Integrated malaria service delivery and its determinants among pregnant women in Ethiopia: Multi level analysis of 2021/22 National Service Provision Assessment Survey.

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Learn more: PMC Disclaimer | PMC Copyright Notice PLoS One . 2026 Apr 15;21(4):e0346831. doi: 10.1371/journal.pone.0346831 Search in PMC Search in PubMed View in NLM Catalog Add to search Integrated malaria service delivery and its determinants among pregnant women in Ethiopia: Multi level analysis of 2021/22 National Service Provision Assessment Survey Kassawmar Angaw Bogale Kassawmar Angaw Bogale 1 Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia Conceptualization, Formal analysis, Methodology, Writing – original draft Find articles by Kassawmar Angaw Bogale 1, * , Kassahun Alemu Kassahun Alemu 2 Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia Supervision, Validation, Writing – review & editing Find articles by Kassahun Alemu 2 , Kindie Fentahun Muchie Kindie Fentahun Muchie 1 Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia 3 Department for Infectious Disease and Tropical Medicine, University Hospital Heidelberg, Heidelberg, Germany Conceptualization, Methodology, Software, Validation, Writing – review & editing Find articles by Kindie Fentahun Muchie 1, 3 , Mulusew Andualem Asemahagn Mulusew Andualem Asemahagn 4 Department of internal medicine, School of Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia Methodology, Supervision, Writing – review & editing Find articles by Mulusew Andualem Asemahagn 4 , Hailemariam Awoke Engedaw Hailemariam Awoke Engedaw 5 Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia Supervision, Visualization, Writing – review & editing Find articles by Hailemariam Awoke Engedaw 5 , Muluken Azage Yenesew Muluken Azage Yenesew 6 Department of Health system and health Economics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia Methodology, Software, Writing – review & editing Find articles by Muluken Azage Yenesew 6 Editor: Khin Thet Wai 7 Author information Article notes Copyright and License information 1 Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia 2 Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia 3 Department for Infectious Disease and Tropical Medicine, University Hospital Heidelberg, Heidelberg, Germany 4 Department of internal medicine, School of Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia 5 Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia 6 Department of Health system and health Economics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia 7 Freelance Consultant, Myanmar, MYANMAR ✉ * E-mail: [email protected] Competing Interests: The authors have declared that no competing interests exist. Roles Kassawmar Angaw Bogale : Conceptualization, Formal analysis, Methodology, Writing – original draft Kassahun Alemu : Supervision, Validation, Writing – review & editing Kindie Fentahun Muchie : Conceptualization, Methodology, Software, Validation, Writing – review & editing Mulusew Andualem Asemahagn : Methodology, Supervision, Writing – review & editing Hailemariam Awoke Engedaw : Supervision, Visualization, Writing – review & editing Muluken Azage Yenesew : Methodology, Software, Writing – review & editing Khin Thet Wai : Editor Received 2025 Jul 19; Accepted 2026 Mar 24; Collection date 2026. © 2026 Bogale et al This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice PMCID: PMC13082725  PMID: 41984977 Abstract Background Malaria in pregnancy poses significant health risks to mothers and their, fetuses, and newborns children in Tropical and subtropical countries including Ethiopia. The delivery of integrating essential malaria services into routine antenatal care is crucial for effective prevention and control. However, evidence on the extent and determinants of this integration in Ethiopia remains limited. Objective This study aimed to assess the delivery of integrated malaria services during ANC visit and its determinants among pregnant women in Ethiopia. Methods We conducted a secondary analysis of the Ethiopia Service Provision Assessment Survey 2021/22, a nationally representative cross‑sectional study. The final sample included 4273 pregnant women nested across 662 health facilities. Factors were identified based on the WHO Malaria in Pregnancy framework. Multilevel logistic regression models were applied to identify significant factors influencing integrated service uptake. Result Only 7.9% of pregnant women attended ANC visits where all components of integrated malaria services were delivered concurrently, with substantial regional disparities. At the client level, women with two previous pregnancies (AOR = 1.67, 95% CI: 1.06–2.62), attending three or more ANC visits (AOR = 1.58, 95% CI: 1.04–2.40) and client who received an Insecticide-Treated Net during ANC (AOR = 2.81, 95% CI: 1.29–6.12) were more likely to attend ANC visits in which integrated malaria services were delivered. Furthermore, clients attending facilities with malaria-trained providers were more likely to receive integrated malaria services during ANC than those attending facilities without such training (AOR = 4.24, 95% CI: 1.80–10.00). Rural facility attendance was also positively associated with integrated malaria service delivery compared with urban facility attendance (AOR = 2.73, 95% CI: 1.04–7.19). Conclusion Integrated malaria service delivery during ANC remains unacceptably low in Ethiopia, constrained by regional disparities and multilevel factors. Strengthen continuity of ANC follow up, updating policy on ITN distribution, strengthening providers’ capacity, and addressing geographic disparities to accelerate progress toward WHO maternal health targets. Background Malaria infection during pregnancy (MiP) continues to be a significant global public health concern, particularly in sub-Saharan Africa, Southeast Asia, and parts of Latin America. Its prevalence in sub-Saharan Africa is as high as 60%, with placental malaria affecting up to 28% of cases [ 1 , 2 ]. MiP poses a serious threat to the health of mothers, fetuses, and newborns ranging from asymptomatic cases to severe anemia and maternal death. Physiological changes during pregnancy increase vulnerability to malaria, leading to unique challenges and severe health risks [ 3 , 4 ]. Clinical manifestations in pregnant women include joint pain, fever, headaches, fatigue, nausea, and anemia, with complications varying across trimesters [ 3 , 5 ]. Beyond maternal health, MiP contributes to unfavorable birth outcomes, including miscarriage, premature delivery, and neonatal death. It can impair placental development and function, leading to poor fetal growth, intrauterine growth restriction, and long-term infant health problems. Even in areas with low-to-moderate transmission, MiP contributes significantly to adverse outcomes including stillbirth, neonatal death, and placental insufficiency [ 4 , 6 , 7 ]. The burden of MiP is further exacerbated by socioeconomic barriers, delayed care-seeking, and limited access to integrated healthcare services delivery. Inadequate diagnosis and mismanagement of malaria cases, along with provider limitations in counseling and clinical skills, compound the challenges in effectively delivering MiP services [ 8 ]. For instance in Sub-Saharan Africa where the high malaria burden and inadequate malaria service during pregnancy reported that Low birth weight (LBW) related to malaria infection during pregnancy was accounted 35% of live births and 11% of neonatal mortality [ 2 ]. Ethiopia, home to over 132 million people, remains malaria-endemic, with 75% of its landmass conducive to transmission and an estimated 70% of pregnant women at risk [ 9 ]. The country aims to eliminate malaria among this group by 2030. While national malaria control efforts achieved substantial progress between 2000 and 2019, recent data indicate that malaria became a major public health problem for pregnant women [ 5 , 10 – 12 ]. Integration of malaria services delivery within antenatal care (ANC) is an essential strategy for improving prevention, early diagnosis, and management of malaria in pregnancy. Effective integration requires not only client engagement but also the simultaneous availability of preventive counseling, trained providers, and facility capacity to diagnose and treat malaria. According to the WHO framework, malaria service integration delivery with ANC is defined as the receipt of ANC in a setting where malaria prevention counseling, provider capability, and facility readiness were simultaneously available during the visit. [ 13 – 17 ]. Despite the several established advantages of malaria service integration with ANC [ 14 – 16 , 18 – 23 ], multilevel factors affect the integration of malaria service delivery into ANC services which leads low uptake of the service by pregnant women. From the system level factors; some countries including Ethiopia did not adopt the inclusion of IPTP and provision of ITN to their health policies [ 24 ] which affects the implementation of service integration. The availability, readiness, and actual provision of services at the facility level also affect the delivery of integrated MiP services [ 21 , 22 , 25 – 28 ]. The shortage of essential commodities and limited capacity of health professional to provide malarias service also affect the implementation of service integration [ 22 , 29 , 30 ] Beyond structural and facility level influences, the effective delivery of integrated service is also shaped by client-level factors such as age, ANC follow-up adherence, pregnancy status, educational status, and awareness of malaria infection and prevention strategies [ 10 , 29 , 31 – 33 ]. While the WHO strongly recommends the delivery of integrating malaria services into ANC to improve prevention and treatment services, and despite malaria remaining endemic in several Ethiopian regions, evidence on the extent and the specific determinants influencing the delivery of integrated malaria service with ANC service remains limited. This study, therefore, uses nationally representative data from the 2021/2022 SPA survey to assess the level of integrated malaria services delivery with ANC and to identify the client and facility-level factors associated with such delivery of integration. Methods Data source and setting Data were derived from the SPA Survey conducted in 2021/22 in Ethiopia. The SPA survey is a nationally representative, facility-based survey conducted by the Ethiopian Public Health Institute (EPHI) and Inner City Fund (ICF) [ 34 ]. The survey employed stratified multistage sampling to collect data from health facilities, health workers, and clients, designed to provide information on the availability and quality of health services at various levels of the healthcare system. All clients (pregnant women) visit the sampled health facilities during data collection were interviewed. The study was conducted across Ethiopia’s nine regions and two city administrations. Data were collected through structured questionnaires administered to health facility representatives, service providers, and exit interviews with pregnant women. Study population and sampling The study population included pregnant women receiving ANC care services, along with their healthcare providers and the facilities where these services were rendered. The SPA Survey employed a multi-stage cluster sampling design to select a nationally representative sample of health facilities [ 34 ]. The survey selected a stratified random sample of 1,407 health facilities, selected with probability systematic sampling. However, data was successfully collected from 1156 facilities; the remaining were permanently closed, not yet operational, under security issues, unreachable, or duplicates of another facility in the sample. From a total of 1156 initial facilities , 662 facilities were ultimately nested in the analysis. The other 494 health facilities were excluded because of they did not provide ANC services, and thus no data were collected on ANC or malaria service integration from these facilities. The number of eligible clients identified and present for ANC services was 4355 . From this initial client pool, 4273 clients were nested within 662 facilities. The final analysis, therefore, was based on 4273 clients, nested within in 662 facilities ( Fig 1 ). Fig 1. Flow diagram of the sampling structure and dataset composition for the analysis of integrated malaria service delivery among pregnant women attending ANC in Ethiopia, 2021/22. Open in a new tab Variables and measurements Integrated malaria service delivery during antenatal care (ANC) was assessed using data from the 2021–22 Ethiopia Service Provision Assessment (SPA) survey. The SPA employs standardized instruments developed by the DHS Program and collects information at three complementary levels: client exit interviews, health care provider interviews, and health facility inventories. Consistent with the WHO framework for integrated malaria services delivery for pregnant women, integration was operationalized by linking these three levels to capture whether pregnant women received coordinated malaria-related services during ANC. Integrated malaria service delivery during ANC. The concurrent presence of three malaria service components during an ANC encounter: (1) malaria prevention counseling on ITN use reported by the client, (2) provider capacity to manage malaria cases according to national guidelines, and (3) facility readiness for malaria diagnosis and treatment. These components reflect process and structural indicators of integrated service delivery derived from the client interview, provider interview, and facility inventory modules of the SPA survey. Indicator 1: Malaria prevention counseling (client-level). Malaria prevention counseling was measured using the client exit interview dataset. Pregnant women attending ANC were asked whether they received counseling on the use of insecticide-treated nets (ITNs) for malaria prevention. This variable was coded as: Yes (1): Client reported receiving counseling on ITN use No (0): Client did not receive counseling on ITN use ITN counseling was selected as the preventive component because it is the standard malaria prevention intervention delivered within ANC services in Ethiopia, whereas ITN receipt typically occurs through community or household-level distribution campaigns. Intermittent preventive treatment in pregnancy (IPTp) is not part of Ethiopia’s national malaria policy and was therefore not included. Indicator 2: Provider capacity for malaria case management (provider-level). Provider capacity to deliver malaria case management was assessed using the health care provider interview dataset. Providers were classified as having malaria case management capacity if they reported routinely providing malaria diagnosis and treatment services as part of their clinical responsibilities. Providers meeting these criteria were coded as: Adequate capacity (1) Inadequate capacity (0) Indicator 3: Facility readiness for malaria diagnosis and treatment (facility-level). Facility readiness was assessed using the facility inventory dataset. Facilities were classified as malaria-ready if they had: At least one functional malaria diagnostic method available on the day of assessment (rapid diagnostic test and/or microscopy), and At least one first-line antimalarial medication in stock consistent with national treatment guidelines. Facilities meeting both criteria were coded as: Ready (1) Not ready (0) This indicator captures the structural capacity required to support integrated malaria service delivery during ANC. Construction of the integrated malaria service delivery variable. The three indicators were combined to generate a composite measure of integrated malaria service delivery, reflecting whether malaria prevention, diagnosis, and treatment services were delivered in a coordinated manner during ANC. Integration status was classified into four mutually exclusive categories: Fully integrated: All three components present Partially integrated: Any two of the three components present Limited integrated: Only one component present Not integrated: None of the components present For regression analyses, the outcome variable was dichotomized as follows: Integrated service delivery (1): all three service components were present. No integrated service delivery (0): at least one of the three service components was not present. This approach aligns with WHO guidance on integrated service delivery and reflects meaningful thresholds for coordinated malaria care during pregnancy. Study covariates. Covariates were selected a priori based on the WHO malaria in pregnancy service integration framework, existing literature, and data availability in the 2021/22 Ethiopia Service Provision Assessment. Variables were grouped into client-level and facility-level factors to reflect the hierarchical structure of the data. Client-level covariates. Client-level variables were extracted from the ANC client exit interview dataset and included: Maternal age group (15–24, 25–34, ≥ 35 years) Educational status (no formal education, primary(grades (1–8), secondary (9–12) or higher (diploma and above) Marital status (married vs. not married) Pregnancy status (gravida) (primigravida vs. multigravida) Number of ANC visits (1, 2, ≥ 3 visits) Receipt of insecticide-treated net (ITN) during ANC (yes/no) Knowledge of fever as a danger sign in pregnancy (yes/no) Payment for ANC services (yes/no) Facility-level covariates. Facility-level variables were obtained from the SPA facility inventory and provider interview datasets and included: Facility location (urban/rural) Facility ownership (public vs. private/NGO) Facility category (hospital vs. health center) Availability of malaria diagnostics (microscopy or rapid diagnostic test) Availability of first-line antimalarial drugs in line with national guidelines Facility malaria training: defined as the presence of at least one ANC service provider at the facility who reported receiving formal training on malaria diagnosis and treatment within the past 24 months (yes/no) Supervision received: defined as whether the facility or ANC provider reported receiving any external supervisory visit related to maternal or malaria services within the last six months (yes/no) All facility- and provider-level variables were linked to clients through the facility identifier and treated as higher-level covariates in the multilevel analysis Operational definition. Integrated malaria Service Delivery: Delivery of coordinated malaria- services during ANC, defined by the concurrent presence of malaria prevention counseling, provider capacity for malaria case management, and facility readiness for malaria diagnosis and treatment. Malaria burden regions were operationally defined as a categorical variable with three levels: “High,” “Moderate,” and “Low.” This classification was based on the endemicity and malaria transmission intensity observed across Ethiopia’s administrative regions, aligned with the national malaria stratification [ 35 ]. High Burden Region: Regions characterized by high prevalence/incidence and higher caseloads. These include Gambela, Benishangul-Gumuz, Amhara, Oromia, and Southern Nations, Nationalities, and Peoples’ Region (SNNPR) regional states. Moderate Burden Region: Regions with moderate case numbers. These include Somalia, Sidama, and Afar regional states. Low Burden Region: Regions with sporadic or minimal malaria transmission. These include Addis Ababa, Dire Dawa city administrations, and Harari regional state. Data management and analysis Missing data management was employed using different techniques. Variables with minimal missingness (<1) (e.g., diagnostic availability, supervision) were conservatively recoded, while those with moderate missingness (> 1) (e.g., guideline availability, training) were addressed using Multiple Imputation by Chained Equations (MICE) with logistic regression models [ 36 ]. The outcome variable was recomputed in each imputed dataset prior to modeling. Health care provider data were first linked to the respective facilities and then aggregated to represent facility-level characteristics. The presence of multicollinearity among independent variables was assessed using Generalized Variance Inflation Factors (GVIF). All GVIF values were well below the common threshold of 5, indicating no significant multicollinearity issues. Descriptive statistics were used to summarize the characteristics of the study population, with categorical variables presented as frequencies and percentages. A forest plot was used to display the regional distribution of malaria service integration among antenatal care (ANC) users. In addition, bar charts were used to illustrate the status of malaria service integration across regions. Multilevel logistic regression analysis was employed to identify factors associated with the receipt of integrated malaria services delivery, accounting for the hierarchical structure of the data where clients were nested within facility. The analysis was conducted using statistical software R (version 4.3) with the lme4 package for mixed-effects models. We used the incremental value of adding different levels of predictors, three multilevel logistic regression models were compared: a null model (intercept only), a client-level model (model I), and a full model (combining client and facility-level predictors). The comparison of the multilevel logistic regression models demonstrated that the facility-level clustering accounted for a substantial proportion of the total variation in integrated malaria services delivery, as reflected by the high intra class correlation coefficient (ICC) of 0.934 in the null model. When client-level and facility-level predictors were sequentially added, the conditional R 2 remained high (0.907 in the final model), indicating that the random effects at the facility level continued to explain most of the variability. However, the marginal R 2 increased from 0.000 in the null model to 0.022 in the full model, showing that the inclusion of fixed predictors modestly improved the model’s ability to explain variation in integration status. The root mean square error (RMSE) decreased slightly from 0.191 to 0.190, suggesting improved predictive performance. Model selection criteria further supported the final model; it had the lowest AIC indicating a superior balance of goodness of fit. Adjusted Odds Ratios (AORs) with their corresponding 95% Confidence Intervals (CIs) and p-values were reported for fixed effects in the final model. We conducted bivariate analyses, and variables with a p-value ≤ 0.2 were retained for final modeling. A p-value of less than 0.05 was considered statistically significant. Ethical considerations The 2022 Ethiopia SPA Survey received ethical clearance from the EPHI and the Institutional Review Board of ICF International. For this secondary analysis, anonyms and publicly available data were used, and no additional ethical approval and consent was required [ 37 ]. Results Socio-demographic and client-level characteristics The study analyzed data from 4,273 pregnant women who received ANC services in Ethiopia, based on the 2021/2022 Ethiopia SPA survey. The analysis of client-level characteristics provides insights into the socio-demographic profile and service utilization patterns of the participants. The mean age of the client was 25.69 years (SD = 4.99), with the largest proportion—1,618 women (37.86%)—falling within the 25–29 years age group. Regarding educational status, 1,475 participants (34.52%) had attained secondary education. The majority of respondents were from urban areas 2,891 (67.65%), and most were multigravidas, accounting for 2,971 women (69.53%). In terms of ANC utilization, nearly half 2,033 (47.58%) of the women had attended only one ANC visit. Alarmingly, a significant majority, 3,847 women (90%) were unaware that fever is a danger sign during pregnancy. Additionally, most participants 3,415 (79.89%) got ANC service free of payment. Concerning malaria prevention, the findings reveal substantial service gaps. Only 123 women (2.88%) reported receiving insecticide-treated nets (ITNs) at the health facility, and just only 859 women (20%) received counseling on ITN use, a key intervention for malaria prevention during pregnancy ( Table 1 ). Table 1. Socio-demographic and client-level characteristics of pregnant women attending ANC in Ethiopia, 2021/22 National Service Provision Assessment (N = 4,273). Characteristic Category Frequency (N) Percentage (%) Maternal Age Group <25 years 1,618 37.86 25–29 years 1,627 38.08 >30 years 1,028 24.06 Education Level No education 911 21.32 Primary (grade 1–8) 1,361 31.85 Secondary (grade 9–12) 1,475 34.52 Higher (college and above) 526 12.31 Gravidity 1 1,302 30.47 2 1194 27.94 3 or more 1777 41.59 ANC Visits 1 2,033 47.58 2 1,001 23.43 3 630 14.74 4 or more 609 14.25 Paid for ANC No 3,415 79.92 Yes 858 20.08 Knows Fever as Danger Sign No 3,847 90.00 Yes 426 10.00 Received ITN No 4,150 97.12 Yes 123 2.88 Counseled ITN use No 3,414 79.90 Yes 859 20.10 Open in a new tab The distribution of facilities and clients in Ethiopia The distribution of clients were varied by regions, For example, the Afar region had the smallest sample size with 85 clients, while the Oromia region represented the largest portion of the study population with 1,176 clients ( Table 2 ). Table 2. Distribution of health facilities and ANC clients across regions in Ethiopia, 2021/22 National Service Provision Assessment Survey. Region Facilities Included Total Clients Afar 24 85 Amhara 108 683 Oromiya 171 1376 Somali 41 220 Benishangul 21 115 SNNP 106 781 Gambella 35 115 Harari 17 80 Addis Ababa 52 379 Dire Dawa 27 126 Sidama 60 313 Total 662 4273 Open in a new tab Facility-level characteristics provide critical insights into the healthcare system environment that pregnant women attended ANC visits where integrated malaria services were delivered. The vast majority of clients 4,157 (97.29%) received services from facilities that offered malaria case management services, including diagnosis and treatment. Additionally, 2,980 (69.74%) of the women received care at facilities equipped with malaria diagnostics (microscope or RDT). Hospitals accounted for the largest share of service locations 3,009 (70.42%). In terms of ownership, governmental facilities dominated the service landscape, with 3,774 (88.32%) of women attending these institutions, while private or NGO facilities served a smaller portion (499; 11.68%). Geographically, majority services were delivered in urban areas, where 2,891 (67.65%) of clients were seen. Notably, 3,070 women (71.85%) were seen at facilities located in high malaria burden regions ( Table 3 ). Table 3. Facility-level characteristics related to integrated malaria service delivery during ANC among pregnant women in Ethiopia, 2021/22 National Service Provision Assessment Survey (N = 4,273). Characteristic Category Frequency (N) Percentage (%) Malaria tx Services avai No 116 2.71 Yes 4,157 97.29 Malaria Test Lab avai No 1,293 30.26 Yes 2,980 69.74 Facility Category Hospital 3,009 70.42 Other Health Facility 1,264 29.58 Ownership Governmental 3,774 88.32 Private/NGO 499 11.68 Location Urban 2,891 67.65 Rural 1,382 32.34 Facility in Malaria Burden Region Low 585 13.68 Moderate 618 14.47 High 3,070 71.85 Open in a new tab Facility malaria tx services” refers to the availability of malaria treatment services, while “malaria test lab availability” refers to the presence of laboratory capacity for malaria testing. Classification and distribution of malaria service delivery As shown in Fig 2 , the majority of pregnant women (53.3%) received ANC services in facilities classified as few integrated, where only one malaria service component was available. Fig 2. Classification and distribution of integrated malaria service delivery during antenatal care among pregnant women in Ethiopia, 2021/22 National Service Provision Assessment Survey. Open in a new tab An additional 37.3% of ANC clients accessed partially integrated. Only 7.9% of pregnant women attended ANC visits where integrated malaria services were delivered.Conversely, 1.5% of clients received ANC services in facilities with no malaria service integration ( Fig 2 ). Integrated malaria ServiceDelivery and disparities across regions in Ethiopia Nationally, only 7.9% (95% CI: 7.1%–8.7%) of pregnant women received ANC care visits where fully integrated malaria services were delivered. Considerable regional disparities were observed in the delivery of integrated malaria services during ANC across Ethiopia. As presented in Fig 3 , the proportion of clients receiving integrated malaria services exceeded the national average in several regions. The highest coverage was recorded in Benishangul Gumuz at 40.0% (95% CI: 31.5%–49.1%), followed by Dire Dawa at 23.8 % (95% CI: 17.2%–32.0%), Gambella at 22.6% (95% CI: 15.9%–31.1%), and Harari at 18.8 % (95% CI: 11.7%–28.7%). Fig 3. Forest plot showing the proportion of integrated malaria service delivery during ANC by region in Ethiopia, 2021/22 National Service Provision Assessment Survey. Open in a new tab Conversely, pregnant women who visited facilities in four regions exhibit integrated malaria service Delivery proportions considerably lower than the national average. Client visit health facilities in Addis Ababa registered the lowest integration proportions at 1.8% [95% CI: 0.9%, 3.8%], followed by Sidama at 3.5% [95% CI: 2.0%, 6.2%], Oromia at 4.7% [95% CI: 3.7%, 5.9%], and S.N.N.P. at 4.9% [95% CI: 3.6%, 6.6%] . The disparities highlight the statistical significance of these regional differences compared to the national average malaria integration ( Fig 3 ). Multilevel logistic regression analysis The multilevel logistic regression analysis model examined factors associated with the delivery of integrated malaria services among ANC clients, accounting for both client-level and facility-level influences. In model, where client- and facility-level factors were simultaneously included, five factors were found to be significantly associated with the integration of malaria services (p < 0.05). At the client level, pregnancy status (gravida), number of ANC visits, and receipt of ITNs were significant predictors. Women with two previous pregnancies were 1.67 times more likely than primigravida women to attend visits in which integrated malaria services were delivered (AOR = 1.67, 95% CI: 1.06–2.62). Similarly, attendance at three or more ANC visits was associated with higher odds of receiving care during visits in which fully integrated malaria services were delivered, compared with attendance at only one ANC visit (AOR = 1.58; 95% CI: 1.04–2.40). Receipt of an ITN during ANC was also positively associated with integrated malaria service delivery (AOR = 2.81; 95% CI: 1.29–6.12). At the facility level, providers training on malaria and facility location were significantly associated with service integration delivery. Clients attending facilities with malaria-trained providers had significantly higher odds of receiving integrated malaria services during ANC than those attending facilities without trained providers (AOR = 4.24; 95% CI: 1.80–10.00). Likewise, clients receiving ANC in rural facilities were more likely to experience integrated malaria service delivery than those in urban facilities (AOR = 2.73; 95% CI: 1.04–7.19). In contrast, knowledge of fever as a danger sign, facility supervision, facility category, and ownership were not significantly associated with integrated malaria service delivery. ( Table 4 ). Table 4. Multilevel determinants of integrated malaria service delivery during ANC among pregnant women in Ethiopia, 2021/22 National Service Provision Assessment Survey. Variables Category Model 1 AOR (95% CI) Final Model AOR (95% CI) Gravida 1 (Ref) 1 1 2 1.61 (1.05–2.45) 1.67 (1.06–2.62) 3 or more 1.25 (0.83–1.90) 1.33 (0.86–2.05) ANC visits 1 (Ref) 1 1 2 1.15 (0.78–1.71) 1.30 (0.84–1.99) 3 or more 1.29 (0.89–1.88) 1.58 (1.04–2.40) Knows fever danger sign No (Ref) 1 1 Yes 1.11 (0.70–1.76) 1.16 (0.65–2.07) Received ITN No (Ref) Yes 2.25 (1.22–4.15) 2.81 (1.29–6.12) Supervision received No (Ref) 1 1 Yes — 1.44 (0.82–2.50) Facility training malaria No (Ref) 1 1 Yes — 4.24 (1.80–10.0) Facility category (Other) Hospital 1 1 Others — 1.99 (0.77–5.12) Ownership of facility Government Private/NGO — 1.81 (0.53–6.16) Location of facility Urban 1 1 Rural — 2.73 (1.04–7.19) Open in a new tab Discussion This study utilized a nationally representative dataset from the 2021/22 Ethiopia SPA survey to assess the level of integration of malaria services delivery during ANC and to identify the multifaceted client and facility-level factors influencing this delivery. The delivery of integrated malaria services into ANC remains critically limited in Ethiopia. This low figure underscores missed opportunities for delivering comprehensive malaria interventions at a critical point of maternal care. This indicates a substantial gap in the country’s efforts to safeguard pregnant women from malaria and achieve its ambitious 2030 malaria elimination goals, aligning with the observed re-emergence of malaria as a top health concern despite previous progress [ 38 ]. The most common pattern observed was limited integration, accounting for 53.3% of all ANC visits. In these cases, although facilities were capable of providing malaria diagnosis and treatment, there was a lack of provider-level engagement or client counseling on malaria prevention. This finding indicates that infrastructure alone is insufficient to guarantee service delivery, and highlights the need to strengthen the human resource and communication components of ANC visits. The findings is consistent with the analysis of service integration delivery in SSA [ 39 ]. These findings reflect systemic challenges in aligning policy, capacity, and practice. Despite WHO recommendations to integrate malaria services—particularly IPTp, case management, and promotion and use of ITN —within ANC [ 17 ], the Ethiopian context lacks full policy adoption, particularly the absence of IPTp-SP and ITN provision at ANC in national guidelines [ 24 ]. Furthermore, the study revealed significant regional disparities in delivery of integration services across Ethiopia. The delivery of integrated malaria services during ANC visits was markedly higher in some regions, indicating significant regional variation relative to the national average. The heterogeneity observed in malaria service integration across regions may stem from various factors. For regions with historically low malaria burden, such as Addis Ababa, the low service integration might be explained by an assumed minimal risk, leading to reduced programmatic focus or awareness regarding malaria in pregnancy. However, the critically low integration delivery was observed in regions like Oromia and S.N.N.P are particularly concerning given that these are recognized as high malaria burden regions. This paradox suggests that despite a high epidemiological need, the health systems in these areas may be overwhelmed, prioritizing acute case management over the integration of preventive and diagnostic services into routine ANC. This could also indicate a lack of specific resource allocation or targeted strategies for MiP within these high-burden contexts. While the delivery of integrated services in regions like Amhara showed a slightly higher (10%) than the national average, it remains critically low when compared to WHO recommendations, which advocate for every pregnant woman to receive comprehensive integrated services during ANC [ 40 ]. This overall scenario strongly indicates that the Ethiopian health system might currently place greater emphasis on general population malaria prevention and treatment strategies, with a notable absence of specific, robust guidelines and programs designed to support the seamless integration of malaria services into ANC. This is further supported by qualitative findings from Ethiopia, which highlight the absence of malaria-specific interventions tailored for pregnant women, leaving them vulnerable to inadequate protection and care [ 29 ]. The multilevel logistic regression analysis revealed important determinants of malaria service integration among pregnant women attending antenatal care (ANC). Women with two previous pregnancies (Gravida 2) and those with three or more ANC visits were more likely to receive care during visits in which fully integrated malaria services were delivered. This could suggest that multiparous women, having navigated the healthcare system before, are more adept at accessing comprehensive care, or that providers are more likely to offer extensive services to women with established records. The findings is consistent with the previous study established, pregnant women previous service experiences are favorable contributor for service integration [ 41 ]. However, this finding contrasts with the widely accepted recommendation that primigravidae should be prioritized for malaria prevention due to their greater susceptibility to malaria infection and its complications . The immune-naïve status of first-time pregnant women places them at higher risk for severe disease and adverse pregnancy outcomes [ 42 , 43 ]. On the other side, those attending three or more ANC visits were 1.48 times more likely to receive care during visits in which fully integrated malaria services were delivered. It’s plausible that as women engage more consistently with ANC services, opportunities for integrated malaria services naturally increase due to repeated interactions with the health system. These findings align with prior finding indicating that increased contact with health facilities enhances access to health education, malaria screening, and preventive interventions [ 10 , 44 ]. The association may also reflect the cumulative benefit of repeat ANC exposure in promoting integrated care. The receiving an ITN during ANC were 2.81 times more likely receiving care during visits in which fully integrated malaria services were delivered. This finding suggests the provision of an ITN may serve as an entry point of a more comprehensive, integrated approach to malaria prevention and control within ANC. It is possible that facilities prioritizing ITN distribution are also more likely to be implementing other components of integrated malaria services, such as counseling and diagnosis. This finding is in line with previous evidence showing that integrated antenatal and malaria services are positively associated with improved ITN access [ 45 ]. At the facility level, this study uncovered important disparities in the delivery of integrated malaria services for pregnant women across geographic and epidemiologic contexts. The finding reveled that clients who visit facilities where providing malaria training were significantly more likely to received care during visits in which fully integrated malaria services were delivered. This aligns with global recommendations emphasizing the need for skilled healthcare workers to deliver quality and integrated care [ 27 , 39 ]. Pregnant women who got service in rural facilities were significantly more likely to received care during visits in which fully integrated malaria services were delivered compared to their urban counterparts. This finding may reflect the targeted public health strategies implemented in rural areas, where maternal and malaria-related mortality have historically been higher [ 46 ]. Additionally, rural health facilities may experience lower patient volumes, allowing for longer consultation times and more opportunities for integrated service delivery [ 47 ]. However, there are contradict findings showed the rural health facilities are limited in accessing of qualified professional, essential commodities that affect the delivery of integrated service [ 48 ]. Strengths and limitations This study’s strengths include its use of nationally representative data from the recent 2021/22 SPA survey, providing robust generalizability. The large sample size and the application of multilevel logistic regression adequately addressed the hierarchical nature of the data, minimizing bias from clustering effects. Furthermore, the comprehensive inclusion of client and facility-level variables allowed for a nuanced understanding of the complex determinants. Nevertheless, certain limitations should be acknowledged. Its cross-sectional design precludes the establishment of causal relationships between the identified factors and service integration and the SPA survey may not fully align with Ethiopia seasonal variation in malaria transmission; this could have influence the malaria service integration practice. In addition, the reliance on facility-based surveys and client exit interviews may be subject to recall bias or social desirability bias. Moreover, the composite operational definition of “integrated malaria services delivery” was stringent, which might contribute to the low overall integration rate. Finally, despite the use of multilevel modeling to account for clustering of clients within facilities, residual unmeasured facility- or community-level factors may still influence the observed associations. Further research using regionally powered surveys or routine health information system data is recommended to generate more robust subnational estimates and to better understand geographic inequities in malaria service integration with ANC services. Conclusion The delivery of integrated malaria services into antenatal care in Ethiopia remains critically low, marked by significant regional disparities and multilevel determinants. Key factors influencing service integration delivery include gravida, ANC visit frequency, and the provision of ITNs at the client level. At the facility level, malaria-specific training and rural location significantly impacted service integration. Addressing these complex challenges necessitates a multi-pronged approach: (i) Policy and Service Readiness: National and regional health authorities should prioritize ensuring that all ANC facilities are equipped with malaria diagnostics, treatment, and trained providers to delivered consistent and integrated services; (ii) Capacity building: continuous in-service training on MiP, including counseling on ITN use and case management, should be integrated into routine professional development programs; (iii) Equity Service delivery: regional disparities highlights the needs of intensified support in high-burden and underserved areas through targeted resource allocation, supportive supervision, and capacity building; (iv) Client Engagement: strengthening demand side intervention through promoting early and consistent ANC attendance and revising national polices to formally integrate ITN distribution into ANC follow up; (v) Health System adaptation: successful rural facility practices should be adapted and scaled to urban and high-burden regions where integration lags and (vi) Future research: Further studies should explore underlying causal pathways to fully understand the determinants of delivery of malaria service integration for pregnant women in Ethiopia. Acknowledgments The authors thank the DHS Program for granting access to the 2022 Ethiopia SPA dataset. We also acknowledge the Ethiopian Public Health Institute and the Ministry of Health for facilitating the survey. The authors also acknowledged Bahir Dar University for the financial and technical supports. Data Availability The data used in this study are publicly available from the Demographic and Health Surveys (DHS) Program. Specifically, the analysis was based on the Ethiopia Service Provision Assessment (SPA) Survey 2021/22. The dataset is anonymized and accessible upon registration and approval through the DHS Program data portal: https://dhsprogram.com/data/ . Funding Statement The author(s) received no specific funding for this work. References 1. Varo R, Chaccour C, Bassat Q. Update on malaria. Med Clin (Barc). 2020;155(9):395–402. doi: 10.1016/j.medcli.2020.05.010 [ DOI ] [ PubMed ] [ Google Scholar ] 2. Bakken L, Iversen PO. 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BMC Health Serv Res. 2024;24(1):850. doi: 10.1186/s12913-024-11257-9 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] PLoS One. doi: 10.1371/journal.pone.0346831.r001 Decision Letter 0 Khin Thet Wai Khin Thet Wai Academic Editor Find articles by Khin Thet Wai Author information Copyright and License information Roles Khin Thet Wai : Academic Editor © 2026 Khin Thet WaiKhin Thet WaiKhin Thet WaiKhin Thet Wai This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 19 Aug 2025 Dear Dr. Bogale, [email protected] . 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.. 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.. 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.. 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. 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'. 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If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Additional Editor Comments : Please do major revisions as required. [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? Reviewer #1: Partly Reviewer #2: Partly ********** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ********** 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.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 #2: Yes ********** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ********** Reviewer #1: This manuscript investigates the uptake of integrated malaria services and its determinants among pregnant women in Ethiopia. Given the substantial burden of malaria during pregnancy, this is a highly significant topic. To enhance the quality of this manuscript, the following suggestions are put forward: 1. In the "Study Population and Sampling" section, the authors should elaborate on the reasons for excluding 494 facilities within the text. 2. The "Variables and Measurements" section could benefit from reorganization to eliminate redundancy. For example, it is recommended that the paragraph describing the outcome variable be merged with its operational definition. 3. In this study, service integration is defined based on three criteria: counseling on insecticide-treated nets (ITNs), the provider's ability to deliver malaria case management in accordance with national guidelines, and the availability of malaria diagnosis and treatment services at the facility. The authors need to provide more specific details on how these variables were measured using the SPA. Additionally, it would be valuable to explain why the focus was placed on counseling on ITNs rather than the receipt of ITNs or other preventive measures such as IPTp. Furthermore, is there a theoretical foundation for constructing such a combined measurement of service integration? 4. The authors report on malaria service integration and disparities across regions in Ethiopia. It is important to clarify whether the SPA data can generate representative results for each individual region. 5. Only a small number of variables mentioned earlier are included in Table 4. Did the authors exclude variables that did not yield significant estimates in the model? Moreover, the difference between Model 1 and the final model should be clearly explained. The authors are advised to report all variables included in both models. Reviewer #2: Thank you for the opportunity to review this interesting article that examines facility- and client-level factors associated with receipt of integrated MiP services during ANC in Ethiopia. Below are major and minor recommendations to help strengthen this important manuscript. Major recommendations: Methods: Consistency in use of the language for the model used, i.e. multilevel mixed effects multivariable logistic regression, is needed. What are the fixed versus random effects in the model? Did you perform a complete case analysis on your analytic sample? How did you handle missing data? How are health care provider (interviews?) handled in your analyses? Did you aggregate them in some way at the facility level? This is confusing throughout the paper and makes interpretability challenging. Is there a reason for listing the Outcome Variable and then the Operational Definition separately? These could be combined as the same thing. It would be helpful to know where each of these variables comes from in the SPA questionnaires. Is there a specific question that corresponds to each? Or are they constructed as composites of questions? Where do data for the malaria regions originate from? SPA or other? What was your approach to variable selection and inclusion in the adjusted models, beyond model building for multilevel models (i.e. did you select variables a priori based on the literature, based on some cutpoint, etc? (Figure 4) Why was region not included in the models? Results/Figures: All figures need some updating to make them interpretable. A map, perhaps of malaria endemicity zones (High, Medium, Low) and regions would be helpful; better yet if it shows the distribution of facilities. Fig 1 would benefit from a redesign to show how clients cluster within facilities, rather than showing facilities and clients side by side. Fig 2 would benefit from reorganizing the key from full to none. The labels as presently listed along the y-axis make this figure difficult to interpret, perhaps due to lack of specificity. Consider using the same language in prose as in the figure to help clarify. Please also clarify whether you are presenting data at the client-level or the facility-level. Fig 3 Is the National Average (7.9%) an actual average? I understand it to be the percent of clients who received care at a facility that met the 3-pronged criteria for integrated MiP in ANC, for clients included in your analytic sample. Also, consider relabeling these results - they aren't really a rate. Perhaps frequency would be a better fit. The section on model assessment should either be reduced to a line or two under the results of the model, or put in supplemental files. Discussion: Consider further exploring in greater detail the effect of cross-sectional data on your results. Were SPA questionnaires administered all at once, or on a rolling basis region-by-region? How does that align / not align with malaria seasonality in Ethiopia? How does timing of client interviews potentially effect integration of MiP in ANC You mention the health extension worker program that includes an element of bed nets and counseling. Please consider going into greater detail about how this could affect your results. If ITNs are not required per national policy as part of MiP services - is this something that is delegated to the CHEWs? Why did you utilize ITN measures but not IPTp, as neither are part of national policy? What was the presence of international aid in Ethiopia, by region, at the time of survey? Could that have had a demonstrable impact on your results? Consider adding a section (that is supported by your findings) that makes public health recommendations/ addresses implications for national policy and/or programming Minor recommendations: 1) needs a thorough copy-edit for typos and grammar 2) double check font type and size in tables and figures (e.g. table 1) 3) acronyms / abbreviations only need to be spelled out at first use rather than repeatedly throughout the manuscript ********** what does this mean? ). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). 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 For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy ..--> Reviewer #1: Yes: Di LiangDi LiangDi LiangDi Liang Reviewer #2: Yes: Elizabeth H LeeElizabeth H LeeElizabeth H LeeElizabeth H Lee ********** [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 . 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 . 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 . 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 [email protected] . Please note that Supporting Information files do not need this step.. Please note that Supporting Information files do not need this step.. Please note that Supporting Information files do not need this step.. Please note that Supporting Information files do not need this step. PLoS One. 2026 Apr 15;21(4):e0346831. doi: 10.1371/journal.pone.0346831.r002 Author response to Decision Letter 1 Article notes Copyright and License information Collection date 2026. PMC Copyright notice 5 Sep 2025 Dear Khin Thet Wai, we revised the manuscript according to the reviewers' suggestions and the editor's recommendation. Attachment Submitted filename: Response to Reviewers_PloS One_26082025.pdf pone.0346831.s002.pdf (142.9KB, pdf) PLoS One. doi: 10.1371/journal.pone.0346831.r003 Decision Letter 1 Khin Thet Wai Khin Thet Wai Academic Editor Find articles by Khin Thet Wai Author information Copyright and License information Roles Khin Thet Wai : Academic Editor © 2026 Khin Thet WaiKhin Thet WaiKhin Thet WaiKhin Thet Wai This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 16 Jan 2026 Dear Dr. Bogale, [email protected] . 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.. 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.. 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.. 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. A 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 . 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 . 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 . 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, Khin Thet Wai, MBBS, MPH, MA Academic Editor PLOS One Journal Requirements: 1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Additional Editor Comments: There are flaws in methods and results sections especially for multiple statistical models. Please do major revisions as required. [Note: HTML markup is below. Please do not edit.] Reviewer's Responses to Questions Comments to the Author 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??> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: (No Response) ********** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: (No Response) ********** 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.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 #2: Yes Reviewer #3: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: No ********** Reviewer #1: Thanks the authors for addressing my previous comments. I still have one concern for this manuscript. Although SPA is a nationally representative dataset, it is not safe to assume that the national-level findings also apply to people at the local level. SPA may not be able to generate regionally representative estimates of service readiness and integration. Thus, the authors should be careful about the interpretation of regional-level findings in Figure 3 and the findings on page 13-14. Reviewer #2: Thank you for your careful attention to initial comments. It appears that some of the figures (e.g. Fig 2) may still require attention based on the prior feedback. Additionally, I would recommend providing more information about study covariates in the methods section. Additional clarity about use of the outcome variables (integration y/n and the stratified integration variable) is needed. There are two places where the number of levels / models appear to be incorrectly noted. pg 9: Model performance was compared across the four models using various indices (line 222 in revisions); and pg 7: Variables were categorized into three hierarchical levels (line 161 in revisions). The authors may also wish to present results stratified by malaria burden area classification or urban/rural status, as a major question remains whether these variables may modify likelihood of receipt of integrated services. Reviewer #3: Thank you to the editor and authors for giving me the opportunity to read this manuscript. I have noted that the authors revised the paper based on other reviewers’ comments. However, I believe the manuscript still requires major revisions, particularly regarding the logical flow, operational definitions of outcome variables, and data analysis. My main comments are as follows: 1. The title suggests an assessment of service uptake, yet there is no mention or analysis of uptake throughout the manuscript. 2. Line 31 mentions “unborn,” whereas line 59 refers to “newborns.” Please ensure consistent terminology. 3. There are several typographical and grammatical errors throughout the manuscript (e.g., lines 50–52). 4. Terms such as “integrated malaria services” and “malaria service integration” are used inconsistently. Please clarify what these mean. Are these based on the authors’ definitions or existing frameworks? Has such integration already been implemented in Ethiopia? If so, when and how? Otherwise, low uptake or limited-service provision may be considered expected rather than exceptional. 5. Line 109: It is unclear whether this is a secondary data analysis or a cross-sectional study. 6. Figure 1 requires improvement for clarity and logical flow. For example, the arrows from nested clients to facilities appear misplaced. 7. Lines 154–155: The text refers to “danger sign knowledge,” but the data reflect only fever. 8. Lines 164–168: Please explain how the three indicators were derived. Were they from the original survey, or defined by the authors? If self-reported by participants, they may be biased and not reflect provider implementation. For indicators 2 and 3, specify the criteria used for classification. 9. In Table 1, font styles are inconsistent. Clarify the meaning of “primary,” “secondary,” and “higher” education. The proportion of participants who “received ITNs” is lower than those “counselled on ITN use.” 10. Table 2 and its corresponding text are not informative. They appear to describe sampling methods rather than findings. Did the original study use unequal sampling across facilities? 11. In Table 3, please define “facility malaria services” and “malaria test lab avai.” 12. Lines 265–270: Present the statistical results for the three main indicators. Lines 276–278 are unclear and need clarification. 13. Table 4 should be expanded. The title is vague. Include cross-tabulated data and corresponding simple logistics regression results (COR etc.) to substantiate the findings. If multiple models were tested, include all results as supplementary material. Variables such as “supervision received” and “facility malaria training,” which appear here but not in prior tables, must be defined and linked to earlier sections. 14. I have not reviewed the Discussion in detail, but the current version is lengthy and repetitive, focusing excessively on “integration of malaria services.” This section should be shortened and made more concise, while the part discussing associated factors should be expanded with references to more relevant studies. ********** what does this mean? ). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). 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 For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy ..--> Reviewer #1: Yes: Di LiangDi LiangDi LiangDi Liang Reviewer #2: No Reviewer #3: No ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation . NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. PLoS One. 2026 Apr 15;21(4):e0346831. doi: 10.1371/journal.pone.0346831.r004 Author response to Decision Letter 2 Article notes Copyright and License information Collection date 2026. PMC Copyright notice 21 Jan 2026 We have revised the manuscript based on the feedback. Attachment Submitted filename: Point by Point response.pdf pone.0346831.s003.pdf (418KB, pdf) PLoS One. doi: 10.1371/journal.pone.0346831.r005 Decision Letter 2 Khin Thet Wai Khin Thet Wai Academic Editor Find articles by Khin Thet Wai Author information Copyright and License information Roles Khin Thet Wai : Academic Editor © 2026 Khin Thet WaiKhin Thet WaiKhin Thet WaiKhin Thet Wai This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 4 Feb 2026 Dear Dr. Bogale, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Mar 21 2026 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 [email protected] . 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.. 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.. 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.. 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. A 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 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 . 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 . 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 . 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, Khin Thet Wai, MBBS, MPH, MA Academic Editor PLOS One Journal Requirements: 1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed Reviewer #3: (No Response) ********** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: No ********** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: 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.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 #2: Yes Reviewer #3: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: No Reviewer #3: No ********** Reviewer #1: (No Response) Reviewer #2: Needs a typographical / grammar review by authors. There are many instances where additions / revisions now read with grammatical errors. For example, what is "few integration"? Reviewer #3: Thank you to the authors for revising the manuscript. However, I believe the revisions remain minimal and inadequate in addressing many of the previous comments, partly due to the incorrect referencing of line numbers. I have listed several concerns below. I have not yet reviewed the Abstract, Background, Discussion, or Conclusions. 1. In the tracked-changes version (Lines 211–213), the authors state that the outcome variable was dichotomized as 1 and 0, where “0” indicates that at least one of the three service components was not present. Please clarify this statement. What do you mean by this definition, and how were other possible categories, such as “partially integrated” or “few integrated”, classified or handled? 2. Based on the operational definitions provided, the outcomes seem to evaluate facility performance rather than service uptake by participants. Specifically, in questions 2 and 3 on integrated services (Lines 258–260), the authors describe the presence of malaria prevention counseling, provider capacity for malaria case management, and facility readiness for malaria diagnosis and treatment. These indicators relate to service availability and provider capacity, not the uptake of malaria services by clients. Participants seeking ANC at facilities are already engaging in service uptake. The inability to receive malaria-related services likely reflects provider-side constraints rather than client behavior, meaning the study may not accurately measure “uptake.” 3. Line 296 mentions the use of VIF, while Line 333 refers to excluding variables with p < 0.2. How were these criteria applied when they potentially conflict with each other? 4. Many minor comments from the first review round remain unresolved, including: improvement of Figure 1, inconsistent font styles in Table 1, the limited relevance of Table 2 as a stand-alone table, unclear variable names in Table 3, insufficient expansion of Table 4 to include cross-tabulated data, and lack of improvement in the overall discussion flow. ********** what does this mean? ). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). 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 For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy ..--> Reviewer #1: No Reviewer #2: No Reviewer #3: No ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation . NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. PLoS One. 2026 Apr 15;21(4):e0346831. doi: 10.1371/journal.pone.0346831.r006 Author response to Decision Letter 3 Article notes Copyright and License information Collection date 2026. PMC Copyright notice 18 Feb 2026 Dear Academic Editor, Thank you for the opportunity to further revise our manuscript and for the continued constructive feedback from the reviewers. We have carefully addressed all remaining concerns raised in this round of review. In particular: • The outcome variable has been clarified conceptually and analytically to distinguish between descriptive integration categories and the dichotomized regression outcome. • The interpretation of “integrated malaria service uptake” has been refined to reflect functional receipt of integrated services during ANC encounters rather than facility readiness alone. • The model-building strategy has been clarified, including the sequential use of p-value screening and multicollinearity diagnostics (VIF). • Figures and tables have been revised for clarity, consistency, and interpretability, including redesign of Figure 1 and expansion of Table 4. • Language and terminology throughout the manuscript have undergone a thorough editorial review to correct grammatical inconsistencies and improve readability. • The Discussion section has been streamlined to improve logical flow and better situate findings within existing literature. We believe these revisions have substantially strengthened the methodological transparency, conceptual clarity, and overall presentation of the manuscript. Thank you again for your guidance and consideration. Sincerely, Kassawmar Angaw Bogale Attachment Submitted filename: Point by point responses.docx pone.0346831.s004.docx (18.9KB, docx) PLoS One. doi: 10.1371/journal.pone.0346831.r007 Decision Letter 3 Khin Thet Wai Khin Thet Wai Academic Editor Find articles by Khin Thet Wai Author information Copyright and License information Roles Khin Thet Wai : Academic Editor © 2026 Khin Thet WaiKhin Thet WaiKhin Thet WaiKhin Thet Wai This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 7 Mar 2026 Dear Dr. Bogale, [email protected] . 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.. 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.. 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.. 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. A 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 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 . 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 . 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 . 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, Khin Thet Wai, MBBS, MPH, MA Academic Editor PLOS One Journal Requirements: 1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. 2. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments: Please do revisions as required. [Note: HTML markup is below. Please do not edit.] Reviewer's Responses to Questions Comments to the Author Reviewer #2: (No Response) Reviewer #3: (No Response) ********** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #2: Yes Reviewer #3: No ********** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #2: 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.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.--> Reviewer #2: Yes Reviewer #3: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #2: No Reviewer #3: No ********** Reviewer #2: 1) It does not appear a thorough grammar review was conducted as was recommended previously. For example, (and this is one of many instances): "The finding is consistent with pervious study that the association of integrated antenatal and malaria service quality scores with ITN access [44]." I cannot tell what the authors are trying to state about reference 44 in relation to their findings based on the way this sentence currently reads. 2) I agree with reviewer two that the terminology 'service uptake' is challenging here because the authors are constructing their outcome based on structural and process factors. This seems much more in line with Service Availability and Readiness, not whether women necessarily used the services (e.g. for those who received an ITN, did they employ use of an ITN more often following receipt counseling/education). Indeed, the operational definition is: "Receipt of coordinated malaria-related services during ANC, defined by the concurrent presence of malaria prevention counseling, provider capacity for malaria case management, and facility readiness for malaria diagnosis and treatment. The authors should consider reframing their terminology to be a more accurate reflection of what is actually being measured. How are these constructs used and defined in the published literature? Reviewer #3: Upon my quick reassessment of the revised manuscript, I find that the revisions are superficial and do not adequately address the concerns raised in the previous round of review. In many instances, no substantive changes have been made. Therefore, my comments remain the same as before. ********** what does this mean? ). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). 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? 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Attachment Submitted filename: Point bypoint responses.docx pone.0346831.s005.docx (29.6KB, docx) PLoS One. doi: 10.1371/journal.pone.0346831.r009 Decision Letter 4 Khin Thet Wai Khin Thet Wai Academic Editor Find articles by Khin Thet Wai Author information Copyright and License information Roles Khin Thet Wai : Academic Editor © 2026 Khin Thet WaiKhin Thet WaiKhin Thet WaiKhin Thet Wai This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. PMC Copyright notice 24 Mar 2026 Integrated Malaria Service Delivery and Its Determinants among Pregnant Women in Ethiopia: Multi level Analysis of 2021/22 National Service Provision Assessment Survey PONE-D-25-38971R4 Dear Dr. Bogale, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. 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Kind regards, Khin Thet Wai, MBBS, MPH, MA Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: PLoS One. doi: 10.1371/journal.pone.0346831.r010 Acceptance letter Khin Thet Wai Khin Thet Wai Academic Editor Find articles by Khin Thet Wai Author information Copyright and License information Roles Khin Thet Wai : Academic Editor © 2026 Khin Thet WaiKhin Thet WaiKhin Thet WaiKhin Thet Wai This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. 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Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Khin Thet Wai Academic Editor PLOS One Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Attachment Submitted filename: Response to Reviewers_PloS One_26082025.pdf pone.0346831.s002.pdf (142.9KB, pdf) Attachment Submitted filename: Point by Point response.pdf pone.0346831.s003.pdf (418KB, pdf) Attachment Submitted filename: Point by point responses.docx pone.0346831.s004.docx (18.9KB, docx) Attachment Submitted filename: Point bypoint responses.docx pone.0346831.s005.docx (29.6KB, docx) Data Availability Statement The data used in this study are publicly available from the Demographic and Health Surveys (DHS) Program. Specifically, the analysis was based on the Ethiopia Service Provision Assessment (SPA) Survey 2021/22. 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