Title: Pregnant women’s perception of midwifery-led continuity care model in Ethiopia: A
qualitative study
Version: 3 Date: 08 May 2023
Reviewer:  Lyn Ebert
Reviewer's report:
Thank you for this piece of work. It is much clear to read. I have some extensive editing /grammar
that requires addressing . Apart form that is reads well now. See below for editing and comments.
Response:
Under Abstract
Line 25 should read. Background: A Midwifery-led continuity care…
Line 27 should read. Evidence shows that a midwifery-led….
Line 31 should read. Experience of a MLCC…
Lines 38-44 should read. Results: Thematic analysis revealed that women want a continuity of
care model. Four themes emerged. Three were specific to women’s improved care. That is, (1)
improved continuum of care, (2) improved woman-centred care, and (3) improved satisfaction
of care. Theme four (4), barrier to implementation, was concerned with possible barriers to
implementation of the model.
Line 47 should read. … Woman-centred care…
Under Background
Line 55 should read… A midwifery-led continuity care model…
Line 59 should read… woman-centred care…
Line 60 should read. A midwifery-led continuity care model…
Lines 73-74 should read. Ethiopia shared the highest burden of maternal and neonatal mortality,
with 412 per 100,000 live births and 30 per 1000 live births respectively…
Line 74-76 should read. In Ethiopia, maternity care is affected by fragmentation in the patient
care process, and unnecessary medical intervention. Fragmentation of care results in pregnant
women interfacing with…
Under Study approach and selection of study participants
Lines 101-102 should read… Twenty-three pregnant women…
Line 105 should read. Had similar characteristics such as ..age, gravidity, and educational
background…
Lines 106-1114 should read. The following questions were used as a guide; 1) what is your
experience and perception of maternity care in this hospital? 2) Could you please elaborate
particularly related to continuum of care (i.e. antenatal follow-up, childbirth and postnatal care
service provision? 3) How do you see receiving healthcare service by one or a team of healthcare
professionals particularly (midwives) from pregnancy follow-up up to the postpartum period?
4) Could you tell me more about the advantages and disadvantages of receiving healthcare by
one or a team of healthcare professionals? 5) What are the barriers and facilitates of developing
and implementing midwifery-led continuity care in this hospital?
Under Data collection procedure
Lines 124-125 should read. The in-depth interview was conducted in a place that was convenient
for participants, and where minimum sound disturbance occurred. Line 129 should read.
Conducted the in-depth interviews. The data collectors had experience in qualitative…
Line 131 should read. Three FGDs with 7, 8, and 8 pregnant women…
Line 132-134 should read. The FGDs were conducted in a calm room with minimum sound
disturbance and lasted 50 minutes to one hour.
Under Data analysis
Line 140 should read. …first step was familiarisation of the data through repeated…
Lines 141-145 should read. The next step involves generating initial codes, which helps to
organize data at a specific level. The third step is searching for themes through an examination
of the coded and collected data extracts. Fourth step includes reviewing of themes to ascertain
that each coded data fits properly. The fifth step involves defining and naming each theme and
finally, writing up the final analysis and description of findings.
Lines 148-149. The following sentence is not complete - The translated transcription documents
were imported into. Into what????
Under results
Line 196 should read. Theme 2. Improved woman-centred care
Comment - Please refer to the concept woman-centred care. The word is woman, not women.
Please ensure you use the correct spelling for the International Confederation of Midwives
(ICM) definition and concept ”woman-centred care’.
Line 197 should read. Woman-centred care…
Comment - Again, read your own reference [18]  - Brady S, Lee N, Gibbons K, Bogossian F.
Woman-centred care: An integrative review of the empirical literature. Int J Nurs Stud [Internet].
2019;94:107–19. Available from: https://doi.org/10.1016/j.ijnurstu.2019.01.001. Note they use
the spelling woman.
Lines 200-201 should read. … Midwife-woman relationships are central to the provision of
woman-centred care.
Line 203 should read. … build a friendly midwife-woman
Lines206-208 should read. The finding of this study revealed that receiving care from the same
healthcare providers encourage women to ask about any changes during pregnancy and further
helps them to have more awareness about the changes that occurred during pregnancy.
Lines 225-226 should read. Subtheme 2.3.  Build trustful woman–midwife relationships
It is crucial that the relationship between a midwife and a woman is essential for a positive
Lines 235-236 should read. On the other hand, midwifery-led continuity care builds trust
between the midwife and the pregnant woman, increasing the woman’s confidence in her ability
to birth and reducing her fear.
Lines 243-244 should read. This finding demonstrated that receiving care from the same
healthcare worker improves consistency of information, enabling women to have  and increased
sense of choice about…
Comment – having the same health care worker does not increase informed choice unless you
can be sure the health care worker provides all the evidence and options of care in a manner that
allows the women to make her choice.
Lines 254-257 should read. In this subtheme, study participants highlighted midwife counselling
regarding daily intake of iron and folic acid supplementation, avoidance of unsubscribed drug
intake during the early phase of pregnancy, and unnecessary medical interventions increased
their satisfaction of care provided.
Lines 284 should read - woman.
Comment Only – This refers back to your earlier comment about  having continuity allows
informed choice.  I note here that it clearly reveals this is not the case – In lines 292-294, you
write: “A handful of study participants stated that they prefer to receive care from different
healthcare providers as there are variations in the level of knowledge and skill between
healthcare providers”.   Therefore not all healthcare workers give the same information so how
can we ensure the women get best evidence to make informed choices. That is your next great
piece of work.
Under discussion
Lines 301-302 should read. The current qualitative study aimed to explore pregnant womens
perceptions and experience of midwifery-led continuity care in Ethiopia.
Comment - Under Study approach and selection of study participants, around Lines 93-99, you
need to include information as to whether the participants were receiving continuity of care
because under the discussion section you say, “This study showed that the majority of pregnant
women have received adequate health counselling and promotion during their antenatal visits
which enhance their awareness regarding changes during pregnancy and reduce their fear of
childbirth”
This indicates these women were satisfied with their current model of care. What is their current
model of care? and if it is standard or fragmented care then you are saying they are satisfied with
this model of care. Do you mean…“This study showed that the majority of pregnant women
want to have a model of care that can ensure adequate and individualised health counselling
and promotion during their antenatal visits which enhances their awareness regarding changes
during pregnancy and reduces their fear of childbirth”
Lines 317-318 should read. Our study shows that women who had the experience of receiving
care from a known midwife had reduced fear of asking questions and more importantly reduced
worries and stress.
Lines 320-323 should read. A possible explanation might be that, a positive woman-midwife
relationship positively affects the woman’s childbirth experience.
Line 324 should read. …improves woman centred care and builds a trusting woman-midwife
relationship…
Line 328 should read. …easily recognized women’s social, emotional, physical…
Lines 329-230 should read. midwifery-led care can improve woman-centred care including the
needs of the baby, the woman’s family, and the community.
Line 331 should read. In this study, according to women’s experiences, midwife…
Line 334 should read. received midwifery-led care had a higher rate of satisfaction…
Line 336 should read. studies conducted in Pakistan and China reported the women were
satisfied with…
Lines 337-339 should read. 31]. A possible justification for this finding might be that receiving
care from a known midwife can reduce waiting time in the clinic; enhance the emotional support
for women, thus increasing satisfaction with care.
Line 340 should read. … addresses the individual woman’s needs like…
Line 349 should read. … replaces those midwives who are not available at the workplace due
to various reasons.
Lines 350- 352 should read. Moreover, the occurrence of differences in opinions and /or
preferred care options between the allocated midwife and woman can be a barrier. The absence
of adequate healthcare workers (midwives) for pregnant women is also mentioned as a barrier
to implementing midwifery-led maternity service.
Under strengths and Limitations
Line360 should read. … This study also identified….
Lines 364-366 should read. In addition, data were translated from Amharic language to English
language. While English language experts supported the authors o minimize the bias, some
meaning may have been lost in translation.
Under Conclusion
Lines 379-381 should read. … The government should support a larger study to explore
the possible barriers to implementing a midwifery-led continuity care model across different
settings. Based on the findings from this study, we can conclude that…
Thank you.