PONE-D-19-29080

Effect of Antenatal Depression on Adverse Birth Outcomes in Gondar Town, Ethiopia: A community-based cohort study

PLOS ONE

Dear Dr. Abel Fekadu,

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.

We apologize about the delay in the review process. We invite you to resubmit as the paper received favorable reviews.

We would appreciate receiving your revised manuscript by May 28 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,

Anna Palatnik, M.D.

Academic Editor

PLOS ONE

Journal Requirements:

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

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

http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

Additional Editor Comments (if provided):

Reviewer 1:

This paper was well conceived and well-written. The authors conducted a large survey of pregnant women (n~900) in Gondar town, Ethiopia. The main exposure in the study was antenatal depression and the main outcome was incidence of adverse birth outcome (preterm birth, low-birth weight or still birth). Information on a range of risk factors (e.g. occupation, age, marital status, religion, physical activity, social support, coping strategies, antenatal healthcare attendance etc.) was also collected and including in the data analysis (which was conducted using structural equation modelling). The authors report on the main risk factors for each adverse birth outcome. The main findings in relation to the incidence of still birth indicates that Ethiopia is lagging behind other countries in reducing still births. Depression was not a risk factor for still birth in this study (perhaps due to low power); neither was is associated with low-birth weight or pre-term labour. The main findings suggest that perceived partner support and ability to cope with stress were moderated the relationship between depression and low-birth weight (although the effect was small) - and the effect was stronger when considering preterm birth. There was no main effect for experiencing depression and low-birth weight or preterm birth. So the main take-home message appears to be that interventions efforts might be better focused on increasing partner support and the woman's ability to cope with stress.

The authors neatly report on the study strengths and limitations in the discussion. The survey response rate was extremely high (97.7%).

Comments/queries:

Please provide more information on the collection of data during the second trimester. How regularly were women assessed between the second trimester and the outcome assessment (one month after birth). The data collection and the questionnaire section is somewhat confusing because it suggests that many of the study variables (e.g. partner support, stress coping ability) were assessed at the one-month post birth interview, as opposed to during the second trimester (i.e. during the pregnancy and before the birth outcome data was collected). Please clarify.

There is a bit of confusion in the discussion about the need for studies with larger sample sizes, although the large sample size of the study is listed as a study strength. It appears the authors mean that larger sample sizes are required to study rare outcomes (i.e. still birth) in future.

There appears to be a mix-up in the measurement section re the cutoff score for MUAC (18-22cm should be underweight and 22.5-31cm should be normal).

Reviewer 2:

Abstract

“The impact of psychosocial factors on pregnancy outcomes has been investigated in developed countries but few studies have been conducted in low-income countries.” This sentence does not look really important. If the authors have to report this, how can the outcome differ across culture? Why the HIC findings is not generalizable to LICs?

Introduction

The authors argued that the moderating effect of depression was not studied in Ethiopia. If this is known in other countries, is it not generalizable to other countries like Ethiopia?

Methods

The authors argued that preterm birth was not controlled in previous studies. it is understood that measurement of preterm birth is very problematic as women cannot remember the LMP which might have affected the results. The challenges related to assessment of preterm birth and low birth weight were not stated in limitations. There is also stigma related to reporting stillbirth. How could the authors managed to reduce bias related to such stigma.

The grave limitation of previous studies on the association of depression and LBW were linked to low sample size which was also the case in the current study. How different is the current study from previous studies?

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

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

**********

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: Yes

**********

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: Abstract

“The impact of psychosocial factors on pregnancy outcomes has been investigated in developed countries but few studies have been conducted in low-income countries.” This sentence does not look really important. If the authors have to report this, how can the outcome differ across culture? Why the HIC findings is not generalizable to LICs?

Introduction

The authors argued that the moderating effect of depression was not studied in Ethiopia. If this is known in other countries, is it not generalizable to other countries like Ethiopia?

Methods

The authors argued that preterm birth was not controlled in previous studies. it is understood that measurement of preterm birth is very problematic as women cannot remember the LMP which might have affected the results. The challenges related to assessment of preterm birth and low birth weight were not stated in limitations. There is also stigma related to reporting stillbirth. How could the authors managed to reduce bias related to such stigma.

The grave limitation of previous studies on the association of depression and LBW were linked to low sample size which was also the case in the current study. How different is the current study from previous studies?

Reviewer #2: This paper was well conceived and well-written. The authors conducted a large survey of pregnant women (n~900) in Gondar town, Ethiopia. The main exposure in the study was antenatal depression and the main outcome was incidence of adverse birth outcome (preterm birth, low-birth weight or still birth). Information on a range of risk factors (e.g. occupation, age, marital status, religion, physical activity, social support, coping strategies, antenatal healthcare attendance etc.) was also collected and including in the data analysis (which was conducted using structural equation modelling). The authors report on the main risk factors for each adverse birth outcome. The main findings in relation to the incidence of still birth indicates that Ethiopia is lagging behind other countries in reducing still births. Depression was not a risk factor for still birth in this study (perhaps due to low power); neither was is associated with low-birth weight or pre-term labour. The main findings suggest that perceived partner support and ability to cope with stress were moderated the relationship between depression and low-birth weight (although the effect was small) - and the effect was stronger when considering preterm birth. There was no main effect for experiencing depression and low-birth weight or preterm birth. So the main take-home message appears to be that interventions efforts might be better focused on increasing partner support and the woman's ability to cope with stress.

The authors neatly report on the study strengths and limitations in the discussion. The survey response rate was extremely high (97.7%).

Comments/queries:

Please provide more information on the collection of data during the second trimester. How regularly were women assessed between the second trimester and the outcome assessment (one month after birth). The data collection and the questionnaire section is somewhat confusing because it suggests that many of the study variables (e.g. partner support, stress coping ability) were assessed at the one-month post birth interview, as opposed to during the second trimester (i.e. during the pregnancy and before the birth outcome data was collected). Please clarify.

There is a bit of confusion in the discussion about the need for studies with larger sample sizes, although the large sample size of the study is listed as a study strength. It appears the authors mean that larger sample sizes are required to study rare outcomes (i.e. still birth) in future.

There appears to be a mix-up in the measurement section re the cutoff score for MUAC (18-22cm should be underweight and 22.5-31cm should be normal).

**********

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

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

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

Reviewer #1: No

Reviewer #2: Yes: Orla McBride

[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-19-29080R1

Effect of Antenatal Depression on Adverse Birth Outcomes in Gondar Town, Ethiopia: A community-based cohort study

PLOS ONE

Dear Mr Fekadu,

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 explain how did you achieve such high response rate on the survey, Thank you

We would appreciate receiving your revised manuscript by Jun 20 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,

Anna Palatnik, M.D.

Academic Editor

PLOS ONE

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

[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.

Effect of Antenatal Depression on Adverse Birth Outcomes in Gondar Town, Ethiopia: A community-based cohort study

PONE-D-19-29080R2

Dear Dr. Fekadu,

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

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

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

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

Kind regards,

Anna Palatnik, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: