women to utilize MWH [24, 25]. Although the evidence showed MWHs as a strategy to reduce MMR and stillbirth [26], there is limited data on the level of utilization of MWH in Ethiopia and the intention of pregnant women to use this service. So, this study was directed to assess the intention to use MWH and associated factors such as pregnant women’s attitude, subjective norm, perceived behavioral control, socio-demographic, and obstetrics related to factors [Fig 1].

Fig 1

Conceptual framework, which was adapted from the theory of planned behavior, showed factors associated with intention to use maternity waiting home [27–34].

Methods

Study area and period

This study was conducted in the Gamo Gofa zone, Southern Ethiopia using data of pregnant women of Kamba district from March 10 to April 10, 2019. Kamba district is one of the districts’ in the SNNPR of Ethiopia, part of the Gamo Gofa Zone. It is located 615 km far from Addis Ababa, 390, and 110 km from the capital of SNNPR, Hawassa, and Arba Minch, capital of Gamo Gofa Zone respectively. According to the 2007 national census conducted by the Central Statistical Agency of Ethiopia, this district has a total population of about 155979, of whom about 79273 and 76706 are men and women respectively; 4072 or 3.02% are urban inhabitants. And a total of 30,180 households were counted in this district, resulting in an average of 4.4 persons to a household, and 29,565 housing units. Regarding health facility coverage, Kamba district has one district hospital, 7 health centers each with MWHs, 2 Satellite clinics, and 39 Health Posts. The estimated number of pregnant women in the area was 7163. There are 38 rural and 5 urban administrative kebeles (the smallest administrative units of Ethiopia) found in this district [33]. Of these, the study was collected on randomly selected 11 kebeles [S1 Fig].

Study design and population

A community-based cross-sectional study was conducted using all pregnant women who were living in the Gamo Gofa zone as a source population, and all registered pregnant women in the selected kebeles of Kamba district as the study population. Those pregnant women who lived less than six months in the study area and those who delivered by cesarean section were excluded from the study.

Sampling and study variables

The assumptions used to calculate the maximum sample size for this study were population proportion of intention to use MWHs, 57.3% which was taken from a study done in Jimma district [34] with a 95% confidence level (CI) and an estimated margin of error 5%. With none-response rate of 10% which yields 38, the minimum required sample size = 38 + 376 = 414. Since the sampling technique was multistage, the design effect of 1.5 was considered, and the final total sample size was 621. This study was conducted in the Gamo Gofa zone in southern Ethiopia using the data of pregnant women in the Kamba district, and to run the multistage sampling technique districts in this zone were considered as clusters because there is a homogeneous feature between districts. Then, due to the number of pregnant women estimation in each district and our sample size, the Kamba district was selected randomly. In the Kamba district there are 43 kebeles, and to make the sample being representative to all Kebeles, we took 25% of them (11 kebeles) randomly. Additionally, we employed a design effect of 1.5 to represent the sample to the Gamo Gofa Zone. By considering the heterogeneous feature of Kebeles within a cluster, proportional allocation of pregnant women was done in each selected stratum (Kebele), and in each Kebele, there are assigned HEWs, and these HEWs provide community visits at the household level at least 2 times week and one of their responsibility is to investigate whether pregnant woman/s is present in that household or not, and then to register them. The registration includes the gestational age, EDD, Name, Phone number (if available), the exact location, and others. After obtaining the registration number of pregnant women from health extension workers (HEWs) of each selected Kebele, a simple random sampling technique (lottery method) was applied by using the registration book of pregnant women as a framework.

Furthermore, 621 pregnant women who fulfilled the inclusion criteria were recruited based on their registration number via simple random sampling technique, and an interview was done at the household level for those randomly selected pregnant women [S1 Fig], and variables such as socio-demographic characteristics (age, marital status, religion, educational status, and occupation), obstetric history (current ANC visit, number of ANC visit, previous childbirth history, place of delivery, and experience of MWH), and psycho-social/behavioral variables (direct and indirect attitude, direct and indirect subjective norm, and also direct and indirect perceived behavioral control) were included in the data collection tool [Fig 1].

Operational definitions

Intention to use Maternity Waiting Home (MWH)

An indication of pregnant women’s willingness, and how much effort they are planning, and exert to utilize it. It was measured by questions containing five points Likert scale. Lastly, it was dichotomized into two groups using the mean score. Those who scored above the mean (12.61) were classified as intended to use MWH, whereas those who scored less than or equal to the mean score (12.61) were considered as not intended to use MWH [35].

Attitude towards MWH

The degree of pregnant women’s maternity waiting home utilization behavior is influenced by her emotions, motivations, perceptions, and thoughts. It was measured by using four questions containing a five-point Likert scale. And they are classified into two by using mean as they have favorable and unfavorable attitudes.

Favorable attitude

The respondent’s attitude score > mean (11.59), and

Unfavorable attitude

The respondent’s attitude score less than or equal to the mean score [35].

Indirect attitude

It was computed by multiplying behavioral beliefs of pregnant women concerning each outcome by corresponding outcome evaluation ratings, and then summing these product scores across all outcomes. Finally, the mean (15.93) was used to dichotomize into favorable and unfavorable indirect attitudes [32].

Direct subjective norm

Pregnant women’s perception of using maternity waiting homes. It was measured by four questions containing a five-point Likert scale, and they were classified into two by using mean as they have favorable and unfavorable subjective norms. Those who scored above the mean (10.70) were classified as having favorable subjective norms, but those who scored less than or equal to the mean were classified as having unfavorable subjective norms [35].

Indirect subjective norm

It was computed by multiplying pregnant women’s normative belief about each referent by her motivation to obey with that referent and then summing these product scores across all referents. Finally, the mean score (10.46) was used to dichotomize [32].

Perceived behavioral control

Each pregnant woman’s belief concerning how easy or difficult it is to use maternity waiting homes. It was measured by four questions containing a five-point Likert scale and was classified into two by using mean as they have favorable and unfavorable perceived behavioral control. Those who scored above the mean (11.75) were classified as having favorable perceived behavioral control, and those who scored less than or equal to 11.75 were classified as having unfavorable perceived behavioral control [35].

Indirect perceived behavioral control

It was computed by multiplying each control belief of pregnant woman by her corresponding perceived power (impact) scores and then summing these product scores across all control factors, and finally, those who scored above the mean (14.64) were taken as having favorable indirect perceived behavioral control [32].

Data collection tool, quality control, and procedures

Data were collected using a structured and pre-tested questionnaire through a face-to-face interview. Five trained data collectors (HEWs) who were recruited from health posts, and who were supervised by three supervisors (BSc, Nurses) from health centers were executed for the data collection. The questionnaire was translated from English to Amharic, and then to Gamogna (local language) and back to English by six language experts to assure consistency [S1–S3 Tables]. Face validity was conducted to assess the form of the questionnaire in terms of feasibility, readability, evenness of technique and formatting, and the clearness of the language, that is to assess the presentation and relevance of the measuring tool as to whether the items in the tool emerge to be pertinent, logical, explicit and obvious, and to validate the questionnaire, 2 experts groups on each English, Amharic, and Gamogna language have participated. A pre-test was conducted on 5% of the total sample size among pregnant women in one of the non-selected Kebele before the actual data collection. The training was given for data collectors and supervisors on the objective, and purpose of the study, the respondents’ rights, and the confidentiality of information, informed consent, and techniques of the interview. Finally, data were entered into Epi data version 3.1, and before conducting any analysis; the data pre-processing tasks like data cleaning, coding and recording, variable re-categorization, and identification for inconsistencies were done.

Data analysis and process

First, the data were coded and entered into Epi Data version 3.1 and then exported to SPSS version 24 statistical package for further analysis.

Data cleaning was performed to check for frequencies, and missed values then descriptive analysis such as proportions, percentages, means, and measures of dispersion, tables, and graphs were used to describe the data. To test the association between the independent and the outcome variable, logistic regression analysis was done. All variables at a p-value less than 0.05 in bivariate analysis were entered into multivariate analysis to identify the independent association of variables of intention to use MWH. Finally, significant independent associations were declared at a P-value of less than 0.05 with 95%CI. Hosmer-Lemeshow model fitness test was used to indicate the goodness of the final model, and model fitness is assured when the value is insignificant that is greater than 0.05.

Ethical approval and consent to the participants

Before data collection, Ethical approval was primarily obtained from Debre Markos University research ethical approval committee. Likewise, an official ethical clearance letter was obtained from the Kamba district health bureau. Following an explanation of the purpose of the study, verbal informed consent was obtained from each participant. Also, confirmation was made that they are free to withdraw and discontinue participation without any form of prejudgments. Confidentiality of information and the privacy of participants’ were assured by making their names anonymous.

Results

Prevalence of intention to use maternity waiting homes

A total of 605 pregnant women participated in the study, with an overall response rate of 97.4%. In this study, less than half, 295 (48.8%) with 95% CI (47%-55%) of pregnant women were intended to use maternity waiting homes [S1 Fig], and the mean score of intention to use MWH was 12.61(SD± 4.738).

Socio-demographic characteristics of pregnant women

The mean age of pregnant women who participated in this study was 25.91 with SD ± 5.023. About 33.4% of respondents were found in the age range of 20–24 years. The majority, 562 (92.90%) of respondents were married and 389 (64.3%) of them were housewives. Furthermore, about thirty percent of respondents were completed primary education [Table 1].

Table 1

Socio-demographic characteristics of pregnant women.

Variables	Categories	Frequencies	Percentages
Maternal Age in years	15–19	52	8.60
	20–24	202	33.40
	25–29	194	32.10
	30–34	127	21.00
	35 and above	30	5.00
Religion	Orthodox	191	31.60
	Protestant	335	55.40
	Muslim	79	13.10
Occupation	Housewife	389	64.30
	Merchant	145	24.00
	Government employee	71	11.70
Educational status	Can’t to read and write	177	29.30
	Only read and write	159	26.30
	Primary education	184	30.40
	Secondary education and above	85	14.00
Marital status	Married	562	92.90
	Single	7	1.20
	Widowed	32	5.30
	Divorced	4	0.70

Maternal health services utilization of pregnant women

More than half of respondents had greater than three pregnancy experiences, and the majority (84.79%) of them had given birth before the current pregnancy. Likewise, about 61.60% of the respondents gave their previous childbirth at health institutions [Table 2].

Table 2

Maternal health services utilization among pregnant women.

Variables	Category	Frequency	Percentages
Number of pregnancy	1–2	253	41.80
	>3	352	58.20
ANC visit for current pregnancy	Yes	388	64.10
	No	217	35.90
Number of ANC visit(n = 388)	1st visit	64	16.50
	2nd visit	117	30.20
	3rd visit	118	30.40
	4th visit	89	22.90
Pervious childbirth history	Yes	513	84.80
	No	92	15.20
Place of delivery (n = 513)	Home	197	38.40
	Health institution	316	61.60

Experience in maternity waiting homes utilization

Less than a quarter of the respondents, 130 (21.50%) had past experiences with MWH utilization. Of those who utilized previously, 72 (55.38%) have stayed in the service center for two weeks and only 9 (6.92%) of them have stayed for more than two weeks [Table 3].

Table 3

Past experiences in MWH service utilization among pregnant women.

Variables	Categories	frequencies	Percentages
Previous experiences of MWH	No	475	78.50
	Yes	130	21.50
Reasons for previous utilization(n = 130)	Fear of labor illness	42	32.30
	Fear of death related to delivery	36	27.70
	To get better health care from health professionals	36	27.7
	To get a healthy child	11	8.50
	To get enough rest and free from workload	5	3.80
Duration of stay in MWH previously (n = 130)	<15 days	49	37.70
	Only 15 days	72	55.40
	>15 days	9	6.90

Direct components of Theory of Planned Behavior (TPB)

Two hundred seventy-three (45.10%) of the pregnant women had a favorable attitude to use MWH with a mean of 11.59 (SD ± 4.350). And also, two hundred forty-nine (41.20%) and 327 (54.00%) of the respondents had favorable subjective norm and perceived behavioral control with a mean of 10.70 (SD ±4.565) and 11.75 (SD ±3.723) respectively [Fig 2].

Fig 2

Proportion of direct components of theory of planned behavior among pregnant women in Gamo Gofa zone, Southern Ethiopia, 2019.

Indirect TPB components (indirect attitude, indirect subjective norm, and indirect perceived behavioral control)

Four hundred forty-three (73.2%) of pregnant women had favorable indirect attitudes with a mean score of 15.93% (SD±3.455). Four hundred seventy-six (78.70%) of pregnant women agreed that MWH would help them to get a healthy child. Likewise, 500(82.60%) of them agreed MWH would help them to be happy, and reduce labor fear. Additionally, 352 (58.20%), and three hundred eleven (51.40%) of the respondents mentioned that staying at MWH is very good to get a healthy child and to reduce labor fear respectively.

Two hundred forty-two (40%) of the respondents had favorable indirect subjective norms with a mean score of 10.46 (SD±4.349). Three hundred seven (50.70%) of the participants agreed that HEWs think that they should stay in MWH. Two hundred twelve (35.10%) of them agreed that their husbands think that they should stay in the maternity waiting home. In the motivations to comply with the above normative beliefs, 299 (49.40%) of respondents reported that HEWs’ approval for their stay in MWH was much important. Of them, less than a quarter 128 (21.20%), and 111 (18.30%) were reported that their mothers’ and husbands’ approval to use MWH is much important respectively.

Three hundred nine (51.1%) of the respondents had favorable indirect perceived behavioral control with a mean score of 14.64 (SD±3.738). The majority 495(81.90%) of them reported that it’s unlikely to get enough food in MWH to use it, followed by 447 (73.90%) of them reported they were unlikely to get transportation/walk to long distance. And also 379 (62.70%) pregnant women reported it’s unlikely to get individuals to take care of their family while they staying in MWH. The power of control belief result revealed that 475 (78.50%) and 447 (73.90%) of the respondents agreed that the availability of food and transport accessibility makes it easy to use MWH respectively.

Bivariate and multivariate analysis of factors associated with intention to use maternity waiting home

In the bivariate analysis age of the respondents, educational level, occupation, previous childbirth history, the experience of MWH utilization, the reason for past utilization, and duration of stay at MWH, direct and indirect attitude, direct and indirect subjective norm, and direct and indirect perceived behavioral control were associated with intention to use MWH. However, in the multivariate regression analysis occupation (government employees), previous childbirth history, the experience of MWH, direct and indirect subjective norm, and perceived behavioral control of the respondents were the factors that significantly associated with intention to use maternity waiting home. Respondents who were government employers were 2.87 times (AOR: 2.87, 95%CI: 1.54–5.36) more likely to intend to use MWH as compared to housewives. Pregnant women who had previous childbirth history were 2.1 times (AOR: 2.08, 95%CI: 1.22–3.57) more likely to intend to use MWH than those pregnant women who had not given birth before. According to the findings of this study, pregnant women who had experience in MWH utilization were 4.35 times (AOR: 4.35, 95%CI: 2.63–7.18) more likely intended to use MWH as compared to those who have not utilized it in the past.

Pregnant women with favorable direct subjective norm were 57% (AOR: 1.57, 95%CI: 1.01–2.47) more likely intended to use MWH as compared to those with the unfavorable subjective norm. This study also revealed that indirect subjective norm has a significant association with intention to use MWM i.e. respondents who have favorable indirect subjective norm were 2.2 times (AOR: 2.18, 95%CI: 1.38–3.44) more likely intended to use MWH as compared to those who have an unfavorable indirect subjective norm. The finding from this study showed that both direct and indirect perceived behavioral control have a significant association with intention to use MWH i.e. pregnant women who had favorable direct, and indirect perceived behavioral control was3 times (AOR: 3.00, 95%CI: 2.03–4.43), and84% (AOR: 1.84, 95%CI: 1.25–2.70) more likely intended to use MWH as compared to those with unfavorable direct and indirect perceived behavioral controls respectively [Table 4].

Table 4

Bivariate and multivariate analysis of factors associated with intention to use maternity waiting home among pregnant women.

Variables	Categories	Intended to use MWH	Not intended to use MWH	COR (95%CI)	AOR(95%CI)
Occupation	Government employees	49(8.1%)	22(3.63%)	2.51(1.46–4.30)	2.87(1.54–5.36)**
	Merchant	63(10.41%)	82(13.55%)	0.86(0.59–1.27)	0.69(0.44–1.10)
	House wife	183(30.25%)	206(34.06%)	1	1
Previous history of child birth	Yes	262(43.30%)	251(41.48%)	1.86(1.17–2.95)	2.08(1.22–3.57)*
	No	33(5.45%)	59(9.75%)	1	1
Past experience of MWH	Yes	102(16.86%)	28(4.63%)	5.32(3.37–8.40)	4.35(2.63–7.18)**
	No	193(31.90%)	282(46.61)	1	1
Direct Subjective Norm	Favorable	155(25.62%)	94(15.54%)	2.54(1.82–3.55)	1.57(1.01–2.47)*
	Unfavorable	140(23.14%)	216(35.70%)	1	1
Direct Perceived behavioral Control	Favorable	208(34.38%)	119(19.67%)	3.83(2.73–5.38)	3.00(2.03–4.43)**
	Unfavorable	87(14.38%)	191(31.57%)	1	1
Indirect subjective norm	Favorable	162(26.78%)	74(12.23%)	3.88(2.74–5.49)	2.18(1.38–3.44)**
	Unfavorable	133(21.98%)	236(39.01%)	1	1
Indirect Perceived behavioral Control	Favorable	165(27.27%)	144(23.80%)	1.46(1.06–2.01)	1.84(1.25–2.70)*
	Unfavorable	130(21.49%)	166(27.44%)	1	1

** = p <0.001: strongly significant association;

* = p<0.05: statistically significant, and 1 = reference group

Discussion

This study was conducted to identify the intention to use the maternity waiting homes and associated factors among pregnant women in southern Ethiopia. According to this study, 48.8% (95%CI: 47–55%) of pregnant women were intended to use maternity waiting homes, which indicated that more than 50% of the respondents were not willing to use MWHs. And if they are not willing to stay in the maternity waiting homes, especially for those pregnant women who are from remote areas, the probability of delay to reach health institutions and giving birth at home might be increased which results in the development of different life endanger complication of both the women and their fetuses. This finding is consistent with a previous study conducted in Mettu district, Illubabor zone, Ethiopia which is 48.80% [35]. However, this finding is lower than other previous studies conducted in Jimma district, Ethiopia, which was 57.3% [34] and Butajira, southern Ethiopia, it was 55.1% [36] and a study conducted in Kenya which was 61.1% [28]. These discrepancies could be due to variations in socio-demographic differences among the study areas; disparities in the health service utilization and accessibility; a gap of knowledge about MWH services among the study populations and also the nature of the study. This 48.8% of intention to use maternity waiting homes is greater than a prior study conducted in rural health centers of Ethiopia, which was 27% [29], and a study conducted in rural Kenya which revealed 45% of women intended to use maternity waiting homes [37]. The reasons for this discrepancy might be due to variations in the study period, and the study population.

In this study, the occupation of pregnant women that is being government employees was found to be one of the significantly associated variables with the intention of pregnant women to use MWH as compared to housewives. In contrary to this finding, a study conducted in the Jimma Zone, Ethiopia indicated that housewives had higher odds of the utilization of MWH than farmers/traders/others [38]. Nonetheless, there has been limited scientific evidence concerning this significant association, the possible reason for this association could be due to those women who are government employees might have exposure to information and better insight about MWH services as compared to those women who are housewives.

Intention to use MWH was significantly associated with previous childbirth history. Even if there is no enough data regarding this significant association, the possible reason could be those women who had a history of previous childbirth might have better information about the availability and importance of MWH services during previous health facility visiting than those women who had not ever given birth.

According to the findings of this study, intention to use MWH among pregnant women has a statistically significant relationship with experience in MWH utilization. This finding is supported by a study done in the Jimma district which revealed that women who had the experience of MWH utilization were 16.3% more intended to use MWH than those who do not have experience [34]. The possible reason for this significant association could be; those women who utilized MWH in the past might have better insight into the benefit of staying in MWHs as compared with women who were not ever utilized it.

This study revealed that direct subjective norm was significantly associated with intention to use maternity waiting home which indicated community (most important persons) approval or disapproval to use MWHs affects pregnant women’s intention to utilize it. As a result, intention to use MWH was significantly associated with pregnant women’s favorable direct subjective norm i.e. high community approval to stay in maternity waiting homes increases the intention of pregnant women to wait in it for two weeks before labor starts. This is congruent with a study done in Mettu districts, Ethiopia which depicted that women who had favorable subjective norms were markedly intended to use MWH than their counterparts, and also it is in line with a study conducted in the Jimma district [34, 35]. This could be due to the crucial importance of significant others (husbands, mothers, HEWs, neighbors, and other important persons) of pregnant women in the decision-making process regardless of their willingness to use MWHs.

This study also revealed that indirect subjective norm, which is pregnant women’s agreement or disagreement regarding their husband’s, mother’s, neighbors, and HEWs thinking towards their stay in MWHs, has a noteworthy association with intention to use MWH i.e. pregnant women who have favorable indirect subjective norm (who agreed that other important persons think they should wait in MHWs) were significantly intended to use MWH, and it is supported with a study done in Jimma district, Ethiopia [34]. In the current study, 50.75% and 35.05%) of the respondents agreed that HEWs and their husbands think that they should stay in MWH. This finding is congruent with a study conducted in Jimma district, Mettu District, and rural Zambia in which HEWs and husbands have participated in the decision to use MWHs [25, 34, 35]. The reason for this association could be due to the valuable significance of HEWs and husbands’ role in the utilization of MWH.

The finding from this study showed that direct perceived behavioral control (self-efficacy) that is easiness or difficult to use MWHs has a significant association with intention to use MWH, which indicated an intention to use MWH among pregnant women has an incredible relationship with favorable direct perceived behavioral control of pregnant women i.e. respondents who have low self-efficacy were not willing to stay in maternity waiting homes. This result is compatible with a finding from the Mettu district in which participants with favorable perceived behavioral control were 99% more likely intended to use MWH as compared to unfavorable perceived behavioral control [35], and also it is congruent with a survey done in Jimma, Ethiopia which revealed that direct perceived behavioral control had a significant association with intention to use MWH [34].

In this study, pregnant women who have favorable indirect perceived behavioral control were significantly intended to use MWH as compared to their counterparts which revealed pregnant women’s perception on availability of transportation during advanced gestation, long-distance, availability of sufficient food in the waiting homes, accessibility of individuals who give care for their families at the households, and on desolate surrounding in the maternity waiting homes was related on the women’s intention to use MWHs. This finding is also congruent with a survey done in Jimma which showed a strong significant association between indirect perceived behavioral control and intention to use MWH [34]. The potential rationale for this evenness could be due to parallel perceived barriers such as long-distance/lack of transportation, unavailability of food in MWHs among the two populations since both of them were conducted among rural districts. This study also revealed 81.82% of the respondents reported that it’s difficult to get enough food in MWH during service utilization; it followed by 72.24% of them reported they were unlikely to get transportation or walk to the long-distance, which is supported by previous studies conducted on maternity waiting facilities for improving maternal and neonatal outcome, and in strengthening referral systems in low-resource countries [39, 40]. However, this finding is greater than the study conducted in Butajira in which 41.8% and 33.4% of participants were unlikely to get enough food and transport to go to MWHs respectively [36]. The differences could be due to time variation, socio-demographic differences, and availability of roads and transportation between the populations.

Different kinds of the literature showed the presence of a statically significant association between intention to use MWH and educational level, direct and indirect attitude of pregnant women [34, 35]. However, these variables were not significantly associated with pregnant women’s intention to use MWHs in the multivariate analysis of this study despite the presence of association in bivariate analysis. This illustrates intention to use MWHs is not affected as a result of maternal educational level, and by the view of pregnant women about advantages and disadvantages of staying in maternity waiting homes but it is affected by other enabling factors and perceived barriers.

The community-based nature of this study is its strength, however, as this is a quantitative study, it might lack some hidden attitudes of women that can predict the intention and which would be addressed by qualitative type of studies and it is tough to declare a cause-effect relationship between the outcome and independent variables due to the cross-sectional nature of this study. To avoid selection bias, we used a simple random sampling technique to select the study participants from the list of pregnant women in the health extension workers registration book, and the data were collected in the community at home. However, using the list of pregnant women in the HEWs registration book as a sampling frame may not include new pregnant women and this is one of the limitations of this study. During the interview, social desirability bias might be committed, but to reduce it only volunteer participants were involved, and their names were kept anonymous, a brief overview of the study was provided, we used experienced interviewers, and the interview was carried out using a one-on-one strategy. To avoid interviewer bias, we instruct our interviewers to read each question accurately to the respondents to answer based on their best understanding of the question, do not interpret the question for the respondents, and offer to say again the question precisely as it appears. Generally, we educate our data collectors to avoid any adjustment, explanation, addition, subtraction, suggestion, or change in verbal variation during the interview process. But using HEWs to collect the data is also the other limitation of this study which imposes social desirability bias.

Conclusions

Generally, the intention to use maternity waiting homes among pregnant women is low, which leads to inaccessibility of obstetric care and it will provoke pregnant women to give birth at home without skilled birth attendants that may end up with the development of different life-threatening complications including maternal and neonatal deaths. Community disapproval, low self-efficacy, maternal employment, history of previous childbirth, and past experiences of MWHs utilization are predictors of intention to use MWHs. These findings call for the intervention of the community to increase the intention of pregnant women towards MWH utilization and we authors recommend that:

It is better to mobilize the community and provide health education, concerning MWH service to all the community and mothers to improve the subjective norm.

Community-based stakeholders such as health development armies need to be strengthened and extended to alleviate transportation problems and food shortages, those upshot women with unfavorable perceived control beliefs, through integration with local and federal governments to upsurge perception of mothers towards behavioral controls.

Health care professionals need to advise and counsel the mothers on MWH service at ANC visiting to increase their intention.

In this area, it is better to do further researches in a qualitative approach.

Diagrammatic presentation of sampling procedure used to recruit pregnant women in Kamba District, Gamo Gofa Zone, Southern Ethiopia, 2019.

(DOCX)

Click here for additional data file.

Magnitude of intention to use maternity waiting home among pregnant women in Gamo Gofa zone, Southern Ethiopia, 2019.

(DOCX)

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English version questionnaire.

(DOCX)

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Amharic version questionnaire.

(DOCX)

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Gamogna version questionnaire.

(DOCX)

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English version consent form.

(DOCX)

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Amharic version consent form.

(DOCX)

Click here for additional data file.

Gamogna version consent form.

(DOCX)

Click here for additional data file.

(XLSX)

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11 Nov 2020

PONE-D-20-31704

Intention to use maternity waiting home and associated factors among pregnant women in Kamba District, Gamo Gofa zone, Southern Ethiopia, 2019

PLOS ONE

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2. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as:

-    a description of any inclusion/exclusion criteria that were applied to participant recruitment,

-    a table of relevant demographic details,

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Reviewer #1: Yes

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Reviewer #1: General comments

1. General comments

1.1: Authors should read thoroughly the author’s submission guidelines and strictly follow it for all sections of the manuscript. For this purpose they should download the sample pdf of abstract and sample pdf of manuscript. They should strictly follow the guideline for font size, writing style – upper and lower case writing in title, affiliation, abstract, main manuscript, table titles, figure titles, and references.

1.2: While submitting manuscript authors did not make the manuscript in double space, page numbers and line numbers.

2. English language has to be improved.

2. Title

2.1: Page (P) 2, lines (L) – 7, 9, While writing affiliation, instead of writing College of Health sciences, it should be College of Health Sciences.

2.2: P2, L10 – it should be Department of Public Health, College of Health Sciences

3. Abstract

3.1: P4, L56 – research aim is not the section in abstract. Merge it in background.

3.2: P4, L59 – delete add comma after April 10, and delete /

3.3: P4, L60 – it should be questionnaire and interview.

3.4: P4, L66 – it should be 95%.

3.5: P4, L68 – it should be (AOR

3.6: P 4, L72 – Recommendation is not there – follow guidelines

3.7: P4, L77 – Delete Kamba district and write Ethiopia. For writing Keywords – they should match with MeSH terms.

4. Background

4.1: P5, L79 – It should be World Health Organization

4.2: P5, L81 – It should be health facility instead of hospitals. In your study area there are primary health care units. They are not hospitals.

4.3: P5, L93 – It should be long distance instead of several distances.

4.4: P5, L98 – it should be population instead of populations.

4.5: P5, L101 – give long form of SNNPR as it is appearing first time. It should be Oromia instead of Oromo region. Add and after (56%); and least

4.6: P5, L133 – Add per – it should be as --- attendants as per the 2016.

Comment: Authors did not cite the following publications to add in the background or discussion

a. Kurji J, Gebretsadik LA, Wordofa MA, Sudhakar M, Asefa Y, Kiros G, Mamo A, Bergen N, Asfaw S, Bedru KH, Bulcha G, Labonte R, Taljaard M, Kulkarni M. Factors associated with maternity waiting home use among women in Jimma Zone, Ethiopia: a multilevel cross-sectional analysis. BMJ Open. 2019 Aug 28;9(8):e028210. doi: 10.1136/bmjopen-2018-028210. PMID: 31467047; PMCID: PMC6720516.

b. van Lonkhuijzen L, Stekelenburg J, van Roosmalen J. Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries. Cochrane Database Syst Rev. 2012 Oct 17;10(10):CD006759. doi:10.1002/14651858.CD006759.pub3. PMID: 23076927; PMCID: PMC4098659.

c. Swanson DL, Franklin HL, Swanson JO, Goldenberg RL, McClure EM, Mirza W, Muyodi D, Figueroa L, Goldsmith N, Kanaiza N, Naqvi F, Pineda IS, López-Gomez W, Hamsumonde D, Bolamba VL, Newman JE, Fogleman EV, Saleem S, Esamai F, Bucher S, Liechty EA, Garces AL, Krebs NF, Hambidge KM, Chomba E, Bauserman M, Mwenechanya M, Carlo WA, Tshefu A, Lokangaka A, Bose CL, Nathan RO. Including ultrasound scans in antenatal care in low-resource settings: Considering the complementarity of obstetric ultrasound screening and maternity waiting homes in strengthening referral systems in low-resource, rural settings. Semin Perinatol.

2019 Aug;43(5):273-281. doi: 10.1053/j.semperi.2019.03.017. Epub 2019 Mar 16. PMID: 30979599; PMCID: PMC6597951.

d. Buser JM, Lori JR. Newborn Outcomes and Maternity Waiting Homes in Low and Middle-Income Countries: A Scoping Review. Matern Child Health J. 2017 Apr;21(4):760-769. doi: 10.1007/s10995-016-2162-2. PMID: 27475822.

e. Gaym A, Pearson L, Soe K. Maternity waiting homes in Ethiopia – three decades experience…..

5. Methods

Comment:

a. Follow guideline for section and sub-sections.

5.1: P8, L – 170, make it as April 10, and delete /

5.2: P8, L – 171, Authors should decide whether it should be as Gamo Gofa Zone or it should be used as Gamo Gofa zone in the whole manuscript including titles of tables and figures. Also authors should decide whether the percentages should be presented with one digit or two digit e.g. 3.2 or 3.21. These percentages be consist in the whole manuscript including tables and figures.

5.3: P8, L – 174 and 175, Instead of actual figures of population it can be written as about 160,000 and % male and female.

5.4: P8, L – 190 – 194 either delete this or put it in supplementary information. This formula is not required.

5.5: P9, L – 198, Explain what is Kebele – International reader will not understand.

5.6: P9, L – 203, Fig.2 - This figure can go into supplementary information.

5.6: P9 – There is need to link these two paragraphs giving information about data collection details. (L – 203 and L – 204).

5.7: P9 – Line – 208. Write as insert Fig. 1 here.

5.8: P10 – Line – 225. Write value of mean in the bracket. It should read – the mean () was to ----------

5.9: P10 – Line – 234. Write value of mean in the bracket. It should read – the mean () was to ----------

5.10: P10 – L 237 – Instead of scale and they – it should be scale and were

5.11: P10 – L 247 – 248 – it should be --- health posts who were supervised by three supervisors (B.Sc, Nurses) from health centre.

5.12: P11 – L 270 – Why this statement is required. Earlier you have not described this model. Or describe it little bit it here.

6. Results

Comment: Follow author’s guidelines for paragraph and sub-paragraphs font size, fond type, etc. Also decide number of decimals one or two to be presented percentages in the manuscript and Tables, and figures. It should be consistent.

6.1: P12 - L – 286 – Type – Insert table 1 here

6.2: P12 - L – 290 - Type – Insert table 2 here

6.3: P12 - L – 294 - Type – Insert table 3 here

6.4: P12 - L – 297 - Type – Insert Figure 3 here

6.5: P12 - L – 303 - Type – Insert Figure 4 here

Comment: Your result section description is short. In bivariate and multivariate section you bring AOR descriptions here from discussion section. In discussions do not put analysis figures. Give probable reasons, compare with other studies.

7. Discussions

Comment: Discussion is quite long.

7.1: P14 L – 338 – Instead of Intention it should be intention.

7.2: P15 L – 373 – 374 – It should be --- women who did not use it.

7.3: P16 L – 391 – 392 – It should be --- (16,25,26).

7.4: P16 L – 397 – it should be – perceived

7.5: P16 L – 414 – whether it is unlikely or likely. Check again.

7.6: P16 L – 415 – it should be – -----socio-demographic differences and availability of road and transportation between the populations.

8. Recommendation

Comment: Follow the guidelines of journal. No separate recommendation section. It should be included in conclusions.

9. Declaration

9.1: P18 – L 451 – it should be sacrifice

9.2: P18 – L 458 – Debre Markos University collage of health sciences

10. References

Comment: Follow guidelines for references – how to write authors, and other details of article of the journal, book, chapter in book, website.

10.1: P19 – L 473 – check the authors list……

10.2: P19 – L 485 – Check authors

10.3: P19 – L 488 – check the authors

10.4: P19 – L 494 – check the author, this is not complete.

10.5: P19 – L 499 – why 2012.

10.6: P20 – L 502 – it should be – comma after Columbia University,

10.7: P20 – L 506 – 509 – No. of authors are more than 6. As Vancoure system cannot be more than 6 authors --- after 6th author it should be et.al.

10.8: P20 – L 510 – What is Ruiter?

10.9: P21 – L 535 – 536 – Is this master’s thesis? Which University? Title of this study and this reference is same.

10.10: P21 – L 543 - what is this xxx – xxx – xxx.

10.11: P21 – L 545 – name of journal, vol. and page numbers

10.12: P21 – L 548 – no. of authors 6 and then et.al

10.13: P21 – L 553 – 555 – Check with reference guide. How to refer?

10.14: P21 – 556 – Is it a chapter in the book?

10.15: P21 – 557 – 558 – check how to refer chapter in book.

11. Tables

11.1: Table 1 – titles should be as per guidelines

11.2: Table 2 – titles should be as per guidelines. ANC visit for current pregnancy – yes no. is 386, but next variable – number of ANC visit – total number of 64, 117, 118, 89 is 388. And % are correct with 388 and not with 386.

11.3: Table 3 - titles should be as per guidelines. Delete all % sign. Why one digit percentage is presented for variable – Reasons for previous utilization ---

11.4: Table 4 – titles should be as per guidelines. Below the “*” P=< statistically associated --- should be statistically significant.

12. Figures

12.1: Figure 1: titles should be as per guidelines.

12.2: Figure 2: titles should be as per guidelines. This can go as supplementary attachment.

12.3: Figure 3: titles should be as per guidelines.

12.4: Figure 4: titles should be as per guidelines.

Reviewer #2: It is my pleasure to be designed as a reviewer of this paper, thank you very much!

This a good paper that examined the intention to use MWH, one of the strategies to bridge geographic barriers to access obstetric care.

Comments

Background

1) the background section needs to be restructured for smooth flow from general problem to specific problem statement. In this case, please try to develop themes for each paragraph and link them logically to the issue. You may follow what is intention to use MWHs, what determines women’s intention to use MWHs (individual, community, health system factors) or what is known in the area, what is unknown, contribution of this paper to the scientific knowledge. You need also explain your theoretical framework here. Figure 1 is not described in the text.

2) You use figures from 2016 EDHS data. Please update by 2019 mini-EDHS

3) Page 5, paragraph 3 states transport challenges citing more than 8 years old data. Please update it. The extent problem regarding transport access is not the same as the problem before 2012. Over the last few years, the GoE distributed ambulances to districts to expand access to emergency transport though efficient use and universal access is still a challenge.

Methods

1. the study utilized pregnant women registered in the selected Kebeles as sampling frame and randomly select respondents from that frame. However, it is not well described how pregnant women were registered in the Kebele? How complete the registration was? And how the women or her household was located for interview? It is known the Ethiopian community health information system/family folder or pregnant women registration by HEWs/WDAs are incomplete. As such, this would induce selection bias due to incomplete sampling frame, potentially excluding eligible respondents

2. The analysis section doesn’t mention of account for clustering or not.

3. The outcome variable originally collected as ordinal but later reduced to binary for logistic regression analysis. I think this technique wastes information and may dilute the statistical power. Why you don’t use ordinal regression?

4. Ethical clearance: Not clear whether written or verbal consent was obtained. And was ethical clearance or support letter this study sought from district health office?

Results

1) Figure 2 and 3 are already narrated in the text. No need to present same information with different format.

2) Overall, the result section is presented multiple subheadings without adequate description of the findings. For instance, the Table 4 is narrated in the discussion section. I would bring the results described in the discussion section (narrations with figures with odds ratios) to here.

3) Contrary to other studies, maternal education is not showing effect on the women’s intention to use MWHs. I think it can be related with the model fit or uncontrolled confounding. For instance, being government employee is associated with intention to use MWHs. This could be due to interaction or confounding with education. Please review it again

Discussion

1. Summary the main findings in the first paragraph and dedicate subsequent paragraphs for discussing intention to use and major determinants. Don’t repeat results here (as described above please move the descriptions regarding Table 4 to results section)

2. There are potential biases in this study including selection bias described above, interviewer bias, and social desirability bias that are not mentioned in the discussion section.

3. Conclusion is simply repeating the main finding. Please rewrite to reflect the relevance of the findings to the program, implications to future research, or your concluding comments/take-home messages

4. Some of the recommendations are not grounded from the study findings. For instance, bullet # 2 on page 16.

Language

Finally, there are multiple grammatical errors that needs to edited by someone who has experiences in academic edition. For instance, page 4, paragraph 1 that reads..."one of the three..." not clear what are these; page 5, last paragraph first sentence talks delivery by SBA, but second sentence talks about home delivery. These are not parallel. The third sentence, "...within three.." need to be deleted; page 7, last paragraph first sentence,"... population proportion of 57.3%..." replace by population proportion of intention to use MWHs, 57.3%;

**********

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Reviewer #1: No

Reviewer #2: Yes: Gizachew Tadele Tiruneh

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Submitted filename: Reviewer 1.docx

Click here for additional data file.

21 Jan 2021

Authors’ response to the Academic Editor comments’

When submitting your revision, we need you to address these additional requirements.

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

Authors’ response: The whole document revised based on PLOS ONE’s publication criteria

2. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as:

- a description of any inclusion/exclusion criteria that were applied to participant recruitment,

Authors’ response: Those pregnant women who lived less than six months in the study area, and those who delivered by caesarean section were excluded from the study.

- a table of relevant demographic details,

Authors’ response: The relevant demographic details are included under the study area of this study in a text form.

- a statement as to whether your sample can be considered representative of a larger population,

- description of how participants were recruited, and descriptions of where participants were recruited and where the research took place.

Authors’ response: This study was conducted in Gamo Gofa zone in southern Ethiopia using the data of pregnant woman in Kemba district, and to run the multistage sampling technique districts in this zone were considered as clusters because there is a homogeneous feature between districts. Then, due to the number of pregnant women estimation in each district and our sample size, Kebma district was selected randomly. In Kebma district there are 43 kebeles, and to make the sample being representative to all Kebeles, we took 25% of them (11 kebeles) randomly. Additionally, we employed design effect of 1.5 to represent the sample to Gamo Gofa zone. By considering the heterogeneous feature of Kebeles within a cluster, proportional allocation of pregnant women was done in each selected stratum (Kebele) ,and in each Kebele there are assigned HEWs ,and these HEWs provide community visits at house hold level at least 2 times a week and one of their responsibility is to investigate whether pregnant woman/s is present in that hose hold or not , and then to register them. The registration includes the gestational age, EDD, Name, Phone number (if available), the exact location and others. After obtaining the registration number of pregnant women from health extension workers (HEWs) of each selected Kebele, a simple random sampling technique (lottery method) was applied by using the registration book of pregnant women as a framework. Furthermore, 621 pregnant women who fulfilled the inclusion criteria were recruited based on their registration number via simple random sampling technique, and interview was done at the household level for those randomly selected pregnant women.

3. 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 a 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 original language is written in non-Latin characters, for example Amharic, Chinese, or Korean, please use a file format that ensures these characters are visible.

Authors’ response: The detail of the questionnaire used in this study is included in the supporting information via three languages.

4. Please state whether you validated the questionnaire prior to testing on study participants. Please provide details regarding the validation group within the methods section.

Authors’ response: Face validity was conducted to assess the form of the questionnaire in terms of feasibility, readability, evenness of techniques and formatting, and the clearness of the language, that is to assess the presentation and relevance of the measuring tool as to whether the items in the tool emerge to be pertinent, logical, explicit and obvious and to validate the questionnaire, 2 experts groups on each English, Amharic, and Gamogna language were participated.

5. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

Authors’ response: We obtained verbal consent from all participants, and it was documented using the following consent form.

Consent form

Hello my name is _________________ (name of data collector). I am____________________ (the data collector briefly introduce him/herself), and I am here to collect data on “Intention to use maternity waiting home and associated factors among pregnant women” for research purpose. The objective of this study is to assess intention to use maternity waiting home and associated factors among pregnant women in Gamo Gofa zone. The benefit of your participation in this study is to improve maternal and neonatal health in your community as well as a country as a whole by increasing institutional delivery. Hence, your trustworthy and frank participation is ultimately important to achieve this goal. All the information that you provide must be kept confidentially, and your name and information will not be disclosed. The information you give is only disclosed to the investigators and they will use it only for this research purposes. You’ve a full right to not respond to all or part of the questions.

Are you voluntary to participate in this study? 1. Yes 2. No Thank you!!

The name of Data collector: ____________________

Cell phone of data collector:

Date of data collection:

6. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please delete it from any other section.

Authors’ response: The ethics statement which was appear in declaration section is deleted

7. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables should be uploaded as separate "supporting information" files.

Authors’ response: Revision is made based on your comments

Response to Reviewers’

Reviewer #1: General comments

1. General comments

1.1: Authors should read thoroughly the author’s submission guidelines and strictly follow it for all sections of the manuscript. For this purpose they should download the sample pdf of abstract and sample pdf of manuscript. They should strictly follow the guideline for font size, writing style – upper and lower case writing in title, affiliation, abstract, main manuscript, table titles, figure titles, and references.

Authors’ response: We revised the whole document based on the PLOS ONE’S publication criteria

1.2: While submitting manuscript authors did not make the manuscript in double space, page numbers and line numbers.

Authors’ response: We made a revision, and we include page numbers and line numbers.

2. English language has to be improved.

Authors’ response: We tried to correct all grammatical, spelling, punctuation, and preposition errors in the whole manuscript with language expert.

2. Title

2.1: Page (P) 2, lines (L) – 7, 9, While writing affiliation, instead of writing College of Health sciences, it should be College of Health Sciences.

Authors’ response: we corrected it as College of Health Sciences

2.2: P2, L10 – it should be Department of Public Health, College of Health Sciences

Authors’ response: we corrected it as Department of Public Health, College of Health Sciences

3. Abstract

3.1: P4, L56 – research aim is not the section in abstract. Merge it in background.

Authors’ response: Research aim is merged in the background

3.2: P4, L59 – delete add comma after April 10, and delete /

Authors’ response: It is corrected as from March 10 to April 10, 2019

3.3: P4, L60 – it should be questionnaire and interview.

Authors’ response: It is corrected as a questionnaire and interview.

3.4: P4, L66 – it should be 95%.

Authors’ response: It is corrected as 95%

3.5: P4, L68 – it should be (AOR

Authors’ response: AOR is included

3.6: P 4, L72 – Recommendation is not there – follow guidelines

Authors’ response: Recommendation is deleted

3.7: P4, L77 – Delete Kemba district and write Ethiopia. For writing Keywords – they should match with MeSH terms.

Authors’ response: Kemba district is deleted, and the word Ethiopia is included

4. Background

4.1: P5, L79 – It should be World Health Organization

Authors’ response: It is corrected as World Health Organization

4.2: P5, L81 – It should be health facility instead of hospitals. In your study area there are primary health care units. They are not hospitals.

Authors’ response: It is corrected as health facilities

4.3: P5, L93 – It should be long distance instead of several distances.

Authors’ response: It is corrected as long distance

4.4: P5, L98 – it should be population instead of populations.

Authors’ response: It is corrected as population

4.5: P5, L101 – give long form of SNNPR as it is appearing first time. It should be Oromia instead of Oromo region. Add and after (56%); and least

Authors’ response: It is corrected as Southern Nations, Nationalities, and Peoples' Region (SNNPR) (57%) and Oromia region (56%); and least (8%) in the Gambella region

4.6: P5, L133 – Add per – it should be as --- attendants as per the 2016.

Authors’ response: the preposition per is added

Comment: Authors did not cite the following publications to add in the background or discussion

a. Kurji J, Gebretsadik LA, Wordofa MA, Sudhakar M, Asefa Y, Kiros G, Mamo A, Bergen N, Asfaw S, Bedru KH, Bulcha G, Labonte R, Taljaard M, Kulkarni M. Factors associated with maternity waiting home use among women in Jimma Zone, Ethiopia: a multilevel cross-sectional analysis. BMJ Open. 2019 Aug 28;9(8):e028210. doi: 10.1136/bmjopen-2018-028210. PMID: 31467047; PMCID: PMC6720516.

b. van Lonkhuijzen L, Stekelenburg J, van Roosmalen J. Maternity waiting facilities for improving maternal and neonatal outcome in low-resource countries. Cochrane Database Syst Rev. 2012 Oct 17;10(10):CD006759. doi:10.1002/14651858.CD006759.pub3. PMID: 23076927; PMCID: PMC4098659.

c. Swanson DL, Franklin HL, Swanson JO, Goldenberg RL, McClure EM, Mirza W, Muyodi D, Figueroa L, Goldsmith N, Kanaiza N, Naqvi F, Pineda IS, López-Gomez W, Hamsumonde D, Bolamba VL, Newman JE, Fogleman EV, Saleem S, Esamai F, Bucher S, Liechty EA, Garces AL, Krebs NF, Hambidge KM, Chomba E, Bauserman M, Mwenechanya M, Carlo WA, Tshefu A, Lokangaka A, Bose CL, Nathan RO. Including ultrasound scans in antenatal care in low-resource settings: Considering the complementarity of obstetric ultrasound screening and maternity waiting homes in strengthening referral systems in low-resource, rural settings. Semin Perinatol.

2019 Aug;43(5):273-281. doi: 10.1053/j.semperi.2019.03.017. Epub 2019 Mar 16. PMID: 30979599; PMCID: PMC6597951.

d. Buser JM, Lori JR. Newborn Outcomes and Maternity Waiting Homes in Low and Middle-Income Countries: A Scoping Review. Matern Child Health J. 2017 Apr;21(4):760-769. doi: 10.1007/s10995-016-2162-2. PMID: 27475822.

e. Gaym A, Pearson L, Soe K. Maternity waiting homes in Ethiopia – three decades experience…..

Authors’ response: The listed citations included in the discussion part of the manuscript and this reference (Gaym A, Pearson L, Soe KW. Maternity waiting homes in Ethiopia--three decades experience. Ethiopian medical journal, 2012 Jul;50(3):209-19) is reference number 13 currently and it was reference number 11 previously. But I can’t cite the result of the research, which is entitled by Newborn Outcomes and Maternity Waiting Homes in Low and Middle-Income Countries focusing on the impact of MWHs on neonatal health.

5. Methods

Comment:

a. Follow guideline for section and sub-sections.

Authors’ response: As per the guideline for section and sub-sections, we made revision.

5.1: P8, L – 170, make it as April 10, and delete /

Authors’ response: It is corrected as from March 10 to April 10, 2019

5.2: P8, L – 171, Authors should decide whether it should be as Gamo Gofa Zone or it should be used as Gamo Gofa zone in the whole manuscript including titles of tables and figures. Also authors should decide whether the percentages should be presented with one digit or two digit e.g. 3.2 or 3.21. These percentages be consist in the whole manuscript including tables and figures.

Authors’ response: we used Gamo Gofa zone in the whole document

5.3: P8, L – 174 and 175, Instead of actual figures of population it can be written as about 160,000 and % male and female.

Authors’ response: The preposition about is included.

5.4: P8, L – 190 – 194 either delete this or put it in supplementary information. This formula is not required.

Authors’ response: the formula is deleted

5.5: P9, L – 198, Explain what is Kebele – International reader will not understand.

Authors’ response: We explained it as Kebeles (the smallest administrative units of Ethiopia)

5.6: P9, L – 203, Fig.2 - This figure can go into supplementary information.

Authors’ response: It is put in the supplementary information

5.6: P9 – There is needed to link these two paragraphs giving information about data collection details. (L – 203 and L – 204).

Authors’ response: we create the link by using and variables such as

5.7: P9 – Line – 208. Write as insert Fig. 1 here.

Authors’ response:

5.8: P10 – Line – 225. Write value of mean in the bracket. It should read – the mean () was to ----------

Authors’ response: mean (71.75%) is included

5.9: P10 – Line – 234. Write value of mean in the bracket. It should read – the mean () was to ----------

Authors’ response: mean (31.28%) is included

5.10: P10 – L 237 – Instead of scale and they – it should be scale and were

Authors’ response: It is corrected as scale, and were

5.11: P10 – L 247 – 248 – it should be --- health posts who were supervised by three supervisors (B.Sc, Nurses) from health centre.

Authors’ response: It is corrected as from health posts who were supervised by three supervisors (BSc, Nurses) from health centers were executed the data collection.

5.12: P11 – L 270 – Why this statement is required. Earlier you have not described this model. Or describe it little bit it here.

Authors’ response: We put this model because we checked the goodness of the final model using the value of Hosmer-Lemeshow model fitness test, and we decided that the final model is best fitted when the value is insignificant that is greater than 0.05.

6. Results

Comment: Follow author’s guidelines for paragraph and sub-paragraphs font size, fond type, etc. Also decide number of decimals one or two to be presented percentages in the manuscript and Tables, and figures. It should be consistent.

Authors’ response: Revision is made based on the guideline

6.1: P12 - L – 286 – Type – Insert table 1 here

Authors’ response: Table 1 is inserted

6.2: P12 - L – 290 - Type – Insert table 2 here

Authors’ response: Table 2 is inserted

6.3: P12 - L – 294 - Type – Insert table 3 here

Authors’ response: Table 3 is inserted

6.4: P12 - L – 297 - Type – Insert Figure 3 here

Authors’ response: It is included in the supplementary information

6.5: P12 - L – 303 - Type – Insert Figure 4 here

Authors’ response: It is inserted and labeled as Figure 2 because figure 2 and 3 included in the supplementary information

Comment: Your result section description is short. In bivariate and multivariate section you bring AOR descriptions here from discussion section. In discussions do not put analysis figures. Give probable reasons, compare with other studies.

Authors’ response: we made a description of the bivariate and multivariate analysis in the result section

7. Discussions

Comment: Discussion is quite long.

Authors’ response: We tried to minimize it.

7.1: P14 L – 338 – Instead of Intention it should be intention.

Authors’ response: It is corrected as intention

7.2: P15 L – 373 – 374 – It should be --- women who did not use it.

Authors’ response: It is corrected as women who did not use it

7.3: P16 L – 391 – 392 – It should be --- (16,25,26).

Authors’ response: It is corrected as (16,25,26)

7.4: P16 L – 397 – it should be – perceived

Authors’ response: It is corrected as perceived

7.5: P16 L – 414 – whether it is unlikely or likely. Check again.

Authors’ response: We checked it and it is unlikely

7.6: P16 L – 415 – it should be – -----socio-demographic differences and availability of road and transportation between the populations.

Authors’ response: It is corrected as socio-demographic differences and availability of road and transportation between the populations.

8. Recommendation

Comment: Follow the guidelines of journal. No separate recommendation section. It should be included in conclusions.

Authors’ response: We corrected it based on the guidelines of the journal

9. Declaration

9.1: P18 – L 451 – it should be sacrifice

Authors’ response: It is corrected as sacrifice

9.2: P18 – L 458 – Debre Markos University collage of health sciences

Authors’ response: It is corrected as Debre Markos University College of Health Sciences

10. References

Comment: Follow guidelines for references – how to write authors, and other details of article of the journal, book, chapter in book, website.

Authors’ response: Dear reviewer based on your comments, we checked all references and we took correction for all. Reviewer #2: It is my pleasure to be designed as a reviewer of this paper, thank you very much!

This is a good paper that examined the intention to use MWH, one of the strategies to bridge geographic barriers to access obstetric care.

Line by line response to reviewer#2 comments

Dear reviewer, we authors would like to thank you in advance for your valuable comments, and questions. And we replied for your concerns line by line.

Comments

Background

1) The background section needs to be restructured for smooth flow from general problem to specific problem statement. In this case, please try to develop themes for each paragraph and link them logically to the issue. You may follow what is intention to use MWHs, what determines women’s intention to use MWHs (individual, community, health system factors) or what is known in the area, what is unknown, contribution of this paper to the scientific knowledge. You need also explain your theoretical framework here. Figure 1 is not described in the text

Authors’ response: The background is restructured based on your comment, and also Figure 1 is described and cited.

2) You use figures from 2016 EDHS data. Please update by 2019 mini-EDHS

Authors’ response: Based on your comment, we used mini EDHS 2019 report to indicate the current delivery service coverage but this report did not show the coverage of delivery services based on regions and also did not include maternal mortality rate. Thus we used both EDHS 2016, and mini 2019 reports.

3) Page 5, paragraph 3 states transport challenges citing more than 8 years old data. Please update it. The extent problem regarding transport access is not the same as the problem before 2012. Over the last few years, the GoE distributed ambulances to districts to expand access to emergency transport though efficient use and universal access is still a challenge.

Authors’ response: Even if there is improvement, transport access is still a major problem, and still due to lack of modern transport, people use a locally made stretcher which is supported by the result of this study which revealed 72.24% of the respondents reported they were unlikely to get transportation access or walk to long distance in the study area.

Methods

1. The study utilized pregnant women registered in the selected Kebeles as sampling frame and randomly select respondents from that frame. However, it is not well described how pregnant women were registered in the Kebele? How complete the registration was? And how the women or her household was located for interview? It is known the Ethiopian community health information system/family folder or pregnant women registration by HEWs/WDAs are incomplete. As such, this would induce selection bias due to incomplete sampling frame, potentially excluding eligible respondents

Authors’ response: In each kebele there are assigned HEWs and these HEWs provide community visits at house hold level at least 2 times a week and one of their responsibility is to investigate whether pregnant woman/s is present in that hose hold or not , and then register them. The registration includes the gestational age, EDD, Name, Phone number (if available), the exact location and others. Using this registration list of pregnant women as a frame work, we carried out simple random sampling technique, and interview was done at the household for those randomly selected pregnant women. No selection bias because it was random. To conduct community based study, no other best option to get pregnant women rather than the method that we used.

2. The analysis section doesn’t mention of account for clustering or not.

Authors’ response: This study was conducted in Gamo Gofa zone, and districts in this zone were considered as clusters because there is a homogeneous feature between districts. Due to the number of pregnant women estimation in each district, and our sample size, Kebma district was selected randomly. Then we considered that there is a heterogeneous feature with in a cluster, thus from 43 kebeles in Kemba district we took 25% of them (11 kebeles) randomly. Finally proportional allocation was done in each selected stratum (kebele)

3. The outcome variable originally collected as ordinal but later reduced to binary for logistic regression analysis. I think this technique wastes information and may dilute the statistical power. Why you don’t use ordinal regression?

Authors’ response: Yes, we agree with your comment, however many of the literatures that we cited provide binary logistic regression, and to make a discussion with these literatures, we have conducted binary logistic regression.

4. Ethical clearance: Not clear whether written or verbal consent was obtained. And was ethical clearance or support letter this study sought from district health office?

Authors’ response: The consent that obtained from each participant was verbal consent and before we start data collection support letter was obtained from all respective bodies including the Kemba district health office.

Results

1) Figure 2 and 3 are already narrated in the text. No need to present same information with different format.

Authors’ response: I accept your comment, and both Figures are included in the supportive information

2) Overall, the result section is presented multiple subheadings without adequate description of the findings. For instance, the Table 4 is narrated in the discussion section. I would bring the results described in the discussion section (narrations with figures with odds ratios) to here.

Authors’ response: Revision is made based on your comment

3) Contrary to other studies, maternal education is not showing effect on the women’s intention to use MWHs. I think it can be related with the model fit or uncontrolled confounding. For instance, being government employee is associated with intention to use MWHs. This could be due to interaction or confounding with education. Please review it again.

Authors’ response: Model fitness was assured using Hosmer-Lemeshow goodness of fit and also the mode was built via forward stepwise method and we used Variance Inflation Factor (VIF) to check multicollinearity between independent variables, but no more than 15 % change of the B coefficient.

Discussion

1. Summary the main findings in the first paragraph and dedicate subsequent paragraphs for discussing intention to use and major determinants. Don’t repeat results here (as described above please move the descriptions regarding Table 4 to results section

Authors’ response: Revision is made based on your comment

2. There are potential biases in this study including selection bias described above, interviewer bias, and social desirability bias that are not mentioned in the discussion section.

Authors’ response: Revision is made based on your comment and selection bias, interviewer bias, and social desirability bias are mentioned in the discussion section as the following.

To avoid selection bias, we used simple random sampling technique to select the study participants from the list of pregnant women in the health extension workers registration book and the data were collected in community at home. During the interview, social desirability bias might be committed, but to reduce it only volunteer participants involved, and their names were kept anonymous, a brief overview of the study was provided, we used experienced interviewers, and the interview was carried out using a one-on-one strategy. To avoid interviewer bias, we instruct our interviewers to read each question accurately to the respondents to answer based on their best understanding of the question, do not interpret the question for the respondents, and offer to say again the question precisely as it appears. Generally, we educate our data collectors to avoid any adjustment, explanation, addition, subtraction, suggestion or change in verbal variation during the interview process.

3. Conclusion is simply repeating the main finding. Please rewrite to reflect the relevance of the findings to the program, implications to future research, or your concluding comments/take-home messages

Authors’ response: Revision is made based on your comment and it is corrected as the following

Generally, the intention to use maternity waiting home among pregnant women is less than half, indicated that it is not satisfactory which leads inaccessibility of obstetric cares and it will provoke pregnant women to give birth at home without skill birth attendants that may end up with development of different complications including maternal and neonatal deaths. And intention to use MWH is significantly associated with occupation of respondents, history of previous childbirth, past experiences of MWH utilization, direct and indirect subjective norm, and perceived behavioral control. These findings call for the intervention of the community to increase the intension of pregnant women towards MWH utilization and we authors recommend that:

4. Some of the recommendations are not grounded from the study findings. For instance, bullet # 2 on page 16

Authors’ response: we recommend bullet # 2 based on the findings of this study which revealed 81.82% of the respondents reported that it's difficult to get enough food in MWH during service utilization; and 72.24% of them reported they were unlikely to get transportation or walk to long distance.

5. Language

Finally, there are multiple grammatical errors that needs to edited by someone who has experiences in academic edition. For instance, page 4, paragraph 1 that reads..."one of the three..." not clear what are these; page 5, last paragraph first sentence talks delivery by SBA, but second sentence talks about home delivery. These are not parallel. The third sentence, "...within three.." need to be deleted; page 7, last paragraph first sentence,"... population proportion of 57.3%..." replace by population proportion of intention to use MWHs, 57.3%;

Authors’ response: Based on your comment, language edition is made.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

29 Mar 2021

PONE-D-20-31704R1

Intention to use maternity waiting home and associated factors among pregnant women in Gamo Gofa zone, Southern Ethiopia, 2019

PLOS ONE

Dear Dr. Bitewa,

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Reviewer #2: (No Response)

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Reviewer #2: Yes

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Reviewer #2: Yes

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Reviewer #2: No

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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 #2: This is my second review of this paper. Though it improved from the first version, still it has multiple flaws including grammatical errors and standard writing styles.

Major comments

1. 11 paragraphs introduction is too much for a paper. Reduce to 5-6 paragraphs.

2. Though you described how HEWs are updating pregnant women registration, that is not practical. You cannot be sure the registration is complete. In this case, I expect you to do ad hoc list of pregnant women with the help of the HEWs and WDAs before data collection. As such, this would induce selection bias due to incomplete sampling frame. You need to acknowledge this in the limitation section. Besides, you deployed HEWs as data collectors. This would also induce social desirability bias. Acknowledge this also as a limitation and discuss the implications of these biases on the observed results.

3. You used statistical criteria for selection of variables to include into the multivariate model. Why you did not use your theoretical framework? And you kept silent about the negative findings about the association between intention to use MWHs and the independent variables maternal education and attitude which is contrary to other studies. In such a behavioral study, it is good to base on conceptual frameworks to select variables. As such, you should force to retain “attitude” and “maternal education” in the model. It can also be related with the model fit or uncontrolled confounding. For instance, being government employee is associated with intention to use MWHs. This could be due to interaction or confounding with education. Besides, gravidity (previous history of childbirth) and past experience of MWHs would be correlated. Please review your analysis again, add possible interactions, force retain attitude and maternal education in the model. And if still, no significant associations with your outcome variable, please discuss the negative findings as well. These are important independent variables of interest.

4. Discussion section is still mere repetition of results (of course, you compared with previous literature). You did not summary the main findings, and interpret and discuss implications of your main findings. For instance, in your conclusion you mentioned subjective norm and perceived behavioral control as predictors to intention to use MWHs. You should interpret what subjective norms and perceived behavioral control mean and state as take home messages to readers. Think of it. Subjective norm and perceived behavioral control are still jargons. Can it be interpreted as low subjective norm or high community disapproval, low perceived benefits, and low self-efficacy. If so, you may summarize the main findings as such “The intention to use MWHs is low. Community disapproval, low self-efficacy, and maternal employment…are predictors to use MWHs” And discuss each main finding dedicating a paragraph, of course, without repeating the results.

5. Language: Still there are multiple grammatical errors that needs to edited by someone who has experiences in academic edition.

Minor comments

• Abstract: correct the # of respondents to 605

• Use of consistent decimal point across the text.

• You did not narrate the prevalence of intention to use MWHs in the results section. Please narrate it.

**********

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Reviewer #2: Yes: Gizachew Tadele Tiruneh

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16 Apr 2021

PONE-D-20-31704

Intention to use maternity waiting home and associated factors among pregnant women in Gamo Gofa zone, Southern Ethiopia, 2019

Dear Frank T. Spradley

Academic Editor of PLOS ONE journal

We Authors would like to thank you for your constructive comments, and suggestions. In accordance with the reviewer’s comments, we made a revision. Therefore, we submitted a revised version of the manuscript that addresses the points raised during the review process.

Response to reviewers’ comments

Dear Gizachew Tadele Tiruneh, we Authors would like to thank you for your helpful comments for the second time and based on the comments had given we made revision.

Reviewer # 2: Major comments

1. 11 paragraphs introduction is too much for a paper. Reduce to 5-6 paragraphs.

Authors’ response: The introduction part of the manuscript is reduced to 5 paragraphs based on your comment.

2. Though you described how HEWs are updating pregnant women registration that is not practical. You cannot be sure the registration is complete. In this case, I expect you to do ad hoc list of pregnant women with the help of the HEWs and WDAs before data collection. As such, this would induce selection bias due to incomplete sampling frame. You need to acknowledge this in the limitation section. Besides, you deployed HEWs as data collectors. This would also induce social desirability bias. Acknowledge this also as a limitation and discuss the implications of these biases on the observed results.

Authors’ response: It was very difficult to conduct household survey to identify the number of pregnant women in that dispersed community. That is why we used the list of pregnant women from HEWs with its limitation (it may not include new pregnant women) to get the sampling frame. And acknowledgment is done for this limitation as your comment. The rationale of using HEWs as data collectors is that the sampling technique is simple random sampling and the secreted women in each kebele were very far apart to each other, and if we allocate another data collectors, it may bring false data. But the HEWs know the exact location of each pregnant woman and it is easy to collect the data which eliminate the probability of false recording. As you stated, using HEWs as data collectors might impose social desirability (response) bias and it might increase false positive response. However, the observed results did not show the presence of a significant response bias because the magnitude of intention to use MWH is less than 50% which is low, and the result of a favorable attitude, a favorable subjective norm and perceived behavioral control of the direct TPB components were below 50% and also the indirect attitude, indirect subjective norm, and indirect perceived behavioral control of the respondents were about 50% and less than it and about 50% of the participants agreed that HEWs thinks that they should stay in MWH and about 50% the respondents also reported that HEWs’ approval for their stay in MWH was much important. Similarly, more than 80% of the respondents reported that it's unlikely to get enough food in MWH. So based on these and other findings, we believed that the episode of social desirability bias was very minimal/unlikely. Even if it is, we acknowledged it in the limitation part based on your comment.

3. You used statistical criteria for selection of variables to include into the multivariate model. Why you did not use your theoretical framework? And you kept silent about the negative findings about the association between intention to use MWHs and the independent variables maternal education and attitude which is contrary to other studies. In such a behavioral study, it is good to base on conceptual frameworks to select variables. As such, you should force to retain “attitude” and “maternal education” in the model. It can also be related with the model fit or uncontrolled confounding. For instance, being government employee is associated with intention to use MWHs. This could be due to interaction or confounding with education. Besides, gravidity (previous history of childbirth) and past experience of MWHs would be correlated. Please review your analysis again, add possible interactions, force retain attitude and maternal education in the model. And if still, there is no significant associations with your outcome variable, please discuss the negative findings as well. These are important independent variables of interest.

Authors’ response: To select variables for the final model we considered two methods: 1) the statistical method that is P-value of less than 0.25 rather than 0.05 to increase the number of variables, which is one of the recommended methods for variable selection. 2) If the variable is significantly associated with intention to use MWH in other researches and if that variable is very important predictor of the outcome, we considered it to be included in the finale model. We prefer to use the statistical method of variable selection rather than the theoretical framework because the final model result is very disrupted if we include a variable which is extremely insignificant in the bivariate analysis and also which is not significant in other research findings. But fortunately, the variables maternal education and both direct and indirect attitudes of the respondents were included in the final model because the p-value of these variables was less than 0.25 and then became insignificant in the multivariate analysis. For your evidence, in the bivariate analysis age of the respondents, educational level, occupation, previous childbirth history, experience of MWH utilization, reason for past utilization, and duration of stay at MWH, direct and indirect attitude, direct and indirect subjective norm, and direct and indirect perceived behavioral control were associated with intention to use MWH with P-value of less than 0.25. To assess the interaction between maternal educational level and government employee, and between previous childbirth history and past experience of MWH utilization, we created new variables and these two new variables were included in the model but were remain insignificant with p-value of greater than 0.05. Based on your comment the negative findings also discussed.

4. Discussion section is still mere repetition of results (of course, you compared with previous literature). You did not summary the main findings, and interpret and discuss implications of your main findings. For instance, in your conclusion you mentioned subjective norm and perceived behavioral control as predictors to intention to use MWHs. You should interpret what subjective norms and perceived behavioral control mean and state as take home messages to readers. Think of it. Subjective norm and perceived behavioral control are still jargons. Can it be interpreted as low subjective norm or high community disapproval, low perceived benefits, and low self-efficacy? If so, you may summarize the main findings as such “The intention to use MWHs is low. Community disapproval, low self-efficacy, and maternal employment…are predictors to use MWHs” And discuss each main finding dedicating a paragraph, of course, without repeating the results.

Authors’ response: Discussion part of the manuscript is revised based on your comments. In this study subjective norm of pregnant women to use MWHs is measured as favorable or unfavorable based on the mean value which indicated that pregnant women with unfavorable subjective norm have low subjective norm or high community disapproval. And the concept of self-efficacy is used as perceived behavioral control, which means the perception of the ease or difficulty of pregnant women to use MWHs and unfavorable perceived behavioral control indicates low self-efficacy.

5. Language: Still there are multiple grammatical errors that need to edit by someone who has experiences in academic edition.

Authors’ response: Basic edition is carried out in the whole document.

Minor comments

• Abstract: correct the # of respondents to 605: It is corrected from 621 to 605

• Use of consistent decimal point across the text. It is checked.

• You did not narrate the prevalence of intention to use MWHs in the results section. Please narrate it. It is already narrated in the first 4 lines of the result section of the manuscript without subheadings but now subheading “prevalence of intention to use MHHs” is included.

Submitted filename: Response to Reviewers.docx

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22 Apr 2021

Intention to use maternity waiting home and associated factors among pregnant women in Gamo Gofa zone, Southern Ethiopia, 2019

PONE-D-20-31704R2

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29 Apr 2021

PONE-D-20-31704R2

Intention to use maternity waiting home and associated factors among pregnant women in Gamo Gofa zone, Southern Ethiopia, 2019

Dear Dr. Bitewa:

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