Non-pharmacological labor pain management practice and associated factors among skilled attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia: A cross-sectional study.

BACKGROUND: Labor pain management is crucial to ensure the quality of obstetric care but it is one of the neglected areas in obstetrics. This study aimed to assess the practice of labor pain management and associated factors among skilled attendants working in public health facilities in Southern, Ethiopia from November 1-January 26, 2019.
METHODS: An Institution-based cross-sectional study design was conducted from November 1-January 26, 2019. A simple random sampling technique was used to select a total of 272 obstetric care providers. Data were collected using pretested, and structured questionnaires. Data were entered to Epi data version 3.1 statistical software and exported to SPSS 22 for analysis. Bivariate and multivariate logistic regression analyses were performed to identify associated factors. P-value <0.05 with 95% confidence level were used to declare statistical significance. RESULT: Overall, 37.5% (95%CI: 32%, 43%) of health care providers had a good practice on non-pharmacological labor pain management. Clinical experience of 5 years and above (AOR = 2.91, 95%CI: 1.60, 5.42), favorable attitude (AOR = 2.82, 95%CI: 1.56, 5.07), midwife profession (AOR = 1.45, 95%CI: 1.98, 4.27), and working in satisfactory delivery rooms (AOR = 3.45, 95%CI: 2.09, 7.43), were significantly associated with a health professional good practice of labor pain management.
CONCLUSION: This study showed that the practice of non-pharmacological labor pain management was poor in public health facilities in Gamo and Gofa zone. It was observed that having a favorable attitude, having ≥5 years of work experience, being a midwife by professional, and having a satisfactory delivery room were found to be significant predictors of the practice of non -pharmacological labor pain management. Therefore, all health facilities and concerned bodies need efforts to focus on providing training to midwives on non-pharmacological labor pain management practice.

Introduction

Labour pain is a universal concern for women. Women’s experience of pain during labor varies greatly. Some women feel little pain whilst others find the pain extremely distressing. Addressing pain relief during childbirth is a way of promoting a satisfactory birth experience and a healthy reproductive outcome for women [1-4]. Non-pharmacological labor pain management (NPLPM) methods are non-invasive, cheap, and simple [4-7]. Lack of labor pain management practice is one of the indications of poor quality of care and contributing factors of low utilization of institutional delivery and indirect contributing factors of maternal morbidity and mortality [8, 9]

Globally maternal mortality is unacceptably high. About 295 000 women died during and following pregnancy and childbirth in 2017. The vast majority of these deaths (94%) occurred in low-resource settings, and most could have been prevented. Sub-Saharan Africa and Southern Asia accounted for approximately 86% (254 000) of the estimated global maternal deaths in 2017 [10, 11]. According to EDHS (Ethiopian Demographic and Health Survey), the 2016 report MMR(Maternal Mortality Ratio) in Ethiopia was 412 per 100,000 live birth. Only 26% of births in Ethiopia were delivered at a health facility by a skilled attendant [10]. Studies have shown that the use of non-pharmacological labor pain management during labor is important to improve maternal satisfaction and facilitate mothers’ ability for attachment and infant caregiving [12, 13]. Non-pharmacological labor pain management has many advantages like having shorting the progress of labor, minimizing the need for oxytocin and anesthesia, the strength of maternity care user and providers bonding, reducing instrumental deliveries, and decreasing by 50% of cesarean section [14]. Additionally, anxiety, postpartum depression, postpartum bleeding, postpartum fever, a low Apgar score of neonates (<7 at 5 minutes), and prolonged infant hospitalization can be also decreased [15]. The Ethiopian FMoH (Federal Ministry of Health) has developed and implemented the first standard of midwifery care practice in 2013. Among the practice, competencies stated the provision of physical and psychological support and use of non-pharmacological comfort measures during labor and birth are listed as core competencies under practice standard III [16]. This is one of the components to improve the quality of maternal health services. However, its actual practice is not recognized [17, 18]. Therefore, this study has assessed the practice of labor pain management and associated factors among skilled attendants working in public health facilities in the Gamo and Gofa zone. Southern Ethiopia

Methods

Study area and period

The study was conducted in selected public health facilities in Gamo and Gofa zone in south Ethiopia, November 1–January 26, 2019

Study design

A multicenter cross-sectional study was conducted

Sample size and sampling technique

A simple random sampling technique was used to select two hundred seventy-two (272) sampled obstetric caregivers, (including midwives, nurses, and health officers) who were giving obstetric care in the delivery room.

Inclusion criteria

All obstetric caregivers, (including midwives, nurses, and health officers) who were giving obstetric care in the delivery room were included in the study

Exclusion criteria

Those health care providers who were absent during data collection due to annual leave

Measurement

Knowledge about labor pain management methods was measured by a 14-item questionnaire adapted from previous studies [3, 19, 20]. The scale for assessing knowledge was from 0 to 14 scores. Correct answers were given a score of one and incorrect answers zero. Those who scored less than the mean value were considered to have poor knowledge while those who scored greater than or equal to the mean value were considered as having good knowledge.

Labor pain management practice was measured by a 9-item checklist adapted from previous studies [3, 19, 20]. The checklist for assessing practice was from zero to nine scores. Having correct practice was given a score of one and no practice were zero. Those who scored less than the mean value were considered to have poor practice while those who scored greater than or equal to the mean value were considered as having good practice

Data collection tool

A pretested, structured self-administered, and observational checklist questionnaire was prepared based on reviewing relevant literature. The instrument was pretested for its reliability. Qualified obstetricians and public health expertise reviewed the content validity of the questionnaire. The questionnaires were designed in English. All skilled attendants who were working in labor wards of public health institutions found in the Gamo and Gofa zone and who fulfilled eligibility criteria were interviewed by structured questionnaires. Nine data collectors were recruited and principal investigators supervise the data collection process

Data processing and analysis

Before starting the actual data collection, one-day training was provided for both data collectors and supervisors on objectives and approaches to study subjects. The pretest was conducted 5% of the total sample size outside the study area. The reliability of the questionnaires was checked via SPSS by reliability index measurement for practice questions (Cronbach’s alpha) which was 0.85. Data were coded, cleaned, edited, and entered into EPI data version 3.1 and exported to SPSS version 22.0 for statistical analysis. Descriptive statistics with percentages were employed. All variables were analyzed in bivariate logistic regression and those variables having P-value less than 0.25 were entered into multivariable logistic regression analyses. In multivariable logistic regression analyses variables with P-value, less than 0.05 were considered as significant. Hosmer–Lemeshow goodness of fit test was used to check the model fitness. Adjusted odds ratio with 95% confidence interval was used to determine the presence and direction of the association between covariates and the outcome variable

Ethical approval and consent to participant

The study protocol was ethically approved by the Ethical Review Board (IRB) of Arba Minch University College of Medicine and Health Sciences. An official letter was written to each hospital and health center. The study posed a low or no more than minimal risk to the study participants. Also, the study did not involve any invasive procedures. Accordingly, after the objective of the study was explained, verbal informed consent was obtained from all participants

Results

Socio‑demographic characteristics

272 health professionals participated in the study, yielding a response rate of 96%. The mean age of study participants was 29.9 years old. More than half (57%) of the study participants were females and 155(66.5%) were married. 107(39.3%) of health professionals were orthodox religious followers ().

Knowledge of health care providers on labor pain management practice

Of the total respondents, 223(82.0%) stated back massage can be used to relieve labor pain, and the majority 217(79.8%) of health care providers mentioned relaxation/breathing techniques used to relieve labor pain ( Of the total respondents, 140(51.5%) of health care providers have good knowledge and 132(48.5%) of health care providers have poor knowledge of labor pain management respectively.

The attitude of health care providers towards labor pain management practice

Overall, 195(71.7%) of health care providers have unfavorable attitudes toward labor pain management and 77(28.3%) of health care providers have a favorable attitude. The majority of 263(96.7%) health care providers believe that analgesia is necessary for managing labor pain and 147(54%) believe that labor pain management reduces postpartum depression. Above the half 197(72%) agree that continuous labor support increase maternal and fetal bonding, besides, 198(72.8%) of respondents believe that spousal presence during labor facilitate delivery

The practice of non-pharmacological labor pain management

Of the total respondents, the majority of 154(56.6%) of health care providers allow companions of her choice during labor and delivery and 184(67.6%) health care providers use psychotherapy to relieve labor pain. The majority of 182(66.9%) and 210(77.2%) of health care providers use relaxation/ breathing techniques and massage the back to relieve labor pain respectively ( Overall, 170(62.5%) of health care providers have poor practice and 102(37.5%) have a good practice of non-pharmacological labor pain management

Factors associated with the practice of non-pharmacological labor pain management

Binary Logistic regression was performed to assess the association of each independent variable with practice labor pain management. The factors that showed a p-value of less than 0.25 were added to the multivariable regression model. The result revealed that on the Bivariate analysis variables like clinical year of experience, the attitude of health care providers was some of the variables significantly associated with labor pain management practice

In multivariable logistic regression clinical year of experience, having a favorable attitude, having a favorable delivery room, and being midwifery by profession were some of the variables significantly associated with the practice of non-pharmacological labor pain management at a P-value of <0.05.

Respondents with clinical experience of 5 years and above were 2.91 times more likely to perform good practice than respondents with clinical experience of less and equal to two years with (AOR = 2.91, 95%CI: 1.60, 5.42), and respondents who had a favorable attitude towards labor pain management were 2.82 times more likely performing good practice than others with AOR = 2.82, 95%CI: 1.56, 5.07), in addition to this, those health care providers who were working in favorable delivery rooms were 3.45 times more likely to perform good practice than others with (AOR = 3.45, 95%CI: 2.09, 7.43), those health care providers who have midwifery in the profession were 1.45 times more likely to perform good practice than others with (AOR = 1.45, 95%CI: 1.98, 4.27). ()

Discussion

Pain is more than just a feeling of discomfort that leads to mental health conditions like depression and anxiety. The poor practice may lead to a woman’s dissatisfaction and leads to negative birth and it may affect her emotional well-being and willingness to have another baby. Using non-pharmacological interventions serves as a way of relaxing the woman in labor and making her more comfortable during the process [21].

The finding of this study disclosed that 37.5% of the study participants had a good practice of non-pharmacological labor pain management. The finding of this study was in line with a study done in the Kembata Tembaro zone, Southern Ethiopia (37.9%), and Amhara region referral hospitals (40.1%), respectively [7, 22]. The finding of this study is lower than the studies conducted in Nigeria (48.4%), and Tigray Region, North Ethiopia (43.4%) [1, 23] respectively. The discrepancy might be due to the difference in health facilities and sample size It was consistent with studies done in Bangladesh and Ghana where allowing laboring women to move freely, showing the patient how to bear down, allowing companionship, and massaging the back was the most applied non-pharmacologic pain relief methods [2, 24]. But it was inconsistent with the study done in Nairobi [21]. The discrepancy might be due to the sociocultural characteristics of mothers, health facilities rules and regulations, traditional practices at birth, and poor communication of health professionals.

Clinical years of experience, having a favorable attitude, having a satisfactory delivery room, and being a midwife by profession were some of the variables significantly associated with the practice of non-pharmacological labor pain management in multivariable analyses. This finding is similar to another study conducted in Ethiopia, which showed that clinical years of experience, having a favorable attitude, and having a satisfactory delivery room were associated with the good practice of non-pharmacological labor pain management [1, 19]

Respondents with clinical experience of 5 years and above were 2.91 times more likely to perform good practice than respondents with clinical experience of less and equal to two years. This result was consistent with the study conducted in northern Ethiopia, this could be the reason that the more they stay at work the more they can understand labor pain. Besides the more they stay in a health facility they receive training related to labor pain management and update their knowledge and they will perform more. Respondents who had favorable attitudes towards labor pain management were 2.82 times more likely to perform good practice than others. This finding is similar to other studies conducted in the northern part of Ethiopia [1]. The fact for this is a good attitude of health care professionals is more likely to have the skills and perform the activities in a good manner. Besides, those health care providers who were working in satisfactory delivery rooms were 3.45 times more likely to perform good practice than others. similarly, those health care providers who have midwifery in the profession were 1.45 times more likely to perform good practice than others. The identified factors should be addressed at both institutional and national levels to increase pain management practice for expectant mothers. Providing training for health care providers on non-pharmacological labor pain management and creating a satisfactory delivery room is vital to increases the practice of labor pain management. Besides, it is important for maternity care providers to respect the individuality of each client and be prepared to modify the delivery environment to attract more mothers to the health facility

Conclusion

This study revealed the poor practice of non -pharmacological labor pain management. Favorable attitude, clinical years of experience, a midwife by profession, and having a satisfactory delivery room were found to be significant predictors of the practice of non -pharmacological labor pain management. The identified factors should be addressed to improve pain management for expectant mothers. Poor practice in the birth process may lead to negative birth experiences of the mother and it may affect her emotional well-being and willingness to have another baby. However, supporting women in labor and delivery is vital and one of the components of compassionate and respectful maternity care. It should be emphasized that it should be trained to midwives on non-pharmacological labor pain management practices. Future prospective studies should be needed to examine the effect of non-pharmacologic labor pain management methods on labor pain relief and other related maternal and neonatal outcomes.

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11 May 2020

PONE-D-20-00957

Non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone. Southern Ethiopia

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Reviewer #1: Thank you for your project on this important topics, I have attached my comments int he file, but my big concern about the instrument that you used, no information is given about the instrument how you measured knowledge attitute of providers..

who develop them, validity, reliability ?

My all comments are in the pdf file.

Reviewer #2: General.

Manuscript should be edited by native spekaer.

There are too many grammatical errors in the manuscript. Please correct!

There are many spelling mistakes in the manuscript . Please correct!

For Results:

Is religion of the health professionals effect on good or poor practice of labor pain management? Please briefly comment with a sentence!

Two yes are written in the last line in table 3 (on Acupuncture). One of them should be no.

Discussion:

The discussion was written very poorly. This section should be improved with new references

It should be emphasized the new perspectives in the discussion section in the light of your results

For example: Poor practice in birth process may lead to negative birth experiences of mother and traumatic perception of birth .

It should be emphasized the relationship between good or poor practice and also birth center, birth enviroment, birth team,

It should be given skill training for health care providers on nonpharmacological applications in relieving birth pain.

Suggestioned some references:

Aktaş, S., & Aydın, R. (2019). The analysis of negative birth experiences of mothers: a qualitative study. Journal of reproductive and infant psychology, 37(2), 176-192.

Guise, J. M., & Segel, S. (2008). Teamwork in obstetric critical care. Best practice & research Clinical obstetrics & gynaecology, 22(5), 937-951.

Oosthuizen, S. J., Bergh, A. M., Grimbeek, J., & Pattinson, R. C. (2019). Midwife-led obstetric units working ‘CLEVER’: Improving perinatal outcome indicators in a South African health district. South African Medical Journal, 109(2), 95-101.

Conclusion:

It should be emphasized that ıt should be trained to midwives on non-pharmacological labor pain management practice.

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Submitted filename: PONE-D-20-00957_reviewer.pdf

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1 Jun 2020

Thank you very much we have addressed All comments and suggestions of both reviewers and we have attached response thanks

Submitted filename: Response to reviwers biresaw.docx

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4 Aug 2020

PONE-D-20-00957R1

Non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia: A cross-sectional study

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Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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Reviewer #3: Partly

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Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #3: Yes

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Reviewer #2: The authors mad the corrections given. This study has the ability to raise awareness about good practices, especially in developing countries. For me, ıt is suitable for publication

Reviewer #3: The manuscript has been improved much. However, I do have some major comments.

1. There are still many grammar and spelling errors in the article. For example, “Associated factors among skilled” in the abstract, the first letter should be lower case. “in Southern, Ethiopia”, please add a period at the end of the sentence. Same errors exist in other parts of the manuscript, please carefully check the manuscript and correct these errors.

2. Introduction section, the authors introduced “labor pain management” and its role in the first paragraph. However, the transition to maternal mortality in the second paragraph seems illogical. “labor pain management” is not a key factor of maternal mortality.

3. Methods section, the content is too much and should be reduced. There are some improper English expressions. This research is indeed a facility-based investigation, no need to describe too much the “study area and period” or population.

4. Results section, just summarize the key findings, 3 or 4 tables are enough. The authors used logistic regression model to explore factors associated with good labor pain management. Score is a continuous variable, are the results same if using linear regression model? Does the score vary by facilities or by regions (Gamo vs Gofa)?

5. Discussion section, besides discussing the current status and associated factors of “non-pharmacological labor pain management” among skilled attendants in public health facilities, the authors should address how to improve the practice based on current findings and the guide released by government.

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Reviewer #3: No

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7 Aug 2020

Author’s Point-by-Point Response to the Reviewer's and Editors Reports

Title: Non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia: A cross-sectional study

Corresponding author: Biresaw Wassihun /bireswas@gmail.com

Authors

1. Biresaw Wassihun

2. Yosef Alemayehu

Manscurpuit number: PONE-D-20-00957

Journal: PloS one

Article type: Research article

Point by point response to Reviewers and Editors

First of all, the authors would like to thank Plos one Journal editors and the respective reviewers for reviewing our manuscript and providing the necessary comments to be corrected. As per the comments given, we have made corrections point by point to comment. The authors tried to answer all the issues raised by the editorial team and reviewers. Thank you again providing this interesting and constrictive comment

Point by point response to Editor

Dear Nülüfer Erbil, Ph.D., Prof

1. Please ensure that your manuscript meets PLOS ONE's style requirements

Response: Thank you very much we had applied journal requirement

2. Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process3. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical

Response: Dear respected Editor Nülüfer Erbil, Ph.D., Prof thank you for providing interesting and constrictive comments so, we will provide each separately, thank you again

Point by point response to Reviewer# 3

Reviewer #2: The authors mad the corrections are given. This study can raise awareness about good practices, especially in developing countries. For me, ıt is suitable for publication.

Response: We would like to say thank you very much for your invaluable comments and suggestions. We considered and modified and rewrote again based on your constructive issues regarding language, coherence, and comprehensibility of the manuscript

Reviewer #3: The manuscript has been improved much. However, I do have some major comments.

Question 1. There are still many grammar and spelling errors in the article. For example, “Associated factors among skilled” in the abstract, the first letter should be lower case. “in Southern, Ethiopia”, please add a period at the end of the sentence. Same errors exist in other parts of the manuscript, please carefully check the manuscript and correct these errors

Response 1: We would like to say thank you very much for your invaluable comments and suggestions. We considered, modified, and rewrote again based on your constructive issues regarding language, and grammar. The abstract was corrected as follows

The health and well-being of a mother and child at birth largely determine the future health and wellness of the entire family. Labor pain management is crucial to ensure the quality of obstetric care but it is one of the neglected areas in obstetrics. Therefore, this study aimed to assess the practice of labor pain management and associated factors among skilled attendants working in public health facilities in Southern, Ethiopia from November 1–January 26, 2019

Question 2. Introduction section, the authors introduced “labor pain management” and its role in the first paragraph. However, the transition to maternal mortality in the second paragraph seems illogical. “Labor pain management” is not a key factor of maternal mortality

Response 2: Thank you very much. Dear respected reviewer as you know that one of the factors that affect delivery in public health institutions is the lack of health care providers' support and inadequate quality that is related to pain relief. Based on literature Lack of labor pain management practice is one of the unspoken causes of low utilization of institutional delivery so if there is low utilization of institutional delivery there is a high number of home delivery. Home delivery itself as its contribution to maternal mortality and in Ethiopia majority 74% of mothers gave birth in the home so lack of continuous labor support or lack of compassionate and respectful maternity care will be one of the indirect causes of maternal mortality and morbidity.

Finally, thank you again and we will as modify based on your comment and suggestion

Question 3. In the methods section, the content is too much and should be reduced. There are some improper English expressions. This research is indeed a facility-based investigation, no need to describe too much the “study area and period” or population

Response 3: It was corrected according to your suggestion, as follows

The study was conducted in selected public health facilities in Gamo and Gofa zone in south Ethiopia, from November 1–January 26, 2019

The source population study area and period was corrected accordingly thank you very much

Question 4. Results section, just summarize the key findings, 3 or four tables are enough.

Response 4. It was corrected according to your suggestion and the number of tables was reduced

Question 5 . Does the score vary by facilities or by regions (Gamo vs Gofa)?

Response5 : As a suggestion, we will consider it in the future to assess the disparity of using non-pharmacological labor pain management between health facilities taking health facility as one of the independent variable even including other private health facility

Thanks for your advance

Question 6. In the discussion section, besides discussing the status and associated factors of “non-pharmacological labor pain management” among skilled attendants in public health facilities, the authors should address how to improve the practice based on current findings and the guide released by the government.

Response 6. The correction was made thanks in-depth, for your nice comment

The identified factors should be addressed at both institutional and national levels to increase pain management practice for expectant mothers. Providing training for health care providers on non-pharmacological labor pain management and crating satisfactory delivery room is vital to increases practice of labor pain management. In addition, it is important for maternity care providers to respect the individuality of each client and be prepared to modify the delivery environment to attract more mothers to the health facility

Submitted filename: Response to reviwers biresaw.docx

Click here for additional data file.

15 Oct 2020

PONE-D-20-00957R2

Non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia: A cross-sectional study

PLOS ONE

Dear Dr. Alemu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 29 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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

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

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

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Nülüfer Erbil, Ph.D, Prof.

Academic Editor

PLOS ONE

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #4: All comments have been addressed

**********

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

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

Reviewer #4: Yes

**********

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

Reviewer #4: Yes

**********

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

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

Reviewer #4: 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 #4: Yes

**********

6. Review Comments to the Author

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

Reviewer #4: Thank you for the opportunity to review this manuscript under title Non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia: A cross-sectional study.

The manuscript has been improved so much. However, I do have some minor comments.

There are still many grammar and spelling and style errors in the manuscript.

Abstract section, in the key words changing the word of Labour to labor its better to write the term in manuscript in the same style (unified).

Introduction section, According to EDHS 2016 report MMR in Ethiopia was 412 per 100,000 live birth.

The EDHS abbreviation of what? al so the MMR & FMoH in the paragraph two line 14.

In the end of the introduction section put full stop point (.)

Methods section, put full stop point (.) at the end of each paragraph for example:

A simple random sampling technique was used to select two hundred seventy-two (272) sampled

obstetric caregivers; (including midwives, nurses, and health officers) who were giving obstetric

care in the delivery room.

- Sample size and sampling technique, mention clearly the inclusion and exclusion criteria.

- In the Measurement part, Channing the word of Labour to labor in the line 6 also changing word of the cheek list to check list in the same line.

- In the Ethical approval and consent to participant, write down the number and date of the ethical approve issue

Results section, in general, revision the results interpretation

- Can chinning the (In this study, 272 health professionals) to (272 health professionals participated in the study, yielding a response rate of)

Discussion section, in general, need revision the discussion part

References section, check the number and the sequence of references in the text with the list of the references for example check the numbers 2, 5, 6, sequence.

**********

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 #4: Yes: Warda Hassan Abdullah

[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.

28 Oct 2020

All of the comments was corrected

Author’s Point-by-Point Response to the Reviewer's and Editors Reports

Title: Non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia: A cross-sectional study

Corresponding author: Biresaw Wassihun /bireswas@gmail.com

Authors

1. Biresaw Wassihun

2. Yosef Alemayehu

3. Teklemariam Gultie

Manscurpuit number: PONE-D-20-00957

Journal: PloS one

Article type: Research article

Point by point response to Reviewers and Editors

First of all, the authors would like to thank Plos one Journal editors and the respective reviewers for reviewing our manuscript and providing the necessary comments to be corrected. As per the comments given, we have made corrections point by point to comment. The authors tried to answer all the issues raised by the editorial team and reviewers. Thank you again providing this interesting and constrictive comment

Point by point response to Editor

1. Please ensure that your manuscript meets PLOS ONE's style requirements

Response: Thank you very much we had applied journal requirement

2. Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process

Response: Dear respected Editor thank you for providing interesting and constrictive comments so, we will provide each separately, thank you again

Point by point response to Reviewer# 4

Reviewer #4: Thank you for the opportunity to review this manuscript under title Non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia: A cross-sectional study.

The manuscript has been improved so much. However, I do have some minor comments.

There are still many grammar and spelling and style errors in the manuscript..

Response: We would like to say thank you very much for your invaluable comments and suggestions. We considered and modified and rewrote again based on your constructive issues regarding language, coherence, and comprehensibility of the manuscript

Question 1. There are still many grammar and spelling errors in the article. For example” Abstract section, in the key words changing the word of Labour to labor its better to write the term in manuscript in the same style (unified).

Response 1: We would like to say thank you very much for your invaluable comments and suggestions. We considered, modified, and rewrote again based on your constructive issues regarding language, and grammar. The abstract was corrected

Question 2. Introduction section, According to EDHS 2016 report MMR in Ethiopia was 412 per 100,000 live birth.The EDHS abbreviation of what? al so the MMR & FMoH in the paragraph two line 14.

Response 2: Thank you very much. Dear respected reviewer it was corected accordingly

Question 3. In the end of the introduction section put full stop point (.)

Response 3: It was corrected according to your suggestion

Question 4. Methods section, put full stop point (.) at the end of each paragraph for example:

A simple random sampling technique was used to select two hundred seventy-two (272) sampled

obstetric caregivers; (including midwives, nurses, and health officers) who were giving obstetric

care in the delivery room.

Response 4. It was corrected according to your suggestion

Question 5 . Sample size and sampling technique, mention clearly the inclusion and exclusion criteria.

- In the Measurement part, Channing the word of Labour to labor in the line 6 also changing word of the cheek list to check list in the same line.

Response5 : Thanks for your advance

Question 6. Results section, in general, revision the results interpretation

- Can chinning the (In this study, 272 health professionals) to (272 health professionals participated in the study, yielding a response rate of).

Response 6. The correction was made thanks in-depth, for your nice comment

Question 7 Discussion section, in general, need revision the discussion part

Response7 : Thanks for your advance

Question 8. References section, check the number and the sequence of references in the text with the list of the references for example check the numbers 2, 5, 6, sequence

Response8. we have made correction on it

Question 9 Sample size and sampling technique, mention clearly the inclusion and exclusion criteria

Response9. we have made correction on it as followes

Inclusion criteria

All obstetric caregivers; (including midwives, nurses, and health officers) who were giving obstetric care in the delivery room were inclideded in the study

Exclusion criteria

Those health care provider Absent during data collection due to annual leave

Submitted filename: Response to reviwers biresaw.docx

Click here for additional data file.

18 Jan 2021

PONE-D-20-00957R3

Non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia: A cross-sectional study

PLOS ONE

Dear Dr. Alemu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Mar 04 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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

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

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

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Nülüfer Erbil, Ph.D, Prof.

Academic Editor

PLOS ONE

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #3: All comments have been addressed

**********

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

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

Reviewer #3: Partly

**********

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

Reviewer #3: No

**********

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 #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 #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 #3: The authors performed a cross-sectional study to assess the practice of labor pain management and associated factors among skilled attendants working in public health facilities in Southern, Ethiopia. They found that the practice of non-pharmacological labor pain management was poor. They also observed several risk factors reported in previous studies such as a favorable attitude, at least 5 years of work experience, having a satisfactory delivery room, etc. The findings should be of interest to maternity care providers and public health workers, especially in the underdeveloped areas. Although the manuscript has been improved, I still have some comments.

1. Introduction section. Labor pain management practices include pharmacological and non-pharmacological methods. The author should address the current research status of non-pharmacological pain management when introducing the importance of labor pain management.

2. P17 Table 4, “AOR(≥5 years of experience)=7.0(1.60-3.05)” and “AOR(midwife)=7.13(1.06-4.77)”, I am wondering why the confidence intervals did not include the point estimates. The authors should double check the data and verify the results.

3. In the results section, logistic analysis showed that knowledge was not statistically associated with practice. But in the discussion part, the authors ascribed differences in the practice between this study and others to the differences in knowledge. It is reasonable according to the common sense of KAP theory，but it is not supported by the results of this study. The authors should address it carefully and describe it more appropriately.

4. There are still many grammar and spelling errors in the manuscript.

(1) The introduction part, paragraph 2, line 9, “......facilitate mothers' ability for attachment and infant car giving”. It could be “infant care giving”.

(2) In the measurement part, the criteria for evaluating “attitude” was missing.

(3) In the “data processing and analysis”, line 7, the criteria for selecting variables into logistic regression is p < 0.2, while the corresponding description in the results part is < 0.25 (the third row below Table 3).

(4) The title of the Table 2 was “knowledge of non-pharmacological labor pain management practice in Gamo and Gofa zone Public health facilities southern, Ethiopia”. However, the table contains pharmacological and non-pharmacological items. Please use a suitable title instead.

(5) In the Table 4, please give the full spelling of “HCP” in the footnote.

**********

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 #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.

5 Feb 2021

Author’s Point-by-Point Response to the Reviewer's and Editors Reports

Title: Non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia: A cross-sectional study

Corresponding author: Biresaw Wassihun /bireswas@gmail.com

Authors

1. Biresaw Wassihun

2. Yosef Alemayehu

3. Teklemariam Gultie

Manscurpuit number: PONE-D-20-00957

Journal: PloS one

Article type: Research article

Point by point response to Reviewers and Editors

First of all, the authors would like to thank Plos one Journal editor, and the respective reviewers for reviewing our manuscript and providing the necessary comments to be corrected. As per the comments given, we have made corrections point by point to comment. The authors tried to answer all the issues raised by the editorial team and reviewers. Thank you again for providing this interesting and constrictive comment

Point by point response to Editor

1. Please ensure that your manuscript meets PLOS ONE's style requirements

Response: Thank you very much we had applied the journal requirement

2. Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process

Response: Dear respected Editor thank you for providing interesting and constrictive comments so, we will provide each separately, thank you again

Point by point response to Reviewer# 3

Reviewer #3: Thank you for the opportunity to review this manuscript under the title non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia:

A cross-sectional study.

The manuscript has been improved so much. However, I do have some minor comments.

There are still many grammar and spelling and style errors in the manuscript.

Response: We would like to say thank you very much for your invaluable comments and suggestions. We considered and modified and rewrote again based on your constructive issues regarding the language, coherence, and comprehensibility of the manuscript

Question 1. Introduction section. Labor pain management practices include pharmacological and non-pharmacological methods. The author should address the current research status of non-pharmacological pain management when introducing the importance of labor pain management)

Response 1: We would like to say thank you very much for your invaluable comments and suggestions. We considered, modified, and rewrote again based on your constructive comments

Question 2. 2. P17 Table 4, “AOR(≥5 years of experience)=7.0(1.60-3.05)” and “AOR(midwife)=7.13(1.06-4.77)”, I am wondering why the confidence intervals did not include the point estimates. The authors should double check the data and verify the results.

Response 2: Thank you very much. Dear respected reviewer, it was corrected accordingly

Question 3. In the results section, logistic analysis showed that knowledge was not statistically associated with practice. But in the discussion part, the authors ascribed differences in the practice between this study and others to the differences in knowledge. It is reasonable according to the common sense of KAP theory，but it is not supported by the results of this study. The authors should address it carefully and describe it more appropriately

Response 3: It was corrected according

Question 4. here are still many grammar and spelling errors in the manuscript.

(1) The introduction part, paragraph 2, line 9, “......facilitate mothers' ability for attachment and infant car giving”. It could be “infant care giving

Response 4. It was corrected according to your suggestion

Question 5 . In the “data processing and analysis”, line 7, the criteria for selecting variables into logistic regression is p < 0.2, while the corresponding description in the results part is < 0.25 (the third row below Table 3).

Response5 : Thanks for your advance

Question 6. The title of the Table 2 was “knowledge of non-pharmacological labor pain management practice in Gamo and Gofa zone Public health facilities southern, Ethiopia”. However, the table contains pharmacological and non-pharmacological items. Please use a suitable title instead.

Response 6. The correction was made thanks in-depth, for your nice comment

Question 7 In the Table 4, please give the full spelling of “HCP” in the footnote.

Response 7. we have made correction on it

Submitted filename: Response to reviwers biresaw.docx

Click here for additional data file.

7 Apr 2021

PONE-D-20-00957R4

Non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia: A cross-sectional study

PLOS ONE

Dear Dr. Alemu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 22 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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

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

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Nülüfer Erbil, Ph.D, Prof.

Academic Editor

PLOS ONE

Journal Requirements:

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

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #3: All comments have been addressed

**********

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

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

Reviewer #3: Yes

**********

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

Reviewer #3: Yes

**********

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

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

Reviewer #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 #3: Yes

**********

6. Review Comments to the Author

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

Reviewer #3: The manuscript has been improved. However, I do have some minor comments.

1. P9, abstract, conclusion, line 3: the mentioned factors were significant predictors, not a predictor.

2. P11, measurement, line 6, “labor pain” , the first letter should be uppercased. Line 9, “ ...less than the mean value were considered to have good practice...”. It could be “poor practice”.

3. P12, Data collection tool part, line 3, “Nine data collectors were recruited principal investigators supervise the data collection process”. There should be an “and” between “recruited” and “principal investigators”.

4. P16, Result section. The sex of health care provider was associated with labor pain management practice. But no data presented in the Table 4.

5. P17 Table 4. Please add a footnote for “*”.

6. Discussion section. Last time I mentioned that according to the common sense of KAP theory, knowledge was an influencing factor on practice. But it is not supported by the result of this study. The authors should explain the reasons for the separation of knowledge and practice.

7. There are still some grammar or style errors in the manuscript. For example, many sentences lack a full stop ( “.”). The authors should carefully check the documents to ensure that they meet the journal's format requirements.

**********

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 #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.

21 May 2021

All of the comments was corrected accordingly based on both reviewers and editors comment and suggestion and we have attached point by point response to reviewers and editors

Submitted filename: Response to reviwers biresaw.docx

Click here for additional data file.

5 Jul 2021

PONE-D-20-00957R5

Non-Pharmacological Labor Pain Management Practice and Associated Factors among Skilled Attendants working in public health facilities in Gamo and Gofa zone, Southern Ethiopia: A cross-sectional study

PLOS ONE

Dear Dr. Alemu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Aug 19 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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

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

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Nülüfer Erbil, Ph.D, Prof.

Academic Editor

PLOS ONE

Journal Requirements:

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

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #3: All comments have been addressed

**********

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

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

Reviewer #3: Yes

**********

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

Reviewer #3: Yes

**********

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

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

Reviewer #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 #3: Yes

**********

6. Review Comments to the Author

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

Reviewer #3: The manuscript has been improved. However, there are still some minor errors that need to be corrected.

Question 1. P11, measurement, line 6, “labor pain”, the first letter should be uppercase.

Question 2. P17. The footnote you added to the Table 4, “statical significance at p-value less than 0.05”, spelling mistake for the word "statistical". We know that the table present the 95% confidence intervals, so the statistical level for α is 0.05. The CI of OR does not include 1, indicating that the P value is less than 0.05. If the asterisks in the table have special meaning other than the P value, a footnote should be added. Otherwise, it’s not necessary.

Question 3. Please use punctuation correctly. There are still many sentences lacking a full stop (“.”).

**********

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 #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.

27 Jul 2021

All of the comments was corrected

Submitted filename: Response to reviwers biresaw.docx

Click here for additional data file.

3 Sep 2021

PLOS ONE

Dear Dr. Alemu,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 18 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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

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

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Nülüfer Erbil, Ph.D, Prof.

Academic Editor

PLOS ONE

Journal Requirements:

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

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #3: All comments have been addressed

**********

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

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

Reviewer #3: Yes

**********

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

Reviewer #3: Yes

**********

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

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

Reviewer #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 #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 #3: There are still some errors in the manuscript. The authors must ensure that the grammar, format, and punctuation meet the requirements of the journal.

1.Abstract, Methods, “Institution-based cross-sectional study design was conducted from November 1– January 26, 2019”, It is better to be expressed as “An institution-based cross-sectional study was conducted……”.

2.Abstract, Results, “37.5% (95%CI: 32, 43%) of health care providers……” , it should be “37.5% (95%CI: 32%, 43%). Please pay attention to that the AOR should be described as “(AOR=2.82, 95%CI: 1.56, 5.07)”.

3.Abstract, Conclusion, “It was observed that; having a favorable attitude, having ≥5 years of work experience, …...”. Please remove the “;” from the sentence.

4. Introduction, paragraph 2, line 7, “Studies have been shown that ......”, It should be “Studies have shown that.....”. Line 13, “Additionally, Anxiety, postpartum depression.......”, the first letter of “Anxiety” should be lower-case.

5. Methods, Exclusion criteria, “Those health care providers absent.....”, It should be “Those health care providers who were absent.....”.

6. Results, paragraph 1, line 2, The “SD” in “29.9 ± SD4.89” should be removed.

7. It is better to describe the results using past tense sentences.

8. Table 3, please use the percent sign correctly. And in the sentences that begin with “Health Care providers.....”, “Care” should be lower-case.

9. P16, Table 4, Please use correct table format. Row 5, collumn4, “1,87” should be “1.87”.

10. Except for the comments above, there were still many grammar and style errors in the manuscript. The authors should carefully check the documents.

11. This study focused on non-pharmacological labor pain management practice. However, “pharmacological labor pain management practice” was often mentioned in the manuscript. This kind of expression may confuse readers.

**********

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 #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.