Band of mothers: Childbirth as a female bonding experience

Tara Tasuji; Elaine Reese; Valerie van Mulukom; Harvey Whitehouse

doi:10.1371/journal.pone.0240175

Peer Review History

Original SubmissionMarch 27, 2020
15 Jul 2020 Decision Letter - Mark Nielsen, Editor PONE-D-20-08734 Band of mothers: Childbirth as a female bonding experience PLOS ONE Dear Dr. Tasuji, Thank you for submitting your manuscript to PLOS ONE. As previously conveyed to you, considerable challenges have been encountered securing expert reviews of this work. Comment has now been received from a leader in the field and these are appended here. Rather than prolong matters further waiting for an additional review I have decided to move forward based on the feedback already provided. As you can see, the view is that there is much work to be done to bring the study to a publishable standard. The comments are clear and so I will not restate them here, but needless to say each deserve attention. I would like to offer you the opportunity to invite you to submit a revised version of the manuscript that addresses the points raised. 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(Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Band of mothers: Childbirth as a female bonding experience The study is on a topic of broad relevance. However, there are a number of concerns: - Identity fusion is a subject of interest, but the way this was explored in this study was not convincing. - At 46 pages, with 5 appendices in addition, 5 figures and 8 tables, the paper is difficult to read and overly long. There is considerable repetition, particularly in describing the hypotheses and research questions initially and then in the findings and the discussion. The variation in time since giving birth (1-28 weeks) or the duration of pregnancy (1-40 weeks) at the time of survey completion is not satisfactory. We know that maternal mood and for example, symptoms of depression (as measured by the EPDS) change over the course of the postnatal period and that anxiety and depression symptoms may change over the course of pregnancy. Thus combining all the data from 1-28 weeks after the event of interest is not satisfactory. - The assumptions made in the process of setting up and carrying out this study overemphasise the negative in framing the possible experience of childbirth in terms of trauma and post-traumatic stress disorder (PTSD). This over-pathologising the experience of childbirth and the reliance on the limited quality of small scale studies in the area of PTSD associated with childbirth, often with specific site-based data collection that relies on women requiring and receiving care at specialist centres or else from self-selected online participants, appears to have led to research questions that relate to a relatively small group (it is estimated 3%). - The direct linking to participants of childbirth with trauma is of concern throughout the study write up and in the way it was presented to participants. - Use of the term ‘dysphoria’ – ‘a profound state of unease or dissatisfaction’ which might affect them was not really investigated here, nor was trauma. In questions just devised for this particular study, ie not previously validated, the subject was the childbirth experience and women were simply were asked about how painful and how difficult they had expected their childbirth to be and then about pain intensity and how unpleasant the experience had been generally and then at the peak of pain. These were then combined in an average pain score, again not validated. - The details of the measures used are presented separately in multiple appendices and there is no overall information about what women were told initially about the study that might encourage them to complete the survey or not and the basic instructions used in the online version. How the study was framed to participants is key in analyzing the data and interpreting the findings. See below: e.g. S2 Appendix. Adapted Version of the Posttraumatic Diagnostic Scale – Self-Report Version for DSM-5 for the Postpartum Questionnaire. Below is a list of problems that people sometimes have after experiencing a traumatic event. Please read each statement carefully and choose the number that best describes how often that problem has been happening and how much it upset you over THE LAST MONTH. Rate each problem with respect to your childbirth experience. - Multiple measures were used, giving rise to multiple testing in this cross-sectional study of a small population (n=75) of self-selected postnatal women who were the main target of the analyses presented. Justification of the measures selected is inadequate. - The findings reflect associations and no causal pathways should be implied in the language used or the way the data are presented. A longitudinal population based study with appropriate measures would be needed with a considerably larger sample size. - The correlations presented are not at all surprising. It looks as though some of these occur because what was being measured was the in effect the same thing or at least closely related, with overlaps between the contructs and co-morbidities. - It is of concern that the measures validated and published by other authors and then selected for the study described were used with adapted wording and thus were in effect changed. -The hypothesized links with postnatal health were not really investigated and it was not possible to do so. In summary the paper reads like an exploratory pilot study. To be acceptable considerable editing would be required, however, there are methodological issues that it may well not be possible to address The title ‘Band of mothers: Childbirth as a female bonding experience’ is an attractive one, but the paper and study methods do not adequately reflect this in the substantial material offered. The contributions and role of the author and co-authors of are not provided and should be clear. ****** 6. 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Revision 1
28 Aug 2020 Author Response August 28, 2020 Dear Dr. Nielsen: Thank you for your comments on our paper and those of the reviewer. Please consider the revised version of our research article “Band of mothers: Childbirth as a female bonding experience” for publication in PLoS ONE. We have addressed each point raised by the reviewer. The study is on a topic of broad relevance. However, there are a number of concerns: - Identity fusion is a subject of interest, but the way this was explored in this study was not convincing. We have clarified our specific reasons for why identity fusion in mothers is interesting and important. Please see pp. 3-5 in the introduction and 34-35 in the discussion. - At 46 pages, with 5 appendices in addition, 5 figures and 8 tables, the paper is difficult to read and overly long. There is considerable repetition, particularly in describing the hypotheses and research questions initially and then in the findings and the discussion. We have radically streamlined the manuscript to cut out 11 pages from our original submission. In the process, we have rewritten and streamlined the hypotheses so that they are now clearer. The variation in time since giving birth (1-28 weeks) or the duration of pregnancy (1-40 weeks) at the time of survey completion is not satisfactory. We know that maternal mood and for example, symptoms of depression (as measured by the EPDS) change over the course of the postnatal period and that anxiety and depression symptoms may change over the course of pregnancy. Thus combining all the data from 1-28 weeks after the event of interest is not satisfactory. The weeks of pregnancy and age of baby variables were not significantly correlated with identity fusion. For the antenatal group, the weeks of pregnancy variable was also not significantly correlated with expected pain and difficulty. For the postpartum group, the age of baby variable was also not significantly correlated with perceived sharedness, pain, and the thinking measures. We have presented this information in the preliminary analyses section on pp. 20. - The assumptions made in the process of setting up and carrying out this study overemphasise the negative in framing the possible experience of childbirth in terms of trauma and post-traumatic stress disorder (PTSD). This over-pathologising the experience of childbirth and the reliance on the limited quality of small scale studies in the area of PTSD associated with childbirth, often with specific site-based data collection that relies on women requiring and receiving care at specialist centres or else from self-selected online participants, appears to have led to research questions that relate to a relatively small group (it is estimated 3%). We have reframed the introduction to note that childbirth is not a traumatic event for most women; indeed, it is typically a joyful and life-changing event. However, it is a physically demanding and highly emotional experience for all women, so it is a good candidate for fusion. The prevailing theory when we began this research was that highly dysphoric events led to fusion. Since that time, there are suggestions that intensely positive events can also lead to fusion. We have cited this research in the introduction, and noted as a limitation in the discussion that we did not measure childbirth-related joy, which we suggest would be useful in future research. Because our study is the first to test childbirth-related fusion, we hope that other researchers will be inspired to refine and expand upon our initial findings in future studies. - The direct linking to participants of childbirth with trauma is of concern throughout the study write up and in the way it was presented to participants. We have reframed the introduction and the discussion to focus less on trauma and more on the emotional intensity of childbirth. In terms of our presentation of the study to participants, we do not believe that it would have caused harm to participants, and our instructions were thoroughly screened by the Ethics Committee at the University of Oxford. - Use of the term ‘dysphoria’ – ‘a profound state of unease or dissatisfaction’ which might affect them was not really investigated here, nor was trauma. In questions just devised for this particular study, ie not previously validated, the subject was the childbirth experience and women were simply were asked about how painful and how difficult they had expected their childbirth to be and then about pain intensity and how unpleasant the experience had been generally and then at the peak of pain. These were then combined in an average pain score, again not validated. It is true that some of these are new measures developed specifically for our novel purposes. The measures all displayed adequate reliability as detailed on pp. 16. Thus, we believe they are promising, although we acknowledge they will require further validation in future studies. - The details of the measures used are presented separately in multiple appendices and there is no overall information about what women were told initially about the study that might encourage them to complete the survey or not and the basic instructions used in the online version. How the study was framed to participants is key in analyzing the data and interpreting the findings. See below: e.g. S2 Appendix. Adapted Version of the Posttraumatic Diagnostic Scale – Self-Report Version for DSM-5 for the Postpartum Questionnaire. Below is a list of problems that people sometimes have after experiencing a traumatic event. Please read each statement carefully and choose the number that best describes how often that problem has been happening and how much it upset you over THE LAST MONTH. Rate each problem with respect to your childbirth experience. We have clarified these issues. Please see pp. 10 in the text and S1 Appendix for the study advertisement that was posted on all parenting and childbirth-related websites. - Multiple measures were used, giving rise to multiple testing in this cross-sectional study of a small population (n=75) of self-selected postnatal women who were the main target of the analyses presented. Justification of the measures selected is inadequate. It is commonplace to use multiple measures in an exploratory study such as this one, which is the first to address fusion in new mothers. Our streamlined hypotheses have clarified that we are looking for patterns across these measures. - The findings reflect associations and no causal pathways should be implied in the language used or the way the data are presented. A longitudinal population based study with appropriate measures would be needed with a considerably larger sample size. We have deleted all instances of causal language. - The correlations presented are not at all surprising. It looks as though some of these occur because what was being measured was the in effect the same thing or at least closely related, with overlaps between the contructs and co-morbidities. With our streamlined hypotheses, we have cut down on the number of correlations presented. - It is of concern that the measures validated and published by other authors and then selected for the study described were used with adapted wording and thus were in effect changed. As previously indicated, we needed new measures for this novel study; our adaptations will need to be further validated in future research. -The hypothesized links with postnatal health were not really investigated and it was not possible to do so. We acknowledge in the discussion section on pp. 35 that these links are concurrent associations, so we cannot claim causality here. In summary the paper reads like an exploratory pilot study. To be acceptable considerable editing would be required, however, there are methodological issues that it may well not be possible to address Our study is the first to research the phenomenon of childbirth-related fusion, so in that sense it is exploratory. However, with over 160 participants and two groups of mothers (antenatal and postpartum), it went well beyond being a pilot study, which typically would be with 10-20 participants. With the reduction in pages and improved use of language, we hope that the paper now better communicates its significance. The title ‘Band of mothers: Childbirth as a female bonding experience’ is an attractive one, but the paper and study methods do not adequately reflect this in the substantial material offered. We believe that this title accurately reflects our main finding, which was that postpartum mothers demonstrated higher levels of fusion with other mothers compared to antenatal mothers. Thus, the event of childbirth supports bonding of women with other mothers. The contributions and role of the author and co-authors of are not provided and should be clear. We have provided this information in the submission system. We have also provided this information here for your reference: Tara Tasuji: Conceptualization, formal analysis, investigation, methodology, project administration, visualization, writing – original draft preparation, writing – review & editing. Elaine Reese: Conceptualization, formal analysis, methodology, project administration, supervision, writing – review & editing. Valerie van Mulukom: Conceptualization, methodology, writing – review & editing. Harvey Whitehouse: Conceptualization, funding acquisition, methodology, project administration, supervision, writing – review & editing. Sincerely, Tara Tasuji https://doi.org/10.1371/journal.pone.0240175.r002
22 Sep 2020 Decision Letter - Mark Nielsen, Editor Band of mothers: Childbirth as a female bonding experience PONE-D-20-08734R1 Dear Dr. Tasuji, 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, Mark Nielsen, Ph.D. Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0240175.r003
Formally Accepted
30 Sep 2020 Acceptance Letter - Mark Nielsen, Editor PONE-D-20-08734R1 Band of mothers: Childbirth as a female bonding experience Dear Dr. Tasuji: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Mark Nielsen Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0240175.r004

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