Factors affecting men's involvement in maternity waiting home utilization in North Achefer district, Northwest Ethiopia: A cross-sectional study.

BACKGROUND: Maternity waiting home (MWH) is a direct strategy to improve newborn and maternal survival. The utilization of MWH, however, remains very low in Ethiopia. Men involvement in maternal health programs is a key strategy to increase utilization of maternal health services, including MWH. This study defines men involvement in-terms of men's participation in deciding to admit their spouse to an MWH, accompanying their spouse to an MWH, providing financial support, availing food at an MWH, and taking care of the home or children. Thus, the current study aims to identify factors affecting men's involvement in MWH utilization.
METHODS: A community-based cross-sectional study was conducted from October 1st to December 30th, 2018. Four hundred three men were involved in the study. Data were analyzed by the statistical package for social science (SPSS) version 23. Independent predictors were identified by a multivariable logistic regression model. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were reported.
RESULTS: Men's involvement in MWH was 55.6% (50.71, 60.45). Age (AOR = 0.86, 95% CI = 0.82-0.94), knowledge about MWH (AOR = 4.74, 95% CI = 2.65-8.49), decision-making power (AOR = 4.00, 95% CI = 1.38-11.57), and receiving counseling about MWH during spousal antenatal care visits (AOR = 9.15, 95% CI = 3.34-25.03) had statistically significant associations with men's involvement in MWH utilization.
CONCLUSIONS: Nearly, half of the male partners were involved in MWH utilization. Men's age, MWH knowledge, decision-making power, and receiving counseling were factors affecting their involvement in MWH utilization. Interventions targeting to improve male involvement in MWH utilization should focus on building men's knowledge about MWH, increasing male involvement in ANC with an appropriate level of counseling about MWH, and changing patriarchal thinking in society with appropriate behavioral interventions such as community-based health education.

Introduction

Global experiences show that more than 80% of maternal deaths could have been prevented by appropriate and timely interventions performed by skilled professionals in a conducive environment [1, 2]. In 2016, only 26% of women in Ethiopia gave birth at health facilities. This rate is among the lowest in the world. The reasons for non-use of skilled delivery service include notions that facility delivery is not necessary or customary, physical distance to the facility, and lack of transportation [3]. It has been many years since maternity waiting homes (MWHs) have been considered as a direct strategy for increasing health facility delivery and improving maternal and newborn survival [4, 5]. MWHs are residential facilities located near a hospital or a health center that allow pregnant women to wait for the onset of labor. Once labor starts, women move to the health facility so that they can be assisted by a skilled birth attendant [6]. Pregnant women from remote areas, women with a gestational age greater than 37 weeks, women with previous pregnancy/delivery problems (preterm labor, stillbirth, cervical tear), or women with other known risks are eligible for accommodation at MWHs [7, 8]. In 2016, a survey conducted in four regions of Ethiopia reported that 70% of health centers had MWHs [9] and nationally, about half of the facilities had MWHs [10].

Although MWHs commenced operations in the late 1980s in Ethiopia [6], service uptake remains low because of sociodemographic, economic, cultural, and gender- and facility-related constraints [7, 9]. Moreover, in most developing countries, including Ethiopia, most communities assign a low position to women, which makes them dependent on either collective decision-making with their partner or completely dependent on their partner’s decision on issues that affect their health [11]. To overcome such problems, nearly two decades ago, the concept of male involvement in maternal health has been promoted as an essential element of the World Health Organization’s initiative for making pregnancy and childbirth safer [12]. The rationale for seeking the involvement of men includes a view of men as gatekeepers and decision-makers for prompt access to health services, as responsible partners of women, as an important member of the community, and as their preference to be involved as fathers/partners [13]. For example, 55% of women in Ethiopia to 95% of women in Kenya need their husband’s permission to use MWHs [14, 15], while approximately one-third (33%) of mothers in Ethiopia experienced refusal of admission by their husbands [9]. In general, the need for an increased engagement of men in reproductive, maternal, and child health is consistent with several global instruments that promote human rights and gender equity such as the 1994 International Conference on Population and Development program of action and the 1979 Convention on the Elimination of All Forms of Discrimination Against Women [16].

The term “male involvement” varies according to authors [17]. Male involvement in the context of maternal and child health refers to men’s active involvement in the care of their partners and children [16, 18], or it is a broad concept that refers to the various ways in which men relate to reproductive health problems and programs, reproductive rights, and reproductive behavior [19]. Thus, the current study applied an inclusive definition for male involvement in MWHs [17, 20–23], which includes male participation in the decision to admit their spouse to an MWH, accompanying their spouse to an MWH, providing financial support, availing food at an MWH, and taking care of the home and/or the remaining children at home.

Evidence shows improvements in health outcomes where men are actively involved. A systematic review revealed that male involvement is associated with improved maternal health outcomes in developing countries [24]. In African countries, including Ethiopia, male involvement in antenatal care (ANC) and delivery is associated with increased spousal use of skilled birth attendant and postnatal care (PNC) [20, 22, 24–26]. There are also studies addressing factors influencing male involvement in maternal health services such as ANC, delivery, PNC and family planning [17, 18, 20, 21, 23, 27], while there is a lack of evidence about male involvement in MWH utilization. Hence, studying men’s involvement in MWH utilization has paramount importance for policy-makers, programmers, and healthcare planners in designing evidence-based interventions. Therefore, this study aims to determine the extent of male involvement in MWH utilization and identify the factors that affect their involvement in Northwest Ethiopia.

Methods

Study design and settings

A community-based cross-sectional study was conducted in the North Achefer district from October 1st, 2018 to December 30th, 2018. The district is located in the West Gojjam Zone, Amhara regional state, Ethiopia. It has a total of 27 kebeles (“kebele” is the lowest administrative unit in Ethiopia). Regarding health infrastructure, it has one primary hospital, seven health centers, five private clinics and twenty-seven health posts. During the time of data collection, each of the health centers in the district had MWHs, but only five of the health centers had functional MWHs [28].

Sample size and sampling procedure

Initially, we proposed to include 442 male partners in the study, but 403 male partners were involved at the end. A single population proportion formula was used to determine the sample size with the assumption of a 95% confidence level, 50% expected proportion of men involved, and 5% margin of error. The formula: Where; n is the sample size, Zα/2 is critical value for normal distribution at 95% confidence level, p is the expected proportion, and d is the margin of error. We targeted to involve 442 men with consideration of 15% for non-responses. In the North Achefer district, only five health centers had functional MWHs. First, the principal investigator identified 662 mothers who had used MWH in the last one year from the maternity-waiting-home-users registration book. Then, residential profiles (kebeles and gotts “subdivision below kebele in Ethiopia”) of mothers were identified from MWH registration books. Finally, mothers were selected by a table of random numbers. Mothers from nearby districts, divorced and widows were excluded. Men who were living with their spouses were considered in the study.

Study variables and measurements

Male partners were interviewed using a structured Amharic version questionnaire. The questionnaire was developed by reviewing different related literature [17, 20–23]. It was pretested on 5% of the sample size. The pretest was done in the nearby district, designated as South Achefer district. Then, the questionnaire was amended for wording, sequencing and content as the pretest output suggested. We have attached both the Amharic and English versions of the questionnaire as supporting information (S1 and S2 Files). Trained data collectors and supervisors were involved in the data collection process. The interviews were conducted in the respondents’ residential houses. If the selected respondent was not available at the time of the first home visit, two re-visits were made.

The questionnaire comprised sociodemographic variables (age, educational status, wealth index, occupation and number of children); participant’s spousal obstetric history (previous stillbirth, previous health facility delivery, length of stay at an MWH, ANC follow-up, history of spousal obstetric complication); health facility-related variables (basic social services, presence of ambulance, and daily follow-up at MWHs); male partner’s gender thinking (number of wives, decision-making power); and male partner’s knowledge and attitude towards MWH. The wealth index was created using principal component analysis. First, Pearson’s correlation coefficients were determined for each item. An exploratory factor analysis was conducted to obtain the latent variables of the covariance structure. Then, the items were reduced to twelve factors based on the factor loadings, followed by re-analysis of the remaining factors. After that, the factor loadings and dispersal rate of all the factors were determined. Finally, the summative scores were divided into five equal groups (very poor, poor, middle, rich and very rich).

Five knowledge items were used to assess men’s knowledge about MWH. All correct responses on five items were added to produce a composite index. We used eight items with a five-point Likert scale to assess men’s attitudes towards MWH. The sum score was generated by adding individual scores on each item. Those men who scored above the median were considered to have a positive attitude towards MWH utilization otherwise taken as having a negative attitude [29-31].

The outcome variable for this study was men’s involvement in MWH utilization. Six items were used to measure men’s involvement in MWH utilization. The items used include male partner participation in deciding to rest their spouse to an MWH, accompanying their spouse to an MWH, providing financial support while their spouse stay at an MWH, availing food while their spouse stay at an MWH and taking care of the home and/or the remaining children while their spouse stay at an MWH. Each item has yes or no response options and coded 1 yes or 0 no. We added each item score to generate a composite index for male involvement in MWH utilization. Those men who scored less than three were considered as poor male involvement while those who scored greater than or equal to three were considered good male involvement.

Data analysis

Data were checked, coded and entered into Epi-data version 3.1 and exported to SPSS version 23 for analysis. The reliability of items used to measure men’s involvement in MWH utilization and knowledge and attitude towards MWH were checked by Cronbach’s alpha value. The Cronbach’s alpha value of the six items used to assess men’s involvement in MWH utilization was 0.73, which is in acceptable range. Binary logistic regression analysis was used to determine the association between explanatory variables and men’s involvement in MWH utilization. Those candidate variables that were significant (p<0.25) in the bivariable analysis were entered into the multivariable logistic regression analysis. Finally, adjusted odds rations (AORs) with 95% confidence intervals (CIs) were used to identify independent predictors of men’s involvement in MWH utilization.

This research paper is prepared following the “Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)” checklist for cross-sectional study reporting guidelines [32] (S1 Table).

Ethical considerations

Ethical clearance letter was obtained from Institutional Review Board of Bahir Dar University College of Medicine and Health Sciences. The permission letter was obtained from the North Achefer district administrative. Moreover, all the study participants were informed about the purpose and benefit of the study along with their right to refuse. The data collectors read the information sheet and consent form to each study participant until they comprehend the contents. Then, the participants were supposed to show their agreement or disagreement verbally instead of hand signed consent approval. Finally, the data collectors are supposed to circle on the appropriate response of the participant to proceed to the next step. The study participants were reassured to attain confidentiality. We maintained anonymity and confidentiality of information throughout the study process.

Results

Sociodemographic and economic characteristics of the study participants

Four hundred three male partners were involved in the study, resulting in a response rate of 91.2%. Thirty-seven per cent of males were between the age groups of 40–49. The majority, 96.8%, of males were orthodox Christian followers. Ninety-two per cent were Amhara by ethnicity. Eighty-one per cent of males were farmers. Approximately 49% of males were unable to read and write. Nearly 22% of males were rich and 20.8% were poor (Table 1).

Table 1

Sociodemographic characteristics of study participants in North Achefer district, Northwest Ethiopia, 2018.

Variables	Frequency	Percentage
Age category (n = 403)
18–29	77	19.1
30–39	91	22.6
40–49	149	37.0
> = 50	86	21.3
Educational status (n = 403)
Unable to read and write	196	48.6
Read and write only	82	20.3
Primary education	65	16.1
Secondary education	12	3.1
Higher education	48	11.9
Occupation (n = 403)
Farmer	326	80.9
Merchant	27	6.7
Government employee	50	12.4
Number of living children (n = 403)
1	94	23.3
2–4	138	34.3
> = 5	171	42.4
Wealth index quintile (n = 403)
Very rich	80	19.9
Rich	88	21.8
Middle	74	18.4
Poor	84	20.8
Very poor	77	19.1

Obstetric histories of wives

Approximately, 77% of wives gave birth before the current child. About 66.8% of wives had a previous history of health facility delivery and 12.8% had a previous history of obstetric complications. The commonest obstetric complications were hemorrhage (37.5%) and prolonged labor (37.5%). Eighty-six per cent of wives stayed less than fifteen days at MWH for the current child. Eighty-two per cent of wives had ANC follow-up for the current child, of whom 73% of men accompanied their spouse during ANC visit and 65.9% of men received counseling about MWH (Table 2).

Table 2

Study participant’s spousal obstetric history in North Achefer district, 2018.

Variables	Frequency	Percentage
Previous delivery history (n = 403)
Yes	312	77.4
No	91	22.6
Previous health facility delivery (n = 403)
Yes	209	66.8
No	104	33.2
Previous history of obstetric complication (n = 403)
Yes	40	12.8
No	273	87.2
Types of obstetric complications (n = 40)
Preterm labour	2	5.0
Premature rapture of membrane	8	20.0
Hemorrhage	15	37.5
Prolonged labor	15	37.5
Previous stillbirth history (n = 403)
Yes	11	3.5
No	302	96.5
Duration of stay at MWHs (n = 403)
< 7 days	247	61.3
7–13 days	93	23.1
> = 14 days	63	15.6
Spousal ANC visit (n = 403)
No visit	72	17.9
1–3 visits	104	25.8
> = 4 visits	227	56.3
Male partner accompaniment during ANC visit (n = 331)
Yes	255	73.0
No	76	23.0
Male partners got counseling about MWH during ANC visit (n = 331)
Yes	218	65.9
No	113	34.1

MWH maternity waiting home, ANC antenatal care.

Men’s knowledge and attitude towards MWH and gender thinking

Male partners were asked about gender thinking that likely influences their involvement in resting pregnant women in MWH: 17.1% think that childbirth is woman’s affair that does not require the participation of men, 16.1% think that childbirth is a natural phenomenon that should not require much attention from men, and 28.8% think that accompanying wife to an MWH is a woman’s responsibility. Forty-four per cent of men were sole decision-maker in any family affairs. Almost all, 99% of men had monogamous marriage (Table 3).

Table 3

Men’s gender thinking and attitude towards MWH in North Achefer district, 2018.

Variables	Frequency	Percent
Child-birth is a woman’s affair that does not require men participation (n = 403)
Yes	69	17.1
No	334	82.9
Child-birth is natural phenomenon that should not require much attention from men(n = 403)
Yes	65	16.1
No	338	83.9
Accompanying wife to MWH before delivery is a woman’s responsibility (n = 403)
Yes	116	28.8
No	287	71.2
Who is the primary decision-maker in your family in any case that needs decision? (n = 403)
Male alone	179	44.4
Wife alone	50	12.4
Spouses jointly	174	43.2
Male partners having more than one wife (n = 403)
Yes	4	1.0
No	399	99.0
Attitude towards MWH (n = 403)
Positive attitude	148	36.7
Negative attitude	255	63.3

MWH maternity waiting home.

The Cronbach’s alpha value of the knowledge questions was 0.755. The Cronbach’s alpha value of the attitude questions was 0.127. As indicated in Table 3, 36.7% of men had a positive attitude.

Men’s involvement in maternity waiting home

The Cronbach’s alpha value of the items used to measure men’s involvement in MWH was 0.73. The mean and median of men involvement scores were 3.26 and 4 respectively.

Overall, 55.6% of male partners had good involvement in MWH utilization (Fig 1). Findings from specific indicators of male involvement show that 56.3% of men had decided to rest their spouses at an MWH, 54.1% accompanied their spouse to an MWH, 52.6% provided financial support while their spouses stayed at an MWH, 62.5% availed food while their spouses stayed at an MWH and 45.9% looked after the home and/or the remaining children while their spouses were at an MWH (Table 4).

Fig 1

Overall men’s involvement in maternity waiting home utilization, North Achefer district, 2018.

Table 4

Distribution of men’s involvement in MWH utilization in North Achefer district, 2018.

Variables	Frequency	Percent
Decided to admit their spouse in MWH for current child (n = 403)
Yes	227	56.3
No	176	43.7
Accompanied their spouse to an MWH for current child (n = 403)
Yes	218	54.1
No	185	45.9
Provided financial support for their spouse while they went to/were at MWH for the current child (n = 403)
Yes	212	52.6
No	191	47.4
Availed food when their spouse and relatives were at MWHs (n = 403)
Yes	252	62.5
No	151	37.5
Looked after the home and/or children while their spouses were at MWHs for the current child (n = 403)
Yes	185	45.9
No	218	54.1
Arranged transport when their spouse went to MWHs (n = 403)
Yes	218	54.1
No	185	45.9

MWH maternity waiting home.

Factors influencing men’s involvement in MWH utilization

A multivariable logistic regression model was fitted to identify predictors of men involvement in MWH utilization. In the bivariable logistic regression analysis, variables with p-values less than 0.25 were considered as candidate variables for the multivariable logistic regression model. Thus, age, occupation, educational status, number of live children, wealth index, distance from MWH, duration of stay at MWH, knowledge about MWH, attitude towards MWH, decision-making power, spousal ANC follow-up, previous spousal health facility delivery, previous spousal obstetric complication, and receiving counseling about MWH during spousal ANC follow-up were entered into the multivariable model. There were variables with wide confidence intervals in the model. This might be explained by sample size adequacy and presence of cells with small observation.

Based on findings from multivariable logistic regression analysis, a year increase in age was associated with a 14% decrease in the likelihood of men’s involvement in MWH utilization (AOR = 0.86, 95% CI = 0.82–0.94). MWH knowledge of male partners was positively associated with their involvement in MWH utilization. A unit increase in MWH knowledge score was associated with 4.74 times increase in the likelihood of involvement in MWH utilization (AOR = 4.74, 95% CI = 2.65–8.49). Men who were a primary decision-maker in family affair were 4 times more likely to be involved in MWHs compared to those who have made shared decision (AOR = 4.00, 95% CI = 1.38–11.57). Those male partners who have received counseling about MWH during spousal ANC follow-up were 9 times more likely to involve in MWH utilization compared to those who have not received counseling (AOR = 9.15, 95% CI = 3.34–25.03) (Table 5).

Table 5

Factors affecting male partners’ involvement in MWH utilization in North Achefer district, 2018.

Variables	Male involvement		COR (95% CI)	AOR (95% CI)
	Good	Poor
Age in year			0.86(0.84, 0.89)	0.86(0.82,0.94)**
MWH Knowledge score			8.57(5.29,13.87)	4.74(2.65,8.49)**
Decision maker in family affair
Male alone	31.8%	12.7%	2.18(1.41,3.40)	4.00(1.38,11.57)*
Wife alone	0.7%	11.7%	0.06(0.02,0.19)	0.29(0.05,1.75)
Partners jointly	23.1%	20%	1	1
Received counseling about MWH
Yes	55%	10.9%	19.78(11.07,35.36)	9.15(3.34,25.03)**
No	6.9%	27.2%	1	1

COR crude odds ratio, AOR adjusted odds ratio,

* indicates variables that are significant at p<0.05,

** indicates variables that are significant at p<0.001,

MWH maternity waiting home.

Discussion

The study revealed that men involvement in MWH utilization was 55.6% with 95% CI (50.71–60.45). Our study also identified that age, knowledge towards MWH, decision-making autonomy and receiving counseling about MWH were factors significantly influencing men’s involvement in MWH utilization.

This study revealed that a small proportion of men were involved in MWH. It is assumed low because once a pregnant woman admitted in an MWH, she is supposed to stay there until labor starts. The duration of stay at MWH may range from few days to many weeks. A study done in Ethiopia reported that on average, pregnant women stayed 14.8 days at the MWHs, and approximately 40% of pregnant women stayed for two or more weeks [9]. In the current study also about 16% of pregnant women stayed two or more weeks at MWH and on average they stayed more than a week. The longer the women stay at MWH the more they seek the support of their male partners. If this is not achieved, it could have a negative implication on future use of MWH.

This study identified that an increase in men age was associated with a decrease in men involvement in MWH utilization. This might be due to the fact that as men get older and older, they might develop patriarchal thinking and uncaring attitude for their wife and would be born child. This finding is consistent with a study done in Lemo woreda of Ethiopia [33].

The current study found that men’s knowledge about MWH was associated with increased involvement in MWH utilization. Similarly, our study noted a positive association between receiving counseling about MWH during spousal ANC follow-up and male involvement in MWH utilization. This might be because having knowledge is a prerequisite for practice. If men have awareness about benefit packages of MWH through different outlets, including via health worker counseling, they could be encouraged to be involved in service uptake. This finding is consistent with other studies done to assess men’s involvement in delivery services and in birth preparedness and complication readiness plan in Southern Ethiopia, Lemo district of Ethiopia, Ambo town of Ethiopia, Mekelle town of Ethiopia, Enderta district of Ethiopia, Kenya, India, Mali and Tanzania [14, 23, 34–41].

Men’s sole decision-making in family affairs was positively associated with male involvement in MWH utilization. This finding implies the presence of male dominance in society. The current finding is in-line with a qualitative study done in Zambia [34]. This might be assumed that whenever men are the primary decision makers in a family, they will have the power to allow or refuse their spouses to utilize maternal health services. Men being primary drivers of decision, in turn, might have a cultural implication of male dominance attitude and gender stereotypic outlook in the society, which are a base for gender inequalities and gender-based violence.

The study has limitations. The lack of standardized indicators/tools to measure men’s involvement in MWH utilization may be a limitation of the study. But we have developed the questionnaire through review of related literature and pretested the tool before actual study. In addition, this study is generalizable to male partner whose spouse have used MWH for the most recent birth. The findings can also be generalizable to other similar settings in Ethiopia and outside of Ethiopia. The study, however, cannot tell us the extent of male involvement for those women who have not used MWH.

Conclusions

Nearly, half of male partners showed poor involvement in MWH utilization. Men’s knowledge towards MWH, receiving counseling during spousal ANC visits, men’s sole decision-making in family affairs, and being younger age were factors positively influencing men’s involvement in MWH utilization. Interventions targeting to improve male involvement in MWH utilization should focus on building men’s knowledge about MWH, increasing male involvement in ANC with an appropriate level of counseling about MWH, and changing patriarchal thinking in society through appropriate behavioral interventions such as community-based health education intervention.

STROBE 2007 (v4) statement—Checklist of items that should be included in reports of cross-sectional studies.

(PDF)

Click here for additional data file.

Amharic language version questionnaire.

(PDF)

Click here for additional data file.

English language version questionnaire.

(PDF)

Click here for additional data file.

13 Jul 2021

PONE-D-20-07872

Factors affecting men’s involvement in maternity waiting home care in North Achefer district, Northwest Ethiopia: a cross-sectional study

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The introduction miss the following

1. Description of male involvement as used in this study is missing

2. The state of male involvement in maternity waiting homes

3. What others have reported as far as male involvement is concern

4. What evidence are there in relationship between male involvement and use?

It is not clear what authors are referring to when they talk about knowledge. It created questions which call for clarity

1. knowledge about what?

2. How was it assessed

The same applies to attitudes

Reviewer #2: Reviewer Comments:

1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

I believe that the data collected and the analyses performed support the findings and the conclusions. A few comments are detailed below:

Study sample, page 5, line 100-101: “Males who were currently living with their spouse were considered in the study.” Were males who did not live with their spouse excluded? This is not clear. If males who did not live with their spouse were excluded, why? It would be interesting to include those males, assuming that decision-making may be different in those households or maybe males in those households were less involved?

Results, page 15, line 220: “…a one-year increase in men’s age was associated with a 12% decrease in the likelihood of men involvement in MWH utilization” – This finding is really interesting! As you have explained in the discussion, this may be due to the shift in attitude we are seeing in the newer generations.

Discussion, page 16, line 246-248: Please clarify this sentence. Do you mean that without support from the male partner, the woman will likely have a bad experience with a long MWH stay, therefore, she will likely not want to use the MWH nor recommend others to use MWHs? Maybe explain further on why the woman will have a bad experience without support from her male partner. My understanding is that female escorts usually accompany a pregnant woman during her MWH stay but that male partners provide financially as it is also indicated in the manuscript as part of the support.

Discussion, page 17, line 273: Please expand on the study’s limitations. I do not believe this is the only limitation of the study. I would suggest discussing the generalizability of the study. When discussing limitations, you can also comment on how those limitations may have been mitigated, if possible – for example, the lack of a standardized tool was mentioned as a limitation, but you also mentioned in the methods section that you pretested the questionnaire.

Conclusion, page 17, future interventions: Future interventions could also focus on increasing uptake of male involvement in ANC visits (currently at 73% which is pretty good already), particularly the 4th visit where they get counseling about MWHs, and increase MWH counseling at ANC visit by health facility staff (currently 65.9%). Male partners who received MWH counseling were 9 times more likely to be involved in MWH utilization compared to those who did not.

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

The statistical analyses undertaken has been performed appropriately to my knowledge. Cronbach’s alpha is appropriately used for this study as the questionnaire included questions using the Likert scale to assess male partner’s involvement in MWH utilization. Additional comments are detailed below:

Methods, data analysis: What did you do with the questionnaires that were incomplete? Were they included or excluded?

Table 1, 2, 3, & 4: Please include sample size (n=) below frequency in the tables.

3. Have the authors made all data underlying the findings in their manuscript fully available? The data should be provided as part of the manuscript or its supporting information, or deposited into a public repository. If there are restrictions on publicly sharing data – e.g. participant privacy or use of data from a third party – those must be explained.

The authors indicated that all data are fully available without restriction and can be found within the manuscript and in the supporting information files.

4. Is the manuscript presented in an intelligible fashion and written in standard English? Any typographical or grammatical errors should be corrected at revision, if so please note any specific errors here.

Yes, this manuscript is presented in an intelligible fashion and written in standard English. Specific errors/corrections are noted below:

General, throughout manuscript: Maternity waiting home should be plural throughout the manuscript – maternity waiting homes (MWHs) – where appropriate. Since you gave the abbreviation MWH/MWHs, you can use it instead of writing out maternity waiting home or maternity waiting homes throughout the manuscript.

Page 3, line 45: Add “It has been” to the beginning to the sentence to make it complete. “It has been many years since maternity waiting homes (MWHs) were articulated as...”

Page 3, line 55: “Nationally” should be lower case.

Page 3, line 60: “depend on their partner’s decision...”

Page 4, line 66: “…men’s preference to be involved as fathers/partners.”

Page 4, line 81: “…data collection, each of the seven health centers in the district had a MWH, but only five...”

Page 4, line 83-85: “This reach paper is prepared following…” – This sentence seems to be out of place, maybe put it at the end of the methods section before ethical considerations?

Page 5, line 87: “Initially, we proposed…” change primarily to initially.

Page 5, line 97: What are gotts?

Page 5, line 99: “Maternity-home-user mothers from nearby districts, those who were divorced, and those who had husbands who were deceased were excluded.”

Page 5, line 107: “We have attached both the Amharic and English versions of the questionnaire as supporting information…”

Page 6, line 115: Remove “_” from “social_services”

Page 7, line 164: “Nearly 22% of males were rich…”

Page 9, line 174-176: Be consistent about which term you want to use for men/respondents/male partners. In the same sentence, three different terms are used. Remove apostrophe from “73% of men’s…” on line 175.

Page 11, line 182: “17.1% think that childbirth is a woman’s affair…”

Page 11, line 185: “…accompanying their wife to a MWH to stay before delivery is a woman’s responsibility.” Your variable “accompanying wife to MWH for delivery is a woman’s responsibility” suggests that women deliver at the MWH, but is that true? Women are supposed to be moved to the health facility when labor comes so they deliver in the health facility. MWHs are used only for them to stay before delivery.

Page 13, line 199-200: “56.3% of partners had decided to rest their spouse at a MWH…”

Page 13, line 201: “…provided financial support while their spouse stayed at a MWH…”

Table 4: Variable “accompanied their spouse for resting in MWH for current child”. Use past tense since your other variables are past tense.

Page 15, line 222: “MWH knowledge of male partners was positively associated…”

Page 15, line 221-222: “…associated with a 12% decrease…” AOR = 0.88 is written in text but in Table 5, AOR = 0.86

Page 15, line 225-226: “…associated with a 4.75 times increase…” AOR = 4.75 is written in text but in Table 5, AOR = 4.74

Page 16, line 242: “…assumed low because women are staying at a MWH until labor starts…” delete ‘s from “women’s”.

Page 17, line 271: “…whenever males are the primary decision makers in a family…” When it says “most decision makers” do you mean to say men are the primary decision makers in the household?

Reviewer #3: The manuscript titled, “Factors affecting men’s involvement in maternity waiting home care in North Achefer district, Northwest Ethiopia: a cross-sectional study” requires additional copy editing for English grammar and language. Double check the correct terminology for use versus utilization throughout.

Study variables and measurements

More details need to be provided for how the survey tool was developed. There are several questions in the supplementary file that are not addressed in the presentation of results. Variables are poorly defined. In section 2, wealth is extensively surveyed yet not described in the text. How were wealth quintiles defined? Were responses to questions in Sections 5,6,7 open ended or multiple choice? How were these survey questions derived? Was there any qualitative research guiding survey response choices? I’m not convinced that availing food when their spouse and relatives were at MWHs appropriately measures male partners’ involvement in MWHs. More details are needed about how Likert scales were determined and tested.

Results

Justify the use of so many variables in one multivariable model. In Table 2, consider stratifying duration of stay at MWH and how many ANC visits a woman and spouse attended. Provide rationale for how attitudes were labeled positive or negative. Several results had very wide confidence intervals and potential reasons for the wide intervals need to be offered.

Discussion

Be sure to discuss limitations of the study. Elaborate on the cultural implications of men being the main drivers of decision making. Finally, propose next steps and tell the reader how interventions can “change patriarchal thinking in society” as suggested in the final sentence.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes: Fabiola Moshi

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

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Submitted filename: Manuscript_Clean_Copy.docx

Click here for additional data file.

6 Oct 2021

Responses to reviewers

Response to reviewer #1

Comment #1: The introduction miss the following:

1. Description of male involvement as used in this study is missing

2. The state of male involvement in maternity waiting homes

3. What others have reported as far as male involvement is concern

4. What evidence are there in relationship between male involvement and use?

Response #1: Thank for the comment. We considered the comment in the revised manuscript. But still the authors did get direct literature done on male involvement in MWH instead we reviewed related literature.

Comment #2: It is not clear what authors are referring to when they talk about knowledge. It created questions which call for clarity

1. knowledge about what?

2. How was it assessed

The same applies to attitudes

Response #2: We have revised as per the comment.

Response to reviewer #2

Comment #1: Study sample, page 5, line 100-101: “Males who were currently living with their spouse were considered in the study.” Were males who did not live with their spouse excluded? This is not clear. If males who did not live with their spouse were excluded, why? It would be interesting to include those males, assuming that decision-making may be different in those households or maybe males in those households were less involved?

Response #1: Thank you for this comment, the authors also believe that they might have different character in-terms of decision making, but the outcome of interest of the study is not decision making rather it is male involvement. In fact, the actual number of men who were excluded because of divorce were very few in number, only five males with formal divorce were excluded. Hence, it may not have significant impact on male involvement too.

Comment #2: Results, page 15, line 220: “…a one-year increase in men’s age was associated with a 12% decrease in the likelihood of men involvement in MWH utilization” – This finding is really interesting! As you have explained in the discussion, this may be due to the shift in attitude we are seeing in the newer generations.

Response #2: Thank for emphasizing this finding.

Comment #3: Discussion, page 16, line 246-248: Please clarify this sentence. Do you mean that without support from the male partner, the woman will likely have a bad experience with a long MWH stay, therefore, she will likely not want to use the MWH nor recommend others to use MWHs? Maybe explain further on why the woman will have a bad experience without support from her male partner. My understanding is that female escorts usually accompany a pregnant woman during her MWH stay but that male partners provide financially as it is also indicated in the manuscript as part of the support.

Response #3: Thank you for the comment, we have made revision for clarity of the referred paragraph. The authors interest here is that whenever pregnant women stay for long duration at MWH, they may expect or need to receive more support from their husband irrespective of other accompaniers presence with them. If they didn’t receive support from their husband as expected, this might have bad implication for future use of MWH.

Comment #4: Discussion, page 17, line 273: Please expand on the study’s limitations. I do not believe this is the only limitation of the study. I would suggest discussing the generalizability of the study. When discussing limitations, you can also comment on how those limitations may have been mitigated, if possible – for example, the lack of a standardized tool was mentioned as a limitation, but you also mentioned in the methods section that you pretested the questionnaire.

Response #4: We have made changes accordingly.

Comment #5: Conclusion, page 17, future interventions: Future interventions could also focus on increasing uptake of male involvement in ANC visits (currently at 73% which is pretty good already), particularly the 4th visit where they get counseling about MWHs, and increase MWH counseling at ANC visit by health facility staff (currently 65.9%). Male partners who received MWH counseling were 9 times more likely to be involved in MWH utilization compared to those who did not.

Response #5: Thank you for your remainder to consider in the recommendation. We have considered in the revised version.

Comment #6: Methods, data analysis: What did you do with the questionnaires that were incomplete? Were they included or excluded?

Response #6: The completeness was checked with field supervision.

Comment #7: Table 1, 2, 3, & 4: Please include sample size (n=) below frequency in the tables.

Response #7: We have done so as per the comment.

Comment #8: General, throughout manuscript: Maternity waiting home should be plural throughout the manuscript – maternity waiting homes (MWHs) – where appropriate. Since you gave the abbreviation MWH/MWHs, you can use it instead of writing out maternity waiting home or maternity waiting homes throughout the manuscript.

Response #8: Thank you, revised accordingly.

Comment #9: Page 3, line 45: Add “It has been” to the beginning to the sentence to make it complete. “It has been many years since maternity waiting homes (MWHs) were articulated as...”

Response #9: Done a per the comment

Comment #10: Page 3, line 55: “Nationally” should be lower case.

Response #10: Thank you, done.

Comment #10: Page 3, line 60: “depend on their partner’s decision...”

Response #10: Thank you, done.

Comment #11: Page 4, line 66: “…men’s preference to be involved as fathers/partners.”

Response #11: Thank you, done.

Comment #12: Page 4, line 81: “…data collection, each of the seven health centers in the district had a MWH, but only five...”

Response #12: Thank you, done.

Comment #13: Page 4, line 83-85: “This reach paper is prepared following…” – This sentence seems to be out of place, maybe put it at the end of the methods section before ethical considerations?

Response #13: Thank you, done.

Comment #14: Page 5, line 87: “Initially, we proposed…” change primarily to initially.

Response #14: Thank you, done.

Comment #15: Page 5, line 97: What are gotts?

Response #15: Gotts are subdivision below kebele in Ethiopia. In Ethiopia, there are regions at the top----Zones----Districts----Kebeles----gotts

Comment #16: Page 5, line 99: “Maternity-home-user mothers from nearby districts, those who were divorced, and those who had husbands who were deceased were excluded.”

Response #16: Thank you, done.

Comment #17: Page 5, line 107: “We have attached both the Amharic and English versions of the questionnaire as supporting information…”

Response #17: Thank you, done.

Comment #18: Page 6, line 115: Remove “_” from “social_services”

Response #18: Thank you, done.

Comment #19: Page 7, line 164: “Nearly 22% of males were rich…”

Response #19: Thank you, done

Comment #20: Page 9, line 174-176: Be consistent about which term you want to use for men/respondents/male partners. In the same sentence, three different terms are used. Remove apostrophe from “73% of men’s…” on line 175.

Response #20: We have revised accordingly.

Comment #21: Page 11, line 182: “17.1% think that childbirth is a woman’s affair…”

Response #21: Thank you, done.

Comment #22: Page 11, line 185: “…accompanying their wife to a MWH to stay before delivery is a woman’s responsibility.” Your variable “accompanying wife to MWH for delivery is a woman’s responsibility” suggests that women deliver at the MWH, but is that true? Women are supposed to be moved to the health facility when labor comes so they deliver in the health facility. MWHs are used only for them to stay before delivery.

Response #22: Thank for the comment, we have revised it now.

Comment #23: Page 13, line 199-200: “56.3% of partners had decided to rest their spouse at a MWH…”

Response #23: Thank you, done.

Comment #24: Table 4: Variable “accompanied their spouse for resting in MWH for current child”. Use past tense since your other variables are past tense.

Response #24: Thank you, done.

Comment #25: Page 15, line 222: “MWH knowledge of male partners was positively associated…”

Response #25: Thank you, done.

Comment #26: Page 15, line 221-222: “…associated with a 12% decrease…” AOR = 0.88 is written in text but in Table 5, AOR = 0.86

Response #26: Thank you, done.

Comment #27: Page 15, line 225-226: “…associated with a 4.75 times increase…” AOR = 4.75 is written in text but in Table 5, AOR = 4.74

Response #27: Thank you, done.

Comment #28: Page 16, line 242: “…assumed low because women are staying at a MWH until labor starts…” delete ‘s from “women’s”.

Response #28: Thank you, done.

Comment #29: Page 17, line 271: “…whenever males are the primary decision makers in a family…” When it says “most decision makers” do you mean to say men are the primary decision makers in the household?

Response #29: Thank you, done.

Response to reviewer#3

Comment #1: The manuscript titled, “Factors affecting men’s involvement in maternity waiting home care in North Achefer district, Northwest Ethiopia: a cross-sectional study” requires additional copy editing for English grammar and language. Double check the correct terminology for use versus utilization throughout.

Response #1: Revised as per the comment.

Comment #2: Study variables and measurements: More details need to be provided for how the survey tool was developed. There are several questions in the supplementary file that are not addressed in the presentation of results. Variables are poorly defined. In section 2, wealth is extensively surveyed yet not described in the text. How were wealth quintiles defined? Were responses to questions in Sections 5,6,7 open ended or multiple choice? How were these survey questions derived? Was there any qualitative research guiding survey response choices? I’m not convinced that availing food when their spouse and relatives were at MWHs appropriately measures male partners’ involvement in MWHs. More details are needed about how Likert scales were determined and tested.

Response #2: The tool was developed by review of different literature. In the current revision, we have indicated in the introduction and in the method section, how male involvement has been defined and how we framed the male involvement indicators for the purposed of this study.

Regarding wealth index, now, we have clearly and briefly presented in the “Study variables and measurements” section how the wealth index was created. We have not done qualitative survey to set response options but we have developed through review of available literatures in the area.

In fact, there is universally agreed definition regarding indicators of male involvement in any of reproductive, maternal and child health issues including maternity waiting home. In Ethiopia context, the MWHs are not equipped with basic facilities including kitchen facilities. In these cases, availing food can be a major challenge for pregnant women when they stay at MWH. Hence, we considered availing food as one indicator of male involvement.

Comment #3: Results: Justify the use of so many variables in one multivariable model. In Table 2, consider stratifying duration of stay at MWH and how many ANC visits a woman and spouse attended. Provide rationale for how attitudes were labeled positive or negative. Several results had very wide confidence intervals and potential reasons for the wide intervals need to be offered.

Response #3: We have used p-value less than 0.25 as cut value to select candidate variables for multivariable regression model. We assumed also the sample size is adequate to do so based on the assumption that 10-20 observations per variable considered in the multivariable regression.

We have reanalyzed the ANC and reclassified the length of stay as per recommendation. The possible reason for wider confidence interval may be due to small observation per cells for categorical variables.

Comment #4: Discussion: Be sure to discuss limitations of the study. Elaborate on the cultural implications of men being the main drivers of decision making. Finally, propose next steps and tell the reader how interventions can “change patriarchal thinking in society” as suggested in the final sentence.

Response #4: we have made revision as per the comment.

7 Dec 2021

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Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear authors on your scholarly work; you have brought an important study problem in the area of practice. However, the manuscript has multiple language usage flaws including punctuations, wordings, spelling and mainly grammar errors. These problems are found throughout the manuscript. Moreover, there are several methodological limitations as the reviewers raised. Therefore, please make repeated proof-reading and thorough copyediting before resubmitting the manuscript. This would help increase the readability of the manuscript if published.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

**********

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: No

Reviewer #3: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: PONE-D-20-07872R1

“Factors affecting men’s involvement in maternity waiting home care in North Achefer district, Northwest Ethiopia: a cross-sectional study”

Reviewer Comments:

1.There are still a few grammatical errors. Some suggested changes are highlighted here:

a. Introduction, page 4, lines 76-77: “Thus, the current study applied an inclusive definition for male involvement in MVH, which includes male participation in deciding to rest their spouse to MWH…”

b.Methods, page 6, lines 122-123: “Then, the questionnaire was amended for wording, sequencing, and content…”

c.Methods, page 7, line 149: “The items used include male partner participation in deciding to rest their spouse to MWH…”

d.Results, page 12, line 208: “…should not require much attention from men…”

e.Discussion, page 18, line 285 and conclusion, page 18, line 301: “Men’s sole decision-making in family affairs…”

f.Discussion, page 18, line 289: “Men being primary drivers…”

g.Discussion, page 18, line 293: “The study has limitations.”

2.Results:

a.Typically, the sample size (n=403) is placed inside the table, for example under “frequency”, versus in the table title.

3.Discussion:

a.Page 17, line 270-273: When you say younger men/this age group, which age group are you referring to? In the results it says that a year increase in age was associated with a 14% decrease in the likelihood of men’s involvement – did you also do the multivariable logistic regression model by the age categories in Table 1?

b.Page 18, study limitations: Thank you for addressing my suggestion to discuss additional limitations of the study, specifically the generalizability of the study. However, when I say generalizability, I meant the degree to which your study findings are generalizable to other contexts outside North Achefer District or outside Ethiopia. So when you say “this study is generalizable to male partners whose spouse have used MWH…” is it only generalizable to North Achefer District, throughout Ethiopia, or can it be generalized to other similar contexts?

Reviewer #3: Comment #1: The manuscript titled, “Factors affecting men’s involvement in maternity waiting home care in North Achefer district, Northwest Ethiopia: a cross-sectional study” still requires additional copy editing for English grammar and language.

Comment #2: Update the abstract to include the definition of “male involvement” in the current study.

Also elaborate in the last sentence of the abstract to propose how to change “patriarchal thinking in society” to improve men’s involvement.

Authors state that the current study aimed to identify factors affecting men’s involvement in maternity waiting home care. Please define MWH care? Do the authors mean MWH use?

Comment #3: Study variables and measurements: More details need to be provided for how the survey tool was developed. There are several questions in the supplementary file that are not addressed in the presentation of results. Variables remain poorly defined. Were responses to questions in Sections 5,6,7 open ended or multiple choice? More details are needed about how Likert scales were determined and tested.

Comment #4: Results: Justify the use of so many variables in one multivariable model. Provide rationale for how attitudes were labeled positive or negative. Several results had very wide confidence intervals and potential reasons for the wide intervals need to be offered in the text not only as response to review comments.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

15 Jan 2022

Response to Academic Editor

Comment: Dear authors on your scholarly work; you have brought an important study problem in the area of practice. However, the manuscript has multiple language usage flaws including punctuations, wordings, spelling and mainly grammar errors. These problems are found throughout the manuscript. Moreover, there are several methodological limitations as the reviewers raised. Therefore, please make repeated proofreading and thorough copyediting before resubmitting the manuscript. This would help increase the readability of the manuscript if published.

Response: We tried to edit the entire document of the manuscript. We edited the spelling, space between words, and the whole grammar as much as possible with online grammar and language checkers (Quill bot online checker and Scribendi costumer service). The methodological concerns raised by the reviewers were adequately explained in the point-by-point response to reviewers.

Response to reviewers

Response to reviewer #2

Comment #1: There are still a few grammatical errors. Some suggested changes are highlighted here:

a. Introduction, page 4, lines 76-77: “Thus, the current study applied an inclusive definition for male involvement in MVH, which includes male participation in deciding to rest their spouse to MWH…”

b. Methods, page 6, lines 122-123: “Then, the questionnaire was amended for wording, sequencing, and content…”

c. Methods, page 7, line 149: “The items used include male partner participation in deciding to rest their spouse to MWH…”

d. Results, page 12, line 208: “…should not require much attention from men…”

e. Discussion, page 18, line 285 and conclusion, page 18, line 301: “Men’s sole decision-making in family affairs…”

f. Discussion, page 18, line 289: “Men being primary drivers…”

g. Discussion, page 18, line 293: “The study has limitations.”

Response #1: Thank you for suggesting editorial changes. We have revised the manuscript as per the comments.

Comment #2: Results: a. Typically, the sample size (n=403) is placed inside the table, for example under “frequency”, versus in the table title.

Response #2: We have revised each table so as to include the sample size for each variable.

Comment #3: Discussion: a. Page 17, line 270-273: When you say younger men/this age group, which age group are you referring to? In the results it says that a year increase in age was associated with a 14% decrease in the likelihood of men’s involvement – did you also do the multivariable logistic regression model by the age categories in Table 1?

Response #3a: Thank you for your deep insight about the variable age. Actually, we considered age as a continuous variable in the logistic regression model. Hence, the reviewer concern is very practical that we have revised the discussion in way it suits the result.

b. Page 18, study limitations: Thank you for addressing my suggestion to discuss additional limitations of the study, specifically the generalizability of the study. However, when I say generalizability, I meant the degree to which your study findings are generalizable to other contexts outside North Achefer District or outside Ethiopia. So, when you say “this study is generalizable to male partners whose spouse have used MWH…” is it only generalizable to North Achefer District, throughout Ethiopia, or can it be generalized to other similar contexts?

Response #3b: Thank you for the comment. In fact, since the study follows scientifically sound methods, the findings are generatable to other settings in Ethiopia and outside Ethiopia with similar contexts. We have incorporated your concern in the updated version of the manuscript.

Response to reviewer#3

Comment #1: The manuscript titled, “Factors affecting men’s involvement in maternity waiting home care in North Achefer district, Northwest Ethiopia: a cross-sectional study” still requires additional copy editing for English grammar and language.

Response #1: We have revised the whole manuscript for grammar and language.

Comment #2: Update the abstract to include the definition of “male involvement” in the current study.

Also elaborate in the last sentence of the abstract to propose how to change “patriarchal thinking in society” to improve men’s involvement.

Authors state that the current study aimed to identify factors affecting men’s involvement in maternity waiting home care. Please define MWH care? Do the authors mean MWH use?

Response #2: Thank you for the comment. The abstract is revised to include reviewer’s suggestions. Regarding MWH care Vs MWH use, the authors’ intention was to say MWH use. Thus, we have replaced the word “care” by “use” in the updated version of the manuscript. In the current revision, the tern “use” is replaced by “utilization” in the whole document for consistency and more reflectiveness.

Comment #3: Study variables and measurements: More details need to be provided for how the survey tool was developed. There are several questions in the supplementary file that are not addressed in the presentation of results. Variables remain poorly defined. Were responses to questions in Sections 5,6,7 open ended or multiple choice? More details are needed about how Likert scales were determined and tested.

Response #2: Thank you for the comment. The survey tool was developed by reviewing different relevant literature. We have also done a pretest before the actual survey and we have amended the survey tool as per the feedback received during the pretest. In fact, there may be data assessed by the survey tool but not addressed in the results. However, for sure, we believe that we have addressed all the results that are relevant to the objective of the current study.

The responses to questions in section 5, 6 and 7 were multiple choice. In some cases, more than one answer is possible and questions with such response options were clearly indicated in parenthesis.

Upon literature review, there are studies employing different point Likert scales: two-point scale, three-point scale, four-point scale, five-point scale, seven-point scale and even more than seven-point Likert scale (Chang, 1997, Vagias, 2006, Taherdoost, 2019). The use of below five-point scale could be very conservative or provide restrictive options for raters to choose while the use of seven or more than seven-point scale make rating complex and get sophisticate raters and usually recommended for well-educated raters. Literature also suggests that five-point scale appears to be less confusing and to increase response rate. It is also quite simple for interviewer to read out the complete list of scale descriptors as compared to seven-point or more than seven point Likert scales (Bouranta et al., 2009, Dawes, 2008). Thus, we preferred to use five-point scale since it provides freedom for raters and because of simplicity for rating. Additionally, the current study is a community-based study. In community-based studies where you can find people with diverse level of literacy, the use of a 7-point scale or more than a 7-point scale is not recommended. At the end, the pretest has helped us to check and decide about the understandability and simplicity a five-point Likert scale for raters and interviewers.

Comment #4: Results: Justify the use of so many variables in one multivariable model. Provide rationale for how attitudes were labeled positive or negative. Several results had very wide confidence intervals and potential reasons for the wide intervals need to be offered in the text not only as response to review comments.

The number of variables used in multivariable model were 14. As inclusion criteria, we have used p-value less than 0.25 as cut value to select candidate variables for multivariable regression model. The sample size is also adequate to do so based on the assumption that 10-20 observations per variable considered in the multivariable regression. For example, if we calculate required minimum sample size by taking the upper bound of the assumption (i.e., 20 observations per variable), it will give us 280 (14*20), which is less than the actual sample size.

Regarding the rationale for labeling positive or negative attitude, as a matter of fact, we can find studies that label attitude as favorable or unfavorable and at the same time, we can find studies that label attitude as positive or negative by using attitude mean score or median score. In this study, eight items with a five-point Likert scale were used to assess men’s attitudes towards MWH. Hence, those men who scored above the median were considered to have positive attitude towards MWH use otherwise taken as having negative attitude (Fang et al., 2021, Seid and Hussen, 2018, Dahake and Shinde, 2020). The rational for labeling attitude positive or negative is just to show inclination towards certain behavior. In the case of this study, positive attitude towards MWH utilization means they have inclination to use MWH while negative attitude reflects the behavioral inclination not to use MWH.

Potential reasons for wide confidence interval may include sample size, multicollinearity, and presence of cells with observation very closer to zero. In this study, multicollinearity was checked by variance inflation factor and had no role for the wide confidence intervals observed in the study. Still, the wide confidence intervals might be associated with sample size adequacy and cell with small observation. For example, the variable decision-making in family affair had one cell with small observation. Having said these all, the authors believe that the confidence intervals recorded in this study are not worse to affect the conclusions.

Reference

BOURANTA, N., CHITIRIS, L. & PARAVANTIS, J. 2009. The relationship between internal and external service quality. International Journal of Contemporary Hospitality Management, 21, 275-293.

CHANG, L. 1997. Dependability of anchoring labels of Likert-type scales. Educational and Psychological Measurement, 57, 800-807.

DAHAKE, S. & SHINDE, R. 2020. Exploring Husband's Attitude Towards Involvement in his Wife's Antenatal Care in Urban Slum Community of Mumbai. Indian journal of community medicine : official publication of Indian Association of Preventive & Social Medicine, 45, 320-322.

DAWES, J. 2008. Do data characteristics change according to the number of scale points used? An experiment using 5-point, 7-point and 10-point scales. International journal of market research, 50, 61-104.

FANG, Y., LIU, P. & GAO, Q. 2021. Assessment of Knowledge, Attitude, and Practice Toward COVID-19 in China: An Online Cross-Sectional Survey. The American journal of tropical medicine and hygiene, 104, 1461-1471.

SEID, M. A. & HUSSEN, M. S. 2018. Knowledge and attitude towards antimicrobial resistance among final year undergraduate paramedical students at University of Gondar, Ethiopia. BMC Infectious Diseases, 18, 312.

TAHERDOOST, H. 2019. What Is the Best Response Scale for Survey and Questionnaire Design; Review of Different Lengths of Rating Scale / Attitude Scale / Likert Scale. International Journal of Academic Research in Management (IJARM), 8.

VAGIAS, W. M. 2006. Likert-type scale response anchors. Clemson International Institute for Tourism & Research Development, Department of Parks, Recreation and Tourism Management. Clemson University.

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28 Jan 2022

Factors affecting men’s involvement in maternity waiting home utilization in North Achefer district, Northwest Ethiopia: a cross-sectional study

PONE-D-20-07872R2

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2 Feb 2022

PONE-D-20-07872R2

Factors affecting men’s involvement in maternity waiting home utilization in North Achefer district, Northwest Ethiopia: a cross-sectional study

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