PONE-D-20-29567

Birth Cultures: Home Births in the Chilean Context

PLOS ONE

Dear Dr. Goberna-Tricas,

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.

The manuscript and the reviewers’ comments were carefully evaluated. The manuscript was appreciated by the Reviewers. Nevertheless, as suggested, the manuscript requires extensive improvement before to be considered for publication. Suggested revisions are in detail reported in the Reviewers’ comments.

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We look forward to receiving your revised manuscript.

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Simone Garzon

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

Reviewer #3: Yes

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

Reviewer #1: N/A

Reviewer #2: N/A

Reviewer #3: N/A

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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

Reviewer #3: 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

Reviewer #3: 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: I really value what you have done.

One concern I have is that you seem to accept the claim that medicine has made that hospitalization is responsible for the lowered maternal and infant morbidity and mortality rates historically, and the data does not support that. Over time, parity decreased, age at first births increased, some general public health measures occurred -- all of which improved infant and maternal health. Where we actually have the data we have been able to see that hospitalization and the destruction of midwifery care harmed not improved outcomes.

That was my main concern.

Reviewer #2: Thanks for giving me the opportunity to review this study which uses qualitative methods to explore the social meaning of home births perceived by women giving birth in several regions of Chile. Below some comments into the different sections:

Title

As SRQR guidelines, it would be useful to include the qualitative approach in the title.

Abstract:

An abstract is included with clear aim, methods. Enumeration of categories/subcategories in “Findings” seems a bit confusing. Was there one major theme “home birth journey” with two subthemes: “making the decision to give birth at home” (Why do I need to give birth at home?; the people around me don’t support me), and “giving birth” (Shifting emotions during home birth; I (don’t) want to be alone).

Introduction

The introduction provides a good overview of birth cultures, feminists approach to motherhood and rational for research. Some citations need to be amended to Vancouver style.

Methods

The methods section describes a qualitative approach (using a phenomenological paradigm and feminist perspective) and rational for this. Context, setting, participant selection is generally well described. Perhaps more contextual factors could be described (e.g. maternity health system, general population health, needs). Recruitment process is not very detailed (e.g. written info provided? who gained consent, timeline, how many weeks after birth were women interviewed? how participants were selected among the 100 interested?). Why were those baseline characteristics selected?

The approval ethical statement needs to be updated in the methods section (it is XXX at the moment). In the submission form authors mention ethical approval from the University of Barcelona, Spain. Since this study was conducted in Chile, it is surprising not to have any Chilean regulatory ethical body review or approval. No author has any Chilean affiliation and no Chilean organisation is acknowledged. Could this have any implications for research and contextualisation of findings? It would be useful for authors to clarify this.

In terms of data collection: How were interviews conducted (face to face, online?)? Who did the interviews/researcher’s characteristics and reflexivity? Data analysis and different steps of thematic analysis are very well described. It would be useful to know if any specific techniques were used to guarantee rigour/trustworthiness of data.

Results/Findings

Having here the table with characteristics of interviews of women will be very useful, as well as the timeline for interviews (X days/weeks/months after birth). A summary of 1-2 lines of baseline characteristics will be useful.

It feels that some statements in these sections are not findings from this study explicitly and should perhaps fit better within the discussion section and referenced (e.g. page 15: The infamy surrounding home births is no coincidence. Let us recall that in olden days, women gave birth inside their homes, attended to by a birth assistant. However, the modernisation ushered in by the industrial revolution has resulted in the institutionalisation of birth…..; and women have gone from labouring in the privacy of their homes to inside hospitals. This has led to a lower maternal and neonatal mortality rate;…; page 19: “Obstetric violence encompasses a series of practices and attitudes such as physical aggression toward pregnant women, verbal abuse, acts of coercion, infantilisation and the performance of unjustified caesarean sections…” ; page 22: “The instant the baby is pushed out during a vaginal birth is regarded as a culminating moment, the climax of a series of stages that, from a physiological point of view, correspond to neurohormonal and physical events”; page 24: as stated by Le Breton [37], emotions are ‘a real or imaginary, past, present….etc)

Discussion is well presented with links to empirical data and good refs (again citations and ref need to be updated to Vancouver style). P28. “It is evident that significant scientific evidence exists supporting home birth. However, healthcare professionals still hesitate to recommend it as a safe option” Does this refer to Chile? It feels this is hugely dependant on context. Are there limitations of the study that need to be considered? (e.g. sample size, lack of data on baseline socio-demographic characteristics)

Reviewer #3: This paper describes a well-done study and insightful analysis, which contributes to the understanding of social importance and experience of childbirth in the Chilean context.

The following changes changes would make the paper stronger and easier for the reader assess the merits of the study:

INTRODUCTION

This study has a strong theoretical foundation, but the authors don't make a clear case for the need for the current research. What gap in knowledge is it filling?

Minor note: Robbie Davis-Floyd is a woman. The sentence citing reference 15 should read "for her part..."

There are also a few sentences in the introduction that are not clear:

The dominant structures

crossed by economic and political models that guide the behaviors of society, have

precarious and violated the collective dynamics surrounding motherhood and parenting (Missing a word?)

Situation that worsens in the puerperium with breastfeeding [13] (Incomplete sentence)

However, not all advocates are homogenous. (Do you mean not all contexts are homogeneous?)

METHODS

Can you provide more justification for the geographical diversity of the sample, and how you expected this to affect your results? The availability of health care is very different across the three sample regions. Did you expect the themes to be different?

Please provide more detail regarding sampling and inclusion criteria. You state that you had 110 potential participants, but you only interviewed 30. Were any of them excluded for reasons other than the inclusion criteria?

Also, why 30 participants? Did you think you would reach saturation with 30? Did you actually reach saturation? Was 30 selected for practical considerations?

Please provide more description in the text regarding the two "complementary processes" involved in the interview script development. These processes are not clear. From the figure, it looks like you identified main themes from a literature search-- that's one process. What was the second?

RESULTS

There are several paragraphs in the results section that are more appropriate for the discussion. The results section should describe your findings, not describe related literature.

DISCUSSION AND CONCLUSIONS

These were strong, but could be enhanced by incorporating some of the content that was prematurely included in the results.

Lastly, you state that the "data are available," but do not note how and where readers could access this data. This should be remedied before publication.

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Reviewer #1: Yes: Barbara Katz Rothman

Reviewer #2: No

Reviewer #3: Yes: Fiona H Weeks

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PONE-D-20-29567R1

Birth Cultures: A Qualitative Approach to Home Birthing in Chile

PLOS ONE

Dear Dr. Goberna-Tricas,

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, perform recommended revision by reviewer 3 for final acceptance. 

Please submit your revised manuscript by Apr 16 2021 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,

Simone Garzon

Academic Editor

PLOS ONE

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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.

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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: All comments have been addressed

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

**********

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

Reviewer #1: N/A

Reviewer #3: N/A

**********

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

**********

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

**********

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: apologies for taking so long. All good. And now filling up space because they want 100 characters....

Reviewer #3: The additions regarding the context and sampling decisions greatly strengthen the paper. I have one small note regarding an addition. This sentence is a bit confusing:

Of those, 33% entailed caesarean sections performed via the public system and 63% took place within

the private system, positioning Chile as a country with one of the world’s highest rates of

C-sectioning [31].

I recommend rephrasing for clarity:

Within the public system, 33% of births are by cesarean delivery and 63% of those in private system are by cesarean, positioning Chile as a country with one of the world’s highest rates of

C-sectioning [31].

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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: Fiona H Weeks

[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.]

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Birth Cultures: A Qualitative Approach to Home Birthing in Chile

PONE-D-20-29567R2

Dear Dr. Goberna-Tricas,

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.

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Kind regards,

Simone Garzon

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: