Title: Factors associated with respectful maternity care reported by patients in selected health
facilities in Musanze District, Rwanda: A facility-based cross-sectional study
Version: 4 Date: 31 Mar 2025
Reviewer's report:
Comment of the Paper: Major Revision Required
Strengths of the Paper:
Relevant Topic: The study focuses on Respectful Maternity Care (RMC), a crucial aspect of
maternal health, and addresses a research gap in Rwanda.
Well-Defined Objectives: The study aims to determine the prevalence and associated factors of
RMC, which is clearly outlined.
Use of a Validated Tool: The study employs the Person-Centered Maternity Care (PCMC) Scale,
a well-established tool for assessing RMC.
Ethical Considerations: Ethical clearance from multiple institutions enhances the credibility of
the study.
Major Issues Requiring Revision:
1. Methodological Concerns:
Study Design and Justification:
The cross-sectional design limits causal inferences, which should be acknowledged in the
discussion.
The study mentions that Jhpiego supports three districts, but the reason for purposively selecting
Musanze District over others is unclear.
Sampling and Representativeness:
The study randomly selected health centers, but there is no explanation of whether all facilities
provided equal access to services. Some women may have chosen specific facilities due to better
perceived care, introducing selection bias.
The study claims simple random sampling, but postpartum women were recruited on a first-
come, first-served basis, which does not strictly adhere to a random selection method.
Definition of RMC and Categorization:
The dichotomization of RMC (i.e., considering RMC as received only if women responded
positively to all 30 items) is a very rigid criterion. Women may still experience some level of
RMC even if they did not receive it at every moment.
Statistical Analysis:
The authors used logistic regression, but the choice of cut-off p-value (p<0.1) for bivariate
analysis before inclusion in multivariable models is unconventional.
Multicollinearity between independent variables (e.g., employment, insurance type, and
socioeconomic status) is not addressed.
2. Interpretation of Findings:
Employment and RMC: The finding that employed women had 17.75 times higher odds of
receiving RMC is unrealistically high. This suggests possible confounding or an issue in data
analysis.
Place of Delivery and RMC: The conclusion that health centers provide better RMC than
hospitals should be explored more. Possible explanations, such as staff-patient ratio, facility
policies, or workload differences, should be included.
Cesarean Delivery and RMC: The study suggests that C-section deliveries were more likely to
receive RMC—but why? Were these women given more attention due to their post-operative
condition? This needs discussion.
3. Language and Structural Issues:
Grammar and Sentence Clarity: Several sentences are long, unclear, or grammatically incorrect.
For example:
"We found the prevalence of respectful maternity care to be 65.1% (95%CI: 59.7-70.2)."
Suggestion: "The prevalence of respectful maternity care was 65.1% (95% CI: 59.7–70.2).”
"Observations were that components of RMC were not comprehensively provided due shortage
of staff and limited supervision."
Suggestion: "Some components of RMC were not fully provided due to staff shortages and
limited supervision."
Redundant Phrasing: Some sentences could be more concise. For example:
"Women delivering at health centers had higher odds of receiving RMC compared to those
delivering at hospitals [AOR=3.72, 95%CI:1.41-9.83, p-value=0.008]."
Could be simplified to: "Women who delivered at health centers were more likely to receive
RMC than those who delivered in hospitals [AOR=3.72, 95% CI: 1.41–9.83, p = 0.008]."