PONE-D-19-20515

Prevalence and predictors of uterine rupture among Ethiopian women: A systematic review and Meta- analysis

PLOS ONE

Dear Melaku Desta

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.

Kindly address all feedback provided by the reviewers, with particular attention to the approach used for the meta-analysis and whether the meta-regression should be removed.  Kindly take particular attention to typographical or grammatical errors throughout the manuscript. 

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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: Partly

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

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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: Yes

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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: The paper is generally well written and the methods used are appropriate. I will focus on methods and reporting

Major

1) Meta-analyses of proportions are a bit more complicated since transformations are needed to account for the 0 and 100% limits. Step 1: transformation; step 2: meta-analysis method using standard approach (i.e. inverse variance DerSimonian-Laird); step 3: back-transformation to percentages and plotting. One approach is logit transformation, which is explained in a different context here: http://www.bmj.com/content/352/bmj.i1114. However, a double arcsine transformation is the norm (http://jech.bmj.com/content/early/2013/08/20/jech-2013-203104). The method is implemented in the Stata module metaan http://www.stata-journal.com/article.html?article=st0201. Alternatively you can manually perform using the command you used (I suspect metan, although not referenced).

2) Meta-regression is a stab in the dark usually and is underpowered to detect anything but massive associations (effectively a regression with X observations, where X is the number of available studies). You should discuss this as a major limitation. Even with 60 or 80 studies, it can provide little insight.

3) Cochran Q (i.e. chi-square) is notoriously underpowered to detect heterogeneity, especially for small meta-analyses http://www.ncbi.nlm.nih.gov/pubmed/9595615. I would not use. (see also comment below regarding this and I^2)

4) Exclude the Getahun study which is an outliers and re-analyse - do things change a lot?

5) Report the confidence intervals for I^2 (calculated using heterogi or metaan in Stata) as argued in http://www.ncbi.nlm.nih.gov/pubmed/17974687. A simple formula exists in the seminal 2002 Higgins paper that proposed I^2.

6) Very high heterogeneity estimates which according to some researchers means studies should not be meta-analysed. However, I disagree with that assessment and I am not surprised at all by your heterogeneity estimates. You have large meta-analyses and there is a direct link between meta-analysis size and detected heterogeneity. I disagree with the argument that when large heterogeneity is picked up, studies should not be combined. In my view, large heterogeneity is the norm and it's great if it has been picked up and can be incorporated in the model. It is much more problematic when the underlying heterogeneity is not picked up and studies are "safely" combined under a homogeneity assumption. I think you can use this to defend your decision and the high heterogeneity: http://www.ncbi.nlm.nih.gov/pubmed/23922860

Minor

1) Abstract: I^2 is a statistic, not a test (or a test statistic)

2) There is no p-value associated with I^2, the authors mean Cochran's Q but see my other comment regarding this

3) Stata not STATA (not an acronym)

4) Some language corrections are needed in the methods section, from "Besides,..." onwards (which should read as "Next,...")

5) Which user-written commands in Stata did you use to perform the analyses? please cite.

6) Year may be worth considering in bias assessment, especially if you don't have enough studies for a formal test: http://www.ncbi.nlm.nih.gov/pubmed/25988604. With newer studies we would be more confident.

7) Clarify the weighting for the RR random effects model. Inverse variance (IV) or Mantel Haenszel (MH)? Note that MH is traditionally a fixed effect approach.

8) How was the random-effect model implemented, i.e. how was heterogeneity estimated? There are numerous ways to do so. Did they use the standard DerSimonian-Laird method? If so, please state so. Also there are better performing methods, for example please see https://www.ncbi.nlm.nih.gov/pubmed/28815652 and the metaan command in Stata where these are implemented.

Reviewer #2: This is an important paper in that it documents the continuing high risk of uterine rupture among mothers in Ethiopia.

The Methods and Results need some work.

Table 1. Characteristics of the included studies

Did all the studies define uterine rupture in the same way?

Were the studies population-based or hospital/clinic/village-based?

Are there any other characteristics of the studies that could be tabulated and might be helpful to the reader; e.g., accoucheur?

What was the outcome in the case-control studies? Was it uterine rupture? How can a case-control study provide an estimate of the prevalence of uterine rupture?

What was the design of the cohort study? Were mothers followed up from one pregnancy to the next?

Why did the Gretahun study observe a prevalence of 17%?

The 1996 and 2004 studies seem old; perhaps exclude?

Table 2.

There are not enough studies for a meta-regression; and the results are not critical to conclusions of the paper; and are not very informative. Suggest omit.

Publication bias

The assessment of publication bias is ok, but could be omitted; it doesn’t add much. Publication bias is more of an issue for meta analyses of RCTs.

Heterogeneity

It is probably useful to report I2. Q and the associated p-value could be omitted. They do not add anything.

Figure 1. Flow chart

More details are needed on why three papers could not be assessed and one paper was excluded because of low quality.

As above, Gretahun result is an extreme outlier. Some explanation is needed.

Statistical methods

More details on the methods are needed. For proportions <5% (say), as in your study, the sampling distribution might not be normally distributed. Therefore, some transformation is typically used (e.g., logit, double arcsin). Statistical packages, such as Stata and R, incorporate these transformations into their software programs for meta analyses of proportions. It is likely that the statistical package that you used did the transformation and back-transformation; you should document this.

Writing

The paper is clearly written. There are some typographical and grammatical errors, which should be corrected.

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Reviewer #1: No

Reviewer #2: Yes: Michael Coory

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PONE-D-19-20515R1

Prevalence and predictors of uterine rupture among Ethiopian women: a systematic review and meta-analysis

PLOS ONE

Dear Melaku Desta

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.

While the methods are generally adequate, some improvements and clarification is still required. Many key comments made by the reviewers have not been adequately addressed. Kindly provide a detailed response to each of the comments provided in your response letter, referring to the place in the manuscript the modification has been made or provide justification where changes were not made

Please pay particular attention to the comments regarding the use of meta-regression and subgroup analyses by type of study design. Please address the comment regarding the appropriateness of presenting a prevalence estimate for studies using a case control study design. Kindly define the exposure in more details such as "ANC visit".

Finally, please revise the manuscript to improve the English and formatting throughout including appropriate use of all abbreviations.

We would appreciate receiving your revised manuscript by Mar 19 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,

Vicki Jane Flenady

Academic Editor

PLOS ONE

[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-19-20515R2

Prevalence and predictors of uterine rupture among Ethiopian women: a systematic review and meta-analysis

PLOS ONE

Dear Dr. desta,

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.

Your manuscript has been assessed by two reviewers, whose comments are appended below. One of the reviewers does not think that the revisions have gone far enough to address the concerns that were initially raised; this concern was also noted by the Academic Editor in the last round of review. Therefore, please ensure that you respond to all comments by making the appropriate revisions. To address the remaining concerns about the clarity of the manuscript text, we recommend having your manuscript copy edited for language usage and grammar, for instance by a third party or a professional service.

Please submit your revised manuscript by Sep 28 2020 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 plosone@plos.org. 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.

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). 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: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Emily Chenette

Deputy Editor in Chief

PLOS ONE

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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: (No Response)

Reviewer #3: All comments have been addressed

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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 #3: Yes

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

Reviewer #1: Yes

Reviewer #3: N/A

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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 #3: Yes

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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: No

Reviewer #3: Yes

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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: The structure of the responses was muddled and I couldn't clearly see all the comments I made and the responses.

The language is still a bit poor at times and some of the previous comments have not been actioned and the response regarding them was not clear (e.g. confidence intervals for I^2). Mention the user-written sofware you used in Stata.

Reviewer #3: The manuscript is now well structured and compliant with the reviewers' requests. There are only two notes to make.

Abstract

What is ANC visit? Please clear the acronym before the acronym.

Introduction

Authors reported: …..partial rupture in which a defect in the myometrium is covered by the visceral leaf of the peritoneum….it is a dehiscence. Please, state it.

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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 #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.]

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

Prevalence and predictors of uterine rupture among Ethiopian women: a systematic review and meta-analysis

PONE-D-19-20515R3

Dear Desta

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,

Gizachew Tessema, PhD

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 #1: (No Response)

Reviewer #3: All comments have been addressed

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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: (No Response)

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #3: Yes

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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 #3: Yes

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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 #3: Yes

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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: The language is much better but I still do not see the confidence intervals for I^2 reported, even though the authors say they are reporting then now

Reviewer #3: The authors diligently answered the reviewers' questions and completely corrected the manuscript by submitting the third version of the paper.

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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 #3: Yes: ANDREA TINELLI