Prevalence of depression and associated factors among pregnant women attending antenatal care in public health institutions of Awabale Woreda, East Gojjam Zone, Northwestern Ethiopia: A cross-sectional study.

BACKGROUND: Antenatal depression is a serious health problem and has negative consequences for the mother, fetus, and the entire family. However, it is a neglected component of care especially bay health care providers for women in pregnancy. The purpose of this study was to assess the prevalence of depression and associated factors among pregnant women attending antenatal clinics in public health institutions, in the Awabale Woreda.
METHOD: An institutional-based cross-sectional study was conducted in 2018 and a stratified sampling technique was used to select the study health institutions. All seven public health institutions in Awabale District were included to select 393 mothers and the sample size was proportionally allocated based on the number of target mothers. We used EpiData version 3.1software for data entry and SPSS version 20 software for cleaning and analysis. A Bivariable logistic regression analysis was used to identify the association between each outcome variable and the factor. Again, a multivariable logistic regression analysis was employed to identify factors associated with each outcome variable, and variables with a p-value less than 0.05 were taken as significant variables. Edinburgh Postnatal Depression Scale was used to declare the presence of antenatal depression with a cut point score of 13 and above. RESULT: This study showed that 63(17.8%) pregnant mothers had antenatal depressive symptoms. Women who were employed 85% reduced to develop antenatal depression than housewives [AOR = 0.15(0.001-0.25)]. Pregnant women who attended high school and above educational level were 18 times more likely to develop antenatal depression than women who had no formal education [AOR18.15 (2.73-120.76)]. Women who had poor husband feeling on the current pregnancy were 4.94 more likely to develop antenatal depression than women who had good partner feeling on the current pregnancy [AOR = 4.94(95%CI: 1.78-13.72)]. Women who had a history of depression were 8.2 times to develop antenatal depression than women who had no history of depression [AOR = 8.22 (95%CI: 2.87-23.57)].
CONCLUSION: This study revealed that approximately one-fifth of pregnant women developed antenatal depression. Women's occupational status, educational status, previous history of depression, and poor husband feeling on the current pregnancy were the significant factors of antenatal depression.

Introduction

Pregnancy is the period from the fertilization of the egg by sperm to the delivery of the fetus and usually lasts 40 weeks. Starting from the last normal menstrual period, it is divided into three trimesters, each lasting three months [1]. It is a distinctive social and biological event in a woman’s life [2, 3].

A depressive disorder is an illness that involves the body, mood, and thoughts in which the person has unrelenting sentiments of unhappiness and irrelevance and a lack of aspiration to engage in previously enjoyable activities that last more than two weeks. When these sentiments last for a short period, it may be a case of feeling sadness [4]. It is the most frequent expressive disorder in women and the general population, and one in every five people has depression with more than the twofold increased incidence in women than men [2]. Psychiatric history, stressful life events, lack of social support, teenage pregnancy, low educational level, low income, and violence against women are the factors that make depression prevalent in pregnant women [3, 5, 6].

Antenatal depression means depression that starts from conception to delivery [7]. Pregnant women experience symptoms similar to general depression and may interfere with their normal day-to-day activities. It may occur at any stage of pregnancy and can be a reaction to the pregnancy itself, due to health issues, major life stresses, genetic and biochemical basis, or due to a continuation or relapse of a pre-pregnancy condition [8]. Antenatal depression ends with poor fetal, infant development, and maternal outcomes like small for gestational age, prematurity, intrauterine growth problem; postnatal depression preeclampsia, anemia; educational problem, malnutrition, respiratory disorders, and mental retardation [9-13].

There are studies, which examined the prevalence and associated factors of antenatal depression in low-income countries like Ethiopia; but the result of the studies was not consistent [14, 15]. Some studies have a limitation on addressing pregnant mothers in all age groups and excluded illiterate mothers from the study [3, 16].

Even though the Federal Democratic Republic of Ethiopia’s National Mental Health Strategy promotes a decentralized approach in which mental health services are to be offered from local health institutions up to tertiary hospitals, the service is not being given as expected [17, 18]. Thus the purpose of this study was to assess the prevalence of depression and associated factors among pregnant women attending antenatal clinics in public health institutions, in Awabale Woreda.

Methods

Study area and period

This study was done in Awabale woreda, Amhara region, Northwest Ethiopia in 2018. Awabale woreda is the capital city of East Gojjam Zone in Amhara regional state, Northwest Ethiopia, which is located at 300 km from Addis Ababa, the capital city of Ethiopia, and 265 km from Bihar Dar, the capital city of Amhara region. Awabale woreda has a 146260 total population; about 37413 are females aged 15–49 years [19]. There are seven public health institutions eligible for this study in Awabale Woreda and Antenatal care is provided in all public health institutions. The Woreda has an annual ANC plan of 5590(1309 in Lumame health center, 648 in Shebela health center, 641 in Wejele health center, 665 in Lega health center, 901 in Yesenbet health center, 765 in Tsid-Maryam health center and 661 in Lumame primary hospital) [19].

Study design

An institutional-based cross-sectional study design was employed.

Study participants

All pregnant women attending antenatal care in Awabale Woreda public health institutions were the source population. All pregnant women attending antenatal care in selected public health institutions during the study period were the study population. Pregnant women at any age of gestation who come to the selected health institutions for antenatal care visits during the study period were included in the study and we excluded those who were critically ill during the data collection period.

Sample size

The sample size was calculated based on a single population proportion formula assumption. The prevalence of Antenatal depression was 31.2% from a study conducted in Adama, Ethiopia [15], and a 5% margin of error was used. . We have added a non-response rate of 10% and 330*0.10 = 33. Then the final sample size was 330+33 = 363.

Sampling technique and procedure

Stratified sampling was undertaken to select the study of health institutions. All seven public health institutions in Awabale District were included and the sample size was proportionally allocated based on the number of target mothers (Lumame Health Center = 85, Shebila Health Center = 42, Wejele Health Center = 42, Lega Health Center = 43, Yesenbet Health Center = 58, Tsid-Maryam Health Center = 50, Lumame Primary Hospital = 43). All eligible and consenting women attending for antenatal care during the study period were taken into the study consecutively until the sample size was reached.

Study variables

Dependent variable

Depression during pregnancy (present/absent).

Independent variables

Socio-demographic factors

Maternal age, educational status, marital status, occupation of the mother and family, monthly income.

Obstetric factors

Gravidity, gestational age, history of abortion, unplanned pregnancy.

Psycho-social factors

Social support, relationship with a partner, husband support, violence.

Clinical factors

A self-history of depression, family history of depression, history of chronic illness.

Operational definitions

Antenatal depression

It is an illness in which pregnant women have an Edinburgh Postnatal Depression Scale (EPDS) score of 13 and above [20, 21].

Social support

Is support from the community ranges from a score of 3 to 14 according to the OSLO social support scale. A score of 3–8 is poor support, 9–11 is moderate support, and 12–14 is strong support.

Data collection procedure and data quality control

To assure the data quality, data were collected with face-to-face interviews by attained BSc Midwife in each institution after one-day data collection training was given to them together with two MSc holder midwife supervisors. The questionnaire was structured and pre-tested which was first prepared in English and translated to local (Amharic) language and then again translated back to English by language experts. A pretest was conducted on 18 pregnant women of the sample size in Debre-Elias woreda health institution and the necessary correction on the tool was employed accordingly.

Data collection and measurement tool

EPDS was administered to detect symptoms of depression and their socio-demographic data along with obstetric and psychosocial factors. EPDS is a 10 item questionnaire scored from zero up to three (higher score indicating more depressive symptoms), that has been validated for detecting depression in antepartum and postpartum samples in many countries. The instrument was validated in public health centers in Addis Ababa for postpartum use and showed a sensitivity of 84.6% and specificity of 77.0% at the cutoff score of 7/8 [21]. Those pregnant women who score 13 and above were categorized as depressed women while pregnant women who scored below 13 were considered as non-depressed women [20, 21].

The OSLO-3 item social support scale was used to measure social support for pregnant women. Partners feeling on the current pregnancy can be defined as the sensation of pregnant women about the feeling of their partners concerning the current pregnancy. It was measured by asking whether her partner feeling on the current pregnancy was good or poor. Similarly, husband/partner support was assessed by asking women emotions about their partner’s support to the health of the fetus and continuation of pregnancy. A structured Amharic version questioner containing socio-demographic characteristics, obstetric history, and psychosocial history, history of clinical factors, history of violence, and history of substance abuse was administered.

Data analysis technique

EpiData version 3.1 software was used for data entry and SPSS version 20 was used for analysis. Bivariate logistic regression was employed to identify an association between independent and dependent variables. Variables having a P-value of less than 0.2 in the bivariate logistic regression analysis were fitted into the multivariable logistic regression model to manage confounders. The 95% confidence interval of odds ratio was computed and a variable having P-value less than 0.05 in the multivariable logistic regression analysis was considered as statistically significant.

Ethical consideration

The study was approved by the Institutional Health Research Ethics Review Committee of Debre Markos University, College of health science. An official letter was written from Debre Markos University to the selected health institutions. The participants enrolled in the study were informed about the study objectives, expected outcomes, benefits, and the risks associated with it. Written consent was taken from the participants before the interview.

Result

Socio-demographic factors

Three hundred fifty-four study participants gave the response to the questionnaire, giving a response rate of 97.5. %. The majorities of the respondents were Amhara 351 (99.2%) and orthodox by religion were 293 (82.8%). Three hundred thirty-five (94.6%) of the women were married and 150(44.8%) were farmers in their occupation (Table 1).

Table 1

Socio-demographic characteristics of pregnant women attending ANC in Awabale district, East Gojjam zone, Northwest Ethiopia 2018(n = 354).

Variables		Frequency	Percentage
Maternal Age	≤ 19	17	4.8
	20–34	262	74.0
	≥35	75	21.2
Religion	Orthodox Christian	293	82.8
	Muslim	61	17.2
Ethnicity	Amhara	351	99.2
	Oromo	3	0.8
Marital status	Not married	19	5.4
	Married	335	94.6
Educational status of the respondent	Illiterate(Unable to read and write)	170	48.0
	Elementary school (grade 1–8)	91	25.7
	High school and above	93	26.3
Occupation of the respondent	Employed	69	19.5
	Running personal business	60	16.9
	Housewife	225	63.6
Educational status of the husband	Illiterate(Unable to read and write)	187	55.8
	Elementary school (grade 1–8)	57	17.0
	High school and above	91	27.2
Occupation of the husband	Employed	77	23.0
	Running personal business	108	32.2
	Farmer	150	44.8
Residence	Rural	189	53.4
	Urban	165	46.6
Monthly income	≤ 500	45	12.7
	>500	309	87.3

Obstetric and clinical characteristics

Two hundred nine (59%) of the respondents were gravida one and above. Around 58(16.4%) and 9 (2.5%) of the respondents had a previous history of depression and a family history of depression respectively and 38(10.7%) had a history of chronic illness (Table 2).

Table 2

Obstetrics and clinical characteristics of pregnant women attending ANC in Awabale district, East Gojjam zone, Northwest Ethiopia 2018(n = 354).

Variables		Frequency	Percentage
History of previous pregnancy	No	145	41.0
	Yes	209	59.0
Number of pregnancies	Primigravidas	145	41.0
	Multigravida	209	59.0
Previous history of abortion	N0	167	79.9
	Yes	42	20.1
Type of abortion	Spontaneous	37	88.1
	Induced	5	11.9
History of stillbirth	No	186	89.0
	Yes	23	11.0
Is the current pregnancy planned	No	48	13.6
	Yes	306	86.4
Trimester	First trimester	78	22.0
	Second trimester	195	55.1
	Third trimester	81	22.9
Gestational age at first ANC	Before 16 weeks	254	71.8
	After 16 weeks	100	28.2
Previous history of depression	No	296	83.6
	Yes	58	16.4
Family history of a depressive episode	No	345	97.5
	Yes	9	2.5
History of chronic illness	No	316	89.3
	Yes	38	10.7

Psychosocial, history of violence and substance use

More than Three-fourths (77.4%) of the respondents reported their husbands are happy with the occurrence of current pregnancy and a half (50.8%) of women explored good baby father support to the health of the fetus and continuation of pregnancy. Most 33(47.1%) and 249(70.3%) of the participants complained health-related problems were the most frequent emotionally disturbing factor in their lifetime and during the current pregnancy respectively. According to the OSLO social support scale, 112(31.6%) women have poor, 160(45.2%) moderate, and 82(23.2%) strong social support. Seventy-three (20.6%) of women’s had a history of violence in their lifetime (Table 3).

Table 3

Psychosocial, history of violence and substance use of pregnant women attending ANC in Awabale district, East Gojjam zone, Northwest Ethiopia 2018(n = 354).

Variables		Frequency	Percentage%
Husband feeling on the current pregnancy	Happy(Good)	274	77.4
	Not happy(Poor)	80	22.6
Husband support to the health of the fetus and continuation of pregnancy	Very good	148	41.8
	Good	180	50.8
	Not good	26	7.3
Social support(Based on OSLO social support scale)	Poor	112	31.6
	Moderate	160	45.2
	Strong	80	23.2
The emotionally disturbing factor for the last twelve month	No	284	80.2
	Yes	70	19.8
Psychosocial problems addressed at the antenatal clinic	No	29	8.2
	Yes	325	91.8
Enough information about the pregnancy and expected labor at ANC	No	23	6.5
	Yes	331	93.5
History of violence	No	281	79.4
	Yes	73	20.6
Lifetime history of substance use	No	196	55.4
	Yes	158	44.6
History of substance use during the current pregnancy	No	200	56.5
	Yes	154	43.5

Prevalence of antenatal depression

About 63 (17.8%) of respondents had antenatal depressive symptoms (EPDS score ≥13). More than half (57%) of the respondents were able to laugh and see the funny side of things. On the other hand, (58.5%) of pregnant women felt sad or miserable most of the time (Table 4).

Table 4

EPDS measurement of antenatal depression among pregnant women attending ANC in Awabale district, East Gojjam zone, Northwest Ethiopia 2018(n = 354).

Variables		Frequency	Percentage
I have been able to laugh and see the funny side of things:	As much as I always could	203	57.3
	Not quite as much now	110	31.1
	Not so much now	24	6.8
	Not at all	17	4.8
I have look forward with enjoyment to things:	As much as I ever did	204	57.6
	Rather less than I used to	99	28.0
	Less than I used to	28	7.9
	Hardly at all	23	6.5
I have blamed myself unnecessarily when things went wrong:	Yes, most of the time	111	31.4
	Yes, some of the time	103	29.1
	Not very often	128	36.2
	No, never	12	3.4
I have been anxious or worried for no good reason:	No, not at all	133	37.6
	Hardly ever	82	23.2
	Yes, sometimes	125	35.3
	Yes, very often	14	4.0
I have felt scared or panicky for no very good reason:	Yes, quite a lot	88	24.9
	Yes, sometimes	112	31.6
	No, not much	118	33.3
	No, not at all	36	10.2
Things have been getting on top of me:	Yes, most of the time I haven’t been able to cope at all	105	29.7
	Yes, sometimes I haven’t been coping as well as usual	135	38.1
	No, most of the time I have coped quite well	108	30.5
	No, I have been coping	6	1.7
I have been so unhappy that I have had difficulty sleeping:	Yes, most of the time	139	39.3
	Yes, sometimes	118	33.3
	Not very often	68	19.2
	No, not at all	29	8.2
I have felt sad or miserable:	Yes, most of the time	207	58.5
	Yes, quite often	103	29.1
	Not very often	31	8.8
	No, not at all	13	3.7
I have so unhappy that I have been crying	Yes, most of the time	282	79.7
	Yes quite often	53	15
	Only occasionally	18	5.1
	No, never	1	0.3
The thought of harming myself has occurred to me:	Yes, quite often	0	0
	Sometimes	340	96.0
	Hardly ever	12	3.4
	Never	2	0.6

Factors associated with antenatal depression

Educational status of the respondent [COR = 1.68(95% CI: 1.02, 3.45)], occupation of respondents [COR = 0.37 (95% CI: 0.15, 0.91)], occupation of partners [COR = 0.57(5% CI: 0.27, 1.2)], trimester [COR = 2.4(95% CI: 1.30, 4.42)], unplanned pregnancy [COR = 6.85(95% CI: 3.55,13.22)], poor husband support and feelings [COR = 8.21(95% CI: 4.52, 4.91)], history of depression [COR = 4.21(95% CI: 2.26, 7.84)], history of violence [COR = 4.79(95% CI: 2.65, 8.64)], history of substance use in previous pregnancy [COR = 3.02(95% CI: 1.70, 5.36)] and history of substance use in current pregnancy [COR = 2.70(95% CI: 1.54, 4.75)] were significant factors in the bivariate regression analysis (Table 5).

Table 5

Factors associated with antenatal depression among pregnant women attending ANC in Awabale district, East Gojjam zone, Northwest Ethiopia 2018(n = 354).

variables		Depression		COR(95%CI)	AOR(95%CI)
		No	Yes
Occupational status of the respondent	Employed	63	6	0.37 (0.15, 0.91)	0.15(0.001, 0.25)
	Running personal business	49	11	0.87(0.42, 1.81)	0.48(0.07, 3.21)
	Housewife	179	46	1	1
Educational status of the respondent	Illiterate	147	23	1	1
	Elementary school	64	27	1.68(1.02, 3.45)	1.08(0.18, 6.4)
	High school and above	80	13	1.04(0.5, 2.16)	16.23(2.46, 107.27)
Occupational status of the husband	Employed	66	11	0.57(0.27, 1.2)	1.47(0.21, 10.04)
	Running personal business	102	6	0.20(0.81, 0.5)	0.22(0.044, 1.09)
	Farmer	116	34	1	1
Trimester	First	88	10	2.4(1.30, 4.42)	1.90(0.47, 7.74)
	Second	154	41	1	1
	Third	69	12	0.65(0.32, 1.32)	0.87(0.28, 3.69)
Planned pregnancy	No	24	24	6.85(3.55,13.22)	3.06(0.73, 12.87)
	Yes	267	39	1	1
Social support	Poor	81	31	2.40(1.30, 4.42)	1.14(0.28, 4.61)
	Moderate	138	22	1	1
	Strong	72	10	0.87(0.39, 1.94)	0.92(0.24, 3.61)
Husband feeling on the current pregnancy	Good	248	26	1	1
	Poor	43	37	8.21(4.52, 4.91)	4.86(1.74, 13.58)
Previous history of depression	No	256	40	1	1
	Yes	35	23	4.21(2.26, 7.84)	7.26(2.52, 20.93)
History of violence	No	247	34	1	1
	Yes	44	29	4.79(2.65, 8.64)	1.27(0.34, 4.79)
Lifetime history of substance use	No	116	42	1	1
	Yes	175	21	3.02(1.70, 5.36)	1.88(0.73, 4.84)
History of substance use in the current pregnancy	No	114	40	1	1
	Yes	177	23	2.70(1.54, 4.75)	0.09(0.004, 1.82)

In the multivariable regression analysis; occupational status of the respondent [AOR = 0.15(95%CI 0.001–0.25)], women educational status of high school and above[AOR = 16.23(95%CI 2.46–107.27)], poor husband feeling on the current pregnancy[AOR = 4.86(95%CI: 1.74–13.58)] and the previous history of depression [AOR = 7.26(95%CI: 2.52–20.93)] were significant factors for antenatal depression (Table 5).

Discussion

This study aimed to assess the prevalence of depression and associated factors among pregnant women attending antenatal care in public health institutions of Awabale Woreda, East Gojam zone, Amhara National Regional State, Northwestern Ethiopia, during March-April 2018. The study finding of antenatal depression (17.8%) in the current study was in line with similar reports in Bangladesh (18%) and Ethiopia (19.9%) [22, 23]. The finding of this research was lower than the studies done in China (28.5%) [7], 29.9% and 31.2% in Ethiopia [20, 24], 33.8 in Tanzania [16], 38.5% and 47% in South Africa [16, 25]. This difference might be due to the difference in their population demographic characteristics, study design, period, and the difference in their investigatory or diagnostic tools.

Prevalence of antenatal depression was associated with the occupation of the women, educational status, history of depression, and poor husband feeling in the current pregnancy. Women who were running employees were 85% reduced to develop antenatal depression than housewives [AOR = 0.15(0.001–0.25)]. This might be due to that, those who are employees may have social relationships and may have the satisfaction that makes the women economically independent [26]. Also, those housewife women are expending most of their time at home and alone. This loneliness may put them in depression [27].

Women with high school and above educational levels were 18 times more likely to develop antenatal depression than women who had no formal education [16.23(95%CI 2.46–107.27)]. This might be due to their difficulty in managing interpersonal relationship strains related to academic performance pressure and inability to translate their additional education into better mental health outcomes [28]. On the other hand, different studies in different countries report the association of lower educational status with an increased prevalence of antenatal depression [22, 26, 29].

Those women who had a history of depression had 7.26 times the odds of developing antenatal depression than women who had no history of depression [AOR = 7.26(95%CI: 2.52–20.93)]. The comparable association was also reported from studies conducted in developing and developed countries [20]. This might be due to physical and hormonal changes occurring during pregnancy and the recurrence of depressive symptoms [26]. Conversely, the personal history of previous psychiatric illness was not found to be a significant risk factor for antenatal depression in a study conducted in Lahore, Pakistan [30].

Pregnant women who had poor husband feeling on the current pregnancy were 4.86 times more likely to develop antenatal depression as compared with good husband feeling towards current pregnancy [AOR = 4.86(95%CI: 1.74–13.58)]. This is possible because those partners who had good feelings about the pregnancy authorize the women on their home responsibilities and help women to have care for their health and the health of the fetus. It might be also due to the effect of a poor husband’s feeling on diminishing partner support [20].

The finding of this study shows no significant association between partner occupational status, trimester, unplanned pregnancy, social support, history of violence, and substance use in the multivariable model. This result seems consistent with other findings [20, 31]. On the other hand, contrary to this finding, those women who had a history of substance use had a higher risk of developing antenatal depression [16].

Limitations of the study

We cannot be certain that individuals with an EPDS score ≥ of 13 had depressive illness without confirmation. Social desirability bias due to face-to-face interviews and using cross-sectional studies which do not show causality is also the limitation of this study.

Conclusion

The prevalence of antenatal depression in women attending antenatal care services at public health institutions is high. Women’s occupational statuses, educational status, previous history of depression, and poor husband feeling on the current pregnancy were significant factors for antenatal depression.

(DOCX)

Click here for additional data file.

15 Jul 2021

PONE-D-21-01660

Prevalence and Associated Factors of Pregnant Women attending Antenatal Care in Public Health Institutions of Awabale Woreda, Northwestern Ethiopia: a cross-sectional study

PLOS ONE

Dear Dr. Aynalem,

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

The manuscript has been evaluated by three reviewers, and their comments are available below.

The reviewers have raised a number of major concerns. They particularly note the need for greater detail and clarity in the manuscript’s reporting of the data collection and analyses. They specifically request further detail on the development and validation of the study instruments and further refinement in the statistical modelling. In addition, they note that greater depth of discussion is required with regards to prior literature, in both the introduction and discussion. They also noted the need for professional language assistance, which may help to address the aforementioned issues.

Please submit your revised manuscript by Aug 23 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,

Avanti Dey, PhD

Staff Editor

PLOS ONE

Journal Requirements:

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

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

and

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

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: Partly

Reviewer #2: No

Reviewer #3: No

**********

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

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

**********

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

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

Reviewer #1: 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: No

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: Thank you very much for your interest in antenatal depression.

1. While the study appears to be sound and a very important study area, the authors have, however, failed to address how their findings relate to previous research in this area. A lot of work has been done especially in Ethiopia regarding antenatal depression to the extent that there are three recent systematic literature reviews [Ayano et al (2019), Getinet et al (2018), Zegeye et al (2018)]. The published work such as by Hanlon et al and Bitew et al has laid the foundation in this area of study. In the southern region of Africa, work by Honikman et al, Ng'oma et al, Stewart et al and Kaiyo et al also highlight the magnitude of the burden of antenatal depression. Could the authors align their introduction and discussion to reference such existing literature? The introduction should also highlight why the authors think that antenatal depression is a "serious health problem", and they should also bring out the known "negative consequences for the mother, fetus and the entire family" so as to convince the reader that surely there is need to tackle antenatal depression.

2. Kindly state your eligibility criteria that you used during sampling procedure and clearly explain why it was important to include those women and exclude the ones that were not eligible. The authors need to clearly explain the type of health institutions that are in their study area and why they had to use stratified sampling method to sample the health institutions. How many health facilities are in this region and how many did they use as study sites? How did they sample their participants from each study health facility? The study sample size was 363 but, in the end, they interviewed 354 participants. Does that mean there were no more eligible participants at the study sites? Considering this was a cross-sectional study, I am not sure why they could not reach the required minimum number of participants.

3. To save on repeating themselves, the authors could just have combined STUDY VARIABLES, OPERATIONAL DEFINITIONS & MEASUREMENT TOOLS into one subheading eg STUDY MEASURES and define their terms. For example:

Independent Variable

Antenatal depression, defined as an illness in which pregnant women have an EPDS score of 13 and above, was assessed using the EPDS... then go on to describe the tool.

Same applies to the other variables.

4. Were the study instruments validated for the specific population? The authors mention that the EPDS was validated in Addis Ababa and at a cut-off score of 7/8, it had a sensitivity of 84.6% and specificity of 77.0%. But they went on to use a cut off score of 13 to define their depression caseness. Can the authors please justify their cut off score? Please explain more about the OSLO-3 item social support scale. The authors should also explain the data collection procedures simply and clearly so that the reader can be able to picture what they did exactly. This also helps with reproducibility of their work. As it is, it is not clear how they collected their data.

5. The authors' statistical analyses are very vague. While they have explained how the associations between antenatal depression and the independent variables was identified, they did not explain how their study sample would be described. Descriptive statistics would be very important to describe the sample. The results show that frequencies (and percentages) were computed but this was not stated in their data analysis technique. What were the confounding variables that the authors considered in their multivariate analysis? And how did they come up with the confounders?

6. In the results section, kindly label the tables clearly, and clearly reference your tables in the text. Do not just put tables that have no link to the text. The authors should also explain their results for the reader to clearly follow their arguments. This is particularly about the section headed "Factors associated with antenatal depression"; the following sentence "Age, marital status.... .... ... were significant factors in the bivariate regression analysis". it would be helpful to put in the odd ratios, 95%CI and p values next to the factors eh "Age [COR (95%CI), p value], marital status [COR (95%CI), p value], ... ... ..were significant factors". It would be helpful also to mention the direction of the association. For example, Pregnant women aged below 16 were X times more likely to develop antenatal depression or whatever your results show. Please insert the table that shows the results of the bivariate logistic regression analysis.

7. Like mentioned before, please align your discussion to the previous research done especially in sub-Saharan region. There is also more recent work on this subject you could cite. The authors have highlighted their weaknesses, there is need to show that the study had some strengths well. Otherwise, why would it be worthwhile. Another weakness they can highlight is their study design - cross sectional studies do not show causality and also the social desirable bias due to face to face interviews they administered. With these results, what do the authors recommend to policy makers, researchers, and practitioners. What is their take home message?

8. The study is very important, but the language is unclear. The sentences are too long, winding and thus difficult to understand. I advise the authors to work with a copy editor to improve the flow and readability of the manuscript.

Reviewer #2: Thank you authors for conducting this study. It is timely and important. Here are my comments

1. Revise the title including the topic of study

2. Considering the sample size, high volume of published information on the topic so far in Ethiopia using the dichotomous EDPDS, and most importantly the nature of your outcome variable which is latent variable, I strongly recommend making re-analysis using structural equation modeling and re-write the manuscript in such way. You can use stress-process model or other theoretical model to conceptualize the problem.

Reviewer #3: Dear the authors, thank you for presenting a critical public health issue in the developing countries. This study may be important for the local health planners and researchers.

However, there are plenty of studies in the topic area in the world as well as in Ethiopia. Your paper do not bring any new evidence to the scientific world. I have doubt the relevance of your study considering enough evidence of your topic title in your country. The paper lacks strong justification of the reasons of conducting the study topic in the area

The variables under your study were limited(important variables were missed in your study) and it is difficult to reach conclusion without including all the relevant confounding variables.

From the scientific perspective your study lacks many qualities; e.g. you have large confidence interval which this may be due to inadequate sample size, Data itself is not consistent, or you have outliers in the data, or you have poorly specified model, or you have (partial) collinearity between the variables.

There are a lot of inconsistencies in your study data presentation. e.g in the abstract section you have mentioned women who were running their business were 0.015 times less likely of developing antenatal depression than housewives [AOR=0.015(0.001-0.236)]. however in result section Women who were running their business were 85% reduced to develop antenatal depression than housewives [AOR=0.15(0.001-0.25)]. Moreover, what is found in the abstract, result section are completely different from what is found in the tables. Please see the regression analysis table and description carefully and revise.

more specifically

your study topic lacks the outcome under the study: please revise

Abstract section:

if you add sample size, the study population, analysis run to identify the associated factors and the cut off score

Large confidence interval

Introduction section

The gap for studying this title is not adequately mentioned

There are abundant studies in Ethiopia. this study did not bring any new evidence

the severity, the impact in the study area was not mentioned well

Method section

You have stated stratified sampling as your sampling techniques, so how is all pregnant woman during the study period included in your study?

you have taken the proportion from the study done in Adama. Is Adama and Awabale woreda has the same characteristics in terms of population, health care services, etc.... ?

you have used consecutive sampling(non-probability): I would rather use random sampling(e.g systematic sampling) for generalizability issue. If you have used stratified sampling why did you use consecutive sampling at the end?

what is the reliability score of your tool in your study?

You have mentioned the tool was validated in Ethiopia on postpartum depression. what about antepartum use?

your study was on antenatal depression

How didi you measure the fitness of the model?

how did you measure the strength of association?

Result section

be consistent in the description.

Discussion section

The justification for the difference in the prevalence is not based on your findings, realistic and scientific.

Even you have used two Ethiopian studies for comparison. one is higher and another is lower than your finding. this needs justification

most of the reasons for justification are shallow

Limitations of the study

The EPDS measurement tool is a measurement scale, not a diagnostic tool.....This can't be the limitation. as your objective is not to diagnose the patient

Reference

References were not written to the journal standard

Tables

What is your base to classify rural - urban

Monthly income: the categorization of income seems arbitrary

Only 5 respondents had induced abortion . How did you fit type of abortion variable (the cell count 5) in your regression analysis?

what is the question asked to measure family history of a depressive episode

how does the participants knows depressive episode?

What is the question asked to measure History of chronic illness

how does the participants knows chronic illness? what are the types?

**********

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

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

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

Reviewer #1: Yes: Malinda Kaiyo-Utete

Reviewer #2: Yes: Abel Dadi

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.

17 Jul 2021

thank you for your constructive comments

Submitted filename: Response to reviewers.docx

Click here for additional data file.

31 Aug 2021

PONE-D-21-01660R1

Prevalence of Depression and Associated Factors among Pregnant Women Attending Antenatal Care in Public Health Institutions of Awabale Woreda, East Gojjam Zone, Northwestern Ethiopia: a cross-sectional study

PLOS ONE

Dear Dr. Aynalem,

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 15 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,

Jianguo Wang, PhD

Academic Editor

PLOS ONE

Journal Requirements:

Additional Editor Comments (if provided):

Please carefully address the comments and improve the quality of this manuscript. Most of all is to clearly hightlight the importance or novelty of this research.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: (No Response)

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 #1: Partly

Reviewer #2: (No Response)

Reviewer #3: No

**********

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

Reviewer #1: No

Reviewer #2: (No Response)

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 #1: No

Reviewer #2: (No Response)

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 #1: Yes

Reviewer #2: (No Response)

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 #1: This has improved very much from the previous version. However, the authors still have not addressed the issue of the importance of their work. What have they done differently considering that a lot of work has already been done in Ethiopia. Could they please provide a sound justification for their work?

The methodology section still needs to be revised. There is a lot of repetition.

I suggest the authors send their work to a professional editor.

Reviewer #2: My comments have not been well addressed. There has been a lot of studies on this area so far and I do not think this study brought new evidence that has not been known.

Reviewer #3: Dear authors thank you for presenting important public health problem.

I have forwarded comments and questions in the first review. I don't see much improvement from the first version.

Please go through each comments and questions one by one and respond appropriately.

Please find attached the comments and questions.

Thank you

**********

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

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

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

Reviewer #1: Yes: Malinda Kaiyo-Utete

Reviewer #2: Yes: Abel Dadi

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.

Submitted filename: PONE-D-21-01660_R1_MKU.pdf

Click here for additional data file.

Submitted filename: Comments and questions PONE-D-21-01660_R1.pdf

Click here for additional data file.

1 Sep 2021

Thank you for all of your constructive comments

Submitted filename: response to reviewers.docx

Click here for additional data file.

30 Sep 2021

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

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

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

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Jianguo Wang, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Please carefully address each comment raised by reviewers and improve the quality of manuscript.

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: (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 #1: Partly

Reviewer #3: Partly

**********

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

Reviewer #1: Yes

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 #1: 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 #1: No

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 #1: The authors have not addressed some of the issues raised in the previous review. For example, they state that there is paucity of data on antenatal depression in Ethiopia, yet there is a lot of work published from 2006 (Hanlon et al) to 2021 - a list of these articles have been provided in the attachment.

Their participants were aged between 15-49 years of age. Participants below 18 would ethically require an assent and parental consent to participate in research. However, in their manuscript, the authors do not show how this was obtained. Could they have considered such women as emancipated adults. If so, they should provide reference.

There are so many grammatical and spelling errors. Could the authors consider proof reading (maybe use of a professional editor) to correct these.

Their methodological section is not flowing smoothly. They have repeated a lot of things unnecessarily.

Their referencing style should be consistent with the journal's requirements.

Please find attached comments to the article

Reviewer #3: Dear authors,

Though there are changes from the previous draft, most of my comments and questions are not addressed well.

Please go through each questions and comments and respond

**********

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

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

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

Reviewer #1: No

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.

Submitted filename: PONE-D-21-01660_R2_MKU.pdf

Click here for additional data file.

1 Oct 2021

thank you for your constructive comments and suggestions. you teach me a lot

Submitted filename: response to reviewers.docx

Click here for additional data file.

29 Nov 2021

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

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

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

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Jianguo Wang, PhD

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: (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 #3: Partly

**********

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: Dear authors, thank you for revising the manuscript. There are some changes from the previous drafts.

kindly find some of the remining 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 #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.

Submitted filename: PONE-D-21-01660_R3.pdf

Click here for additional data file.

1 Dec 2021

Dear reviewer #3 thank you for your constructive comments and suggestions. Here are some responses to raised issues.

1. I still has concern on wide confidence interval. the authors should explain this "

�  Like other variables, [AOR18.15 (2.73-120.76)] is gained from the analysis process of the data. This may be due to different reasons like small sample size or inappropriate responses of the study participants

2. Significant percentages of your study participants had low levels of educational status. so, how could they know whether their previous diagnosis was depression or other mental health problems. this is ambiguous unless the medical record of the study respondents reviewed

�  They got the information from their health care providers who diagnosed them.

3. if all pregnant women in the study period included in your study, you have used consecutive sampling technique which is not a probability sampling technique. in that sense it is difficult to generalize your finding. I expect randomization for generalize

�  We were talking about the study population here. But we can use consecutive sampling techniques in special cases like busy work areas.

4. I really don't see the importance of this.

�  The Federal Democratic Republic of Ethiopia's National Mental Health Strategy promotes a decentralized approach in mental health services from local health institutions up to tertiary hospitals but service is not being given as expected. So this is important to get brief information about the prevalence and factors of depression during pregnancy.

5. Please put the reliability of EPDS and Oslo social support scales in your study (cronbatch alpha result)

�  This tool is a validated tool so putting the reliability of the validated tool may not have a value.

6. better to mention some variables were assessed using yes or no response which might not reflect the.....

�  Since we asked yes/no questions, we are not sure they were giving true (diagnosed responses), so we cannot mention the variables that were not confirmed

Submitted filename: response to reviewers.docx

Click here for additional data file.

4 Feb 2022

I hope that efforts should be made to improve the quality of this manuscript.

Please submit your revised manuscript by Mar 21 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

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

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

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

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

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

We look forward to receiving your revised manuscript.

Kind regards,

Jianguo Wang, PhD

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 #1: (No Response)

**********

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

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

Reviewer #1: Partly

**********

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

Reviewer #1: 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 #1: No

**********

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

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

Reviewer #1: No

**********

6. Review Comments to the Author

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

Reviewer #1: Review of the Manuscript: PONE-D-21-01660_R4

“Prevalence of Depression and Associated Factors among Pregnant Women Attending Antenatal Care in Public Health Institutions of Awabale Woreda, East Gojjam Zone, Northwestern Ethiopia: a cross-sectional study”

The manuscript reads much better compared to the previous versions. However, I still have some issues with the manuscript.

Introduction

The authors are still to address the issue of the rationale for their study. As I mentioned previously, a lot of work on antenatal depression has been done in Ethiopia since 2009 (Hanlon et al., 2009; Hanlon et al., 2010). Recently, three systematic literature reviews have been published summarizing the burden of antenatal depression in Ethiopia (Dadi et al., 2020; Gertinet Ayano, 2019; Zegeye et al., 2018). So, please explain what your study is adding to the body of knowledge.

The authors have stated that “The majority of studies on the prevalence of antenatal depression and associated factors have been conducted in developed countries”. However, there has been a lot of work that has been done in developing countries, particular in African countries (M. Kaiyo-Utete & T. Magwali, 2020; MacGinty et al., 2020; Redinger, 2018; Stewart et al., 2014; van der Westhuizen et al., 2018; van Heyningen et al., 2018; Weobong et al., 2014) to mention but a few. Please refer to such studies for your introduction to be more convincing.

The authors mention that “There are studies undertaken on antenatal depression” as a limitation of the studies that were done in low-income countries. Their study is on antenatal depression so how can this be a limitation. Can they please revise their limitations?

Methods and Results

Can the authors please detail how they came up with their sample size?

EPDS is a screening tool hence the pregnant women will have depressive symptoms, not depression.

The authors should revise their statement “About 63 (17.8%) had antenatal depression.”

What do the authors mean by “Two hundred nine (59%) of respondents had a history of pregnancy”? Is it that they were multipara? Please use the correct medical terminology.

The authors could summarise the results of bivariate regression in a table and show the odds ratios (95%:CI; p value) to show the variables that were associated with antenatal depression. The narration “Age, marital status, educational status of the respondent, occupation of respondents and partners, history of abortion and stillbirth, trimester, unplanned pregnancy week at first ANC, poor husband support and feelings, social support, emotionally disturbing factors, history of depression, history of violence and substance use were significant factors in the bivariate regression analysis” is bare of the statistics.

**********

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

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

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

Reviewer #1: No

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

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

4 Feb 2022

Dear reviewer#1 and editors I would like to forward my heart felt gratitude for your comments and time you spent on this paper. Here are point by point responses for your questions you raised.

Please explain what your study is adding to the body of knowledge.

The studies you mentioned as they were done in Ethiopia were done before 11 years so that there may be possible population and environmental change. Again even though there are some current studies in Ethiopia, no study done in study done in the study area which is different in economic and socio-cultural aspect.

Please refer to such studies for your introduction to be more convincing

Corrected

Can they please revise their limitations?

Corrected

Can the authors please detail how they came up with their sample size?

Corrected

The sample size was calculated based on a single population proportion formula assumption. The prevalence of Antenatal depression was 31.2 % from a study conducted in in Adama, Ethiopia [15] and a 5% margin of error was used. initialsamplesize =〖(Z a/2)〗^2*(p(1-p))/w2=〖1.96〗^2*0.312(1-0.312)/((〖0.05)〗^2 )=330. We have added a non-response rate of 10% and 330*0.10=33. Then the final sample size was 330+33=363.

EPDS is a screening tool hence the pregnant women will have depressive symptoms, not depression.

The authors should revise their statement “About 63 (17.8%) had antenatal depression.”

Corrected

What do the authors mean by “Two hundred nine (59%) of respondents had a history of pregnancy”? Is it that they were multipara? Please use the correct medical terminology.

Corrected

Bare of the statistics

Corrected

Submitted filename: Response to the reviewer.docx

Click here for additional data file.

4 Apr 2022

5 Apr 2022

Dear reviewers, thank you for your time you spent on this manuscript and your constructive comments you provided. Here below, we have provided response to your question.

1. We have checked the references and we got an error on reference number 8 and 19.

2. Based on your suggestion we corrected the reference number 8, but the reference number 19 is the annual report of the district which is not published. so, it will be better if you use as a direct reference.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

11 Jul 2022

Prevalence of Depression and Associated Factors among Pregnant Women Attending Antenatal Care in Public Health Institutions of Awabale Woreda, East Gojjam Zone, Northwestern Ethiopia: a cross-sectional study

PONE-D-21-01660R6

Dear Dr. Aynalem,

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

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

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Jianguo Wang, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Please check your English and presentation before final submission. 'Pregnant women had high school and above educational level 18 times higher odds of developing antenatal depression than women who had no formal education' is a little confusing statement.

Reviewers' comments:

5 Oct 2022

PONE-D-21-01660R6

Prevalence of Depression and Associated Factors among Pregnant Women Attending Antenatal Care in Public Health Institutions of Awabale Woreda, East Gojjam Zone, Northwestern Ethiopia: a cross-sectional study

Dear Dr. Aynalem:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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

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

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Jianguo Wang

Academic Editor

PLOS ONE