PONE-D-19-28652

Urinary incontinence among pregnant women in Southern Brazil a population-based cross-sectional survey

PLOS ONE

Dear Mr. TING,

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 ALL the points raised during the review process.

SPECIFIC ACADEMIC EDITOR COMMENTS: Your manuscript was handled by two expert reviewers. Although interest was found in your study, there were some comments that arose that need addressing. These comments include, but are not limited to several statements throughout the manuscript that need clarification or abbreviating along with methodology and statistics that need to be better explained.

We would appreciate receiving your revised manuscript by Apr 25 2020 11:59PM. When you are 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.

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Frank T. Spradley

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: Yes

Reviewer #2: Yes

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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.

Reviewer #1: Yes

Reviewer #2: Yes

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

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

Reviewer #1: Yes

Reviewer #2: No

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5. Review Comments to the Author

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

Reviewer #1: As stated on p. 15, urinary incontinence (UI) is common among pregnant women. The proposed article claims that a positive association exist between pregnant women and UI that is measurable within a define set of inclusion criteria as defined on p. 10. The study is significant given the prevalence and occurrence as stated in the article. The study target population involves a population-based cross-sectional survey of mothers who have given birth within a defined gestational period and/or birth weight (20 weeks gestational age and/or ≥500g).

As mentioned in the article, “regarding sample size, two calculations were performed to estimate prevalence and factors associated with UI in pregnant mothers for the proposed study.” Data obtained from retrospective 2016 perinatal surveys was used to identify association factors and estimate prevalence ratio. Adjustments for eventual losses and adjustments for potential confounders were taken into account and well defined.

Informed consent forms were appropriately signed and provided to birth mothers prior to implementing the study. In addition, a signed copy of the informed consent was retained at the hospital.

In terms of data quality and integrity, data management involved follow up telephone calls and home visits to account for consistency of data. As mentioned in the article, approximately 10% of the interviews were retaken to "evaluate the quality of the data collected."

The study power involved the use of multivariate analysis that followed a hierarchical model to link prevalence of the UI to associated variables with adjusted expected outcomes. Based on this model, the study determined the prevalence of UI in gestational period, lowest observed rate of UI in the study population, the highest frequency of urinary urgency among other variables as outlined in the study.

P. 12 The study outcome was clearly defined.

P.19 Reference list clearly demonstrates literature review for relevant systematic review, meta-analysis, REDcap, and essential tools needed for medical statistics on public health related issues.

Reviewer #2: Dear Author!

This is a cross-sectional study aiming at estimating the prevalence of and risk factors for urinary incontinence during pregnancy among women living in Rio Grande, Brasil.

My comments for you are listed below:

General:

Why did you not separate the conditions stress urinary incontinence and urgency urinary incontinence, which are quite different in etiology?

Abstract:

- UI is a frequent pathology = UI is a frequent condition

- Measure the prevalence = estimate the prevalence

Background:

- “…and increases with age” =”…and the prevalence increases with advancing age”

- This is a journal read mainly by health care professionals, it is therefore unnecessary to explain that UI may be experienced by both sexes. What is essential, however, is that you use the background section to focus on why it is important to examine UI in your population, when similar studies have been performed in other populations. Are you f.i. suspecting that women in Rio Grande would be especially prone to UI due to (I am just guessing) heavy rural work or young age at first delivery?

- Rewrite the following, since in its present form it seems like all factors should be present in the same patient: “The probability of occurrence of UI, even after adjustment, was significantly higher among those who were older than 30 years old at current pregnancy, whose first pregnancy was before the age of 20 or after 30, who reached the end of gestation weighing 90 kg or more, who exercised regularly during pregnancy and who reported frequent urinary urgency during the gestational period.”

Methods:

- First paragraph-shorten or remove

- Why cut-off at 20 weeks?

- Power-calculation hard to follow, and must be better described: especially the following part “…ratio between exposed and unexposed/exposed of 15/85, prevalence of disease among the unexposed of 9.8% and 1.6 risk ratio..”

- eventual losses = eventual lost to follow-up/ lost data or deaths?

- Remove repeated statements like, like p.4 “…the following question: "During this gestation, did you ever lose urine unintentionally?" A positive response would mean puerperae had UI during this gestational period.”

- Condense the text from “Three interviewers collected data….” to “…

was performed using Stata statistical package version 12.0. “

- When were the 10% of the interviews retaken? Did you consider recall bias? What happened when the data were inconsistent, which questionnaire was used- the first or the second?

- Explain the advantage of using Poisson regression models in non-longitudinal data instead of regular linear or logistic regression?

- Remove inadequate racial expressions like skin color, white, brown, black etc. (also in results section and tables)

Results:

- Incredible that more than 99% participated voluntarily in a study, how was this possible?

- Do not repeat extensively in text what is in presented the tables

Discussion:

- Modify strong expressions such as “this is due to the loss of….”, rather use “this may be due to..” or similar.

- Great age= old age/ advanced age

Conclusions:

- Avoid the expression causally associated, since to detect causal effects from a cross-sectional study would be very hard.

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Reviewer #1: Yes: Barbara A. Wilson

Reviewer #2: 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 be viewed.]

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 us at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-19-28652R1

Urinary incontinence among pregnant women in Southern Brazil a population-based cross-sectional survey

PLOS ONE

Dear Mr. TING,

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. ALL of the reviewers' comments and concerns must be addressed in your revision.

We would appreciate receiving your revised manuscript by Jun 12 2020 11:59PM. When you are 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.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

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

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

Reviewer #1: Abstract revisions were appropriately applied.

As stated on p. 15, urinary incontinence (UI) is common among pregnant women.  The proposed article claimed that a positive association exists between pregnant women and UI that is measurable within a defined set of inclusion criteria as defined on p. 10.  The study is significant given the prevalence and occurrence as stated in the article.  The study target population involves a population-based cross-sectional survey of mothers who have given birth within a defined gestational period and/or birth weight (20 weeks gestational age and/or ≥500g).

As mentioned in the article, “regarding sample size, two calculations were performed to estimate prevalence and factors associated with UI in pregnant mothers for the proposed study.”    Data obtained from retrospective 2016 perinatal surveys was used to identify association factors and estimate prevalence ratio.  

Informed consent forms were appropriately signed and provided to birth mothers prior to implementing the study.   In addition, a signed copy of the informed consent was retained at the hospital. 

In terms of data quality and integrity, data management involved follow up telephone calls and home visits to account for consistency of data.  As mentioned in the article, approximately 10% of the interviews were retaken to "evaluate the quality of the data collected."  

The study power involved the use of multivariate analysis that followed a hierarchical model to link prevalence of the UI to associated variables with adjusted expected outcomes.   Based on this model, the study determined the prevalence of UI in gestational period, lowest observed rate of UI in the study population, the highest frequency of urinary urgency among other variables as outlined in the study.  

P. 12 The study outcome was clearly defined.

P.19 The reference list clearly demonstrates literature reviews on public health related issues.

Reviewer #2: Dear Author!

Thank you for the response to my comments and your effort to improve the paper.

I still have a few comments regarding the methods section:

-You do not have to over-explain the power calculation in a statistical sense, however I am asking you to explain or reference your assumptions. Where did the ratio of unexposed/exposed to UI come from? I suppose the power calculation was performed before you started the study and not performed post-hoc?

- The expression “losses” should be briefly explained: for instance: ..losses, including women who did not want to participate in the study or who left the hospital before being invited to participate….

- I still find the entity “skin color” problematic. Since the Brazilian population is ethnically mixed, the genetic importance of skin color is dubious. Because skin color does not have any relevance for your results, and in order to avoid offending readers, I would recommend the removal of this entity. However, I leave the decision to the editor.

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

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

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

Reviewer #1: No

Reviewer #2: 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 be viewed.]

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 us at figures@plos.org. Please note that Supporting Information files do not need this step.

Urinary incontinence among pregnant women in Southern Brazil: a population-based cross-sectional survey

PONE-D-19-28652R2

Dear Dr. TING,

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

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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With kind regards,

Frank T. Spradley

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #2: All comments have been addressed

**********

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

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

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

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

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

Reviewer #2: Yes

**********

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

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

Reviewer #2: Yes

**********

6. Review Comments to the Author

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

Reviewer #2: Dear author!

Regardless of what may be expressed in other Brazilian papers, I find the use of skin colour as an entity hard to swallow.However, I leave the decision upon this issue to the Editor. I have no further comments.

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

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

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

Reviewer #2: No