PONE-D-21-20712Postpartum depression and associated risk factors among mothers in Galle, Sri LankaPLOS ONE

Dear Dr. Therese Roysted Solas,

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.

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ACADEMIC EDITOR:

Please address the comments mentioned in the additional comments section below:

​Please submit your revised manuscript by October 10, 2021. 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Yeetey Akpe Kwesi Enuameh, MD, MSc, DrPH

Academic Editor

PLOS ONE

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We will update your Data Availability statement on your behalf to reflect the information you provide

Additional Editor Comments (if provided):

The topic is of great relevance to maternal and child health... there are some issues that when addressed should enhance the outlook of the paper... Please address the comments of the reviewer...

1. The title of the current paper and that by Fan et al., 2020 are quite similar. Could you please come out clearly as to what differs between your paper and the earlier published one, more so when the study population seems to be the same.

2. Lines 17 & 40: The prevalence estimates provided here were 1996 figures... could there not have been much more recent ones? Also add the estimates from South Asia - as you compare it in the conclusion...

3. Lines 56 - 58: I am not clear about this point... what has this to do with PPD? I read over the cited article, did not come across a relationship between poverty and quality of parenting... please clarify...

4. Lines 92 - 93: Why the assumption based on 1996 figures? More so, when there was a 2017 study in the same population?

5. Lines 94 - 95: Why all mothers????? We the readers are not privy to information on deliveries in the study community... Also, the results section (line 159) has 975 persons... you have not clearly stated how was that arrived at... were those all the mothers interviewed? any mothers not included? response rate?

6. Line 98: Will suggest this section be structured as e.g., data collection methods, tools, and process.

7. Lines 106 - 107: check this.... specificity????

8. Lines 109 - 115: Is the information presented here related to data collection?

9. Line 114: Is the ICD used for classification or diagnosis?

10. Line 126: Label this as a sub-section e.g., variables considered.

11. Lines 159 - 162: Please make reference to table 2.

12. Lines 193 - 195: Revise the title to be much more concise.

13. Line 201: Mention "EPDS Question 10" in the "Methods section" as part of the data collection tools.

14. Lines 214 - 216: Were these characteristics also in the 2017 study? If so, state that clearly... if not, then provide the appropriate citation.

15. Finally, please follow the reporting guidelines for Cross-sectional studies as provided in the link to guide your paper: https://www.equator-network.org/reporting-guidelines/strobe/. Also review the PLOS ONE guidelines on publications: https://journals.plos.org/plosone/s/criteria-for-publication

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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: Partly

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

Reviewer #1: Yes

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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

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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

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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 study addresses a key issue however there are some modifications required.

Background

The authors provide some useful information about postpartum depression in the background. Considering that a very similar study had already been conducted in the catchment area however, I think the authors could have provided more information on PPD in Sri Lanka and Galle. In addition, information on the validated tools used in measuring PPD in Sri Lanka as stated in the previous study are also relevant to this study. They could have been stated and appropriately referenced in this section as well.

For example, the fact that the EPDs have been translated into Sinhalese and validated in Sri Lanka is important information that should be made known in the background paper. Additionally, PPD in Sri Lanka is reported to have decreased since 2011 and the background of this paper should have captured this information.

Justification of study: Lines 71-74

The study was justified on the grounds that the similar study conducted in the same area in 2017 showed a PPD lower than that of another study conducted in Sri Lanka in 2004. However, a lot could have happened between 2004 to 2017 when the new study was conducted. Various reasons could have contributed to the difference and a proper review of the programs and interventions put in place between 2004 to 2017 could have provided more information as to why this difference was observed. Additionally, the 2017 paper indicated that there had been a general reduction in PPD from 2011, so the reduction should not really come as a surprise anyway. In my view therefore, there is not a strong justification for this study and it does not really offer anything new as it stands.

Recommendation: A comparative analysis or trend analysis between the previous studies from 2011 to 2017 will give a better justification for the study and provide a clearer picture of PPD in Sri Lanka. Therefore, if the data is available, I recommend that the authors provide some more information on PPD between 2011 to 2017. The authors can also make a stronger justification for the study using the timing of their administration of their EPDs if it differs significantly from other studies in Sri Lanka

Methods

The collection of data using the EPD form is not really clear. Was the PPD information collected as part of the routine data collection or the team specifically went out to the field and collected this data using midwives?

This distinction should be made clearer in the write up. It is clear that the team made use of routine records for the other variables but as things stand now one gets the impression that the PPD information was collected in the same way. I am not sure that is the case however if the previous 2017 study is anything to go by.

Additionally, if this is not the case then, I am also wondering why informed consent (verbal at least) was not required? Was this study simply a secondary analysis of routine data?

How often is screening done for PPD at the facility? Was the EPD form only employed because of this current study? If the screening form and PPD data is readily available, then the team could also do a trend analysis or provide some more information on PPD in the catchment area prior to the study.

Lines 104-109: The study made use of the Tamil and Sinhala versions of the EPDS. Additionally, the study also talks about illiterate participants. Who are the illiterate participants? Are illiterate participants in this case participants who could not read Tamil and Sinhala?

Results

The results are well presented. Some of the confidence intervals are really wide though and the authors should take a second look at their analyses and the assumptions made for their models. Example New born death aOR 28.9 (4.5-185.1). The authors did not present any findings from their chi square analysis.

Discussion

Line 209: According to the authors they dealt with women who had just given birth. However, in earlier chapters, they spoke about women who had given birth 4 to 6 weeks ago. The authors should be consistent as time is important in measurement of PPD. The study in 2017 for example had two time points (10 days and 4 weeks).

Recommendation: In the 2017 study, it was recommended that further studies on the effect of time since delivery on PPD should be looked at. Since the form is administered routinely, the authors can look at the different time periods that the forms are administered to make a stronger case about PPD in Sri Lanka.

Conclusion

The conclusion here is much better than that the one in the abstract. The authors could look at revising the one in the abstract

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Reviewer #1: No

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PONE-D-21-20712R1Risk of postpartum depression in Sri Lanka: A population-based study using a validated screening toolPLOS ONE

Dear Dr. Solas,

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.

==============================

Some issues related to consistency of expressions used, grammatical and structural errors to not make the manuscript fit for publication at this point in time. Please patiently and meticulously address the issues raised below and resubmit.

==============================

Please submit your revised manuscript by March 22, 2022. 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: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Yeetey Akpe Kwesi Enuameh, MD, MSc, DrPH

Academic Editor

PLOS ONE

Journal Requirements:

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.

Additional Editor Comments:

Thanks to the authors for the efforts at revising the manuscript. Though Reviewer 1 has cleared the paper for publication, there are still some issues to be addressed to enhance its outlook. I have made comments on the part of the paper with tracked changes. There are several grammatical and structural errors in the manuscript, as such I would recommend it being submitted for proof-reading to rectify most of those errors.

1. Though the title has been revised, the content of the paper seems to be at variance. Is the focus on "Risk of PPD", OR "Prevalence of PPD" or "Prevalence of risk of PPD"? That should come out clearly and consistently throughout the manuscript.

ABSTRACT

2. Lines 40 & 41: Please revise the grammar and sentence structure to enhance clarity.

3. Line 42: Should the sentence not be "The prevalence of PPD among mothers with EPDS score 9 and above was..."? To the best of my understanding, the prevalence is of PPD and not EPDS.

4. Line 47: The "thoughts of self-harm" should be appropriately linked to PPD... Just mentioning it does not add any value to its presence...

5. Line 48: can 9.4% be referred to as "a significant proportion"???

6. Lines 50 & 51: Would it not have been simpler to just say as the data shows that "a higher cut-off produces reduced PPD prevalence estimates"? The current statement is quite ambiguous...

INTRODUCTION

7. Line 64: "suggest" or "suggests"?

8. Lines 73 & 74: how is this related to PPD? that would be very helpful to contextualize the information on "self-harm".

9. Line 94: "put focus" does not seem to be the right expression

10. Line 98, 104 & 105: Revise the sentences grammatically and structurally to enhance its clarity

11. Lines 106: Is the focus of the study "Prevalence of mothers at risk of PPD" or "prevalence of mothers with PPD"????

12. Line 113: Under point 1, which study is being "repeated"?

13. Line 114: Postpartum women do not attend "antenatal clinics", so please revise

PARTICIPANTS

14. Line 138: Would it not be best to add that this sample size (907) was close to the 975 that delivered over the period and as such they were all included in the study?

15. Line 140 & 141: Why not say "mothers with incomplete EPDS records were excluded from the study"?

STUDY TOOL

16. Line 152 & 153: The sentence seems to be contained in the next, so why not incorporate one into the other?

17. Line 156: Would be great if the influence of "thoughts of self-harm" on PPD could be clearly stated

DATA COLLECTION

18. Line 170: pregnant women in this study cannot have EPDS records as the information is collected after 4 weeks of delivery..

DATA ANALYSIS

19. Lines 199 - 202: The non-use of the Pearson Chi-square test in data analysis was raised by Reviewer 1.... this was not reflected in the results section...

20. Lines 206 - 208: "Thoughts of self-harm" seem to be a very important feature of this study - could you clearly state the importance of this to PPD or its influence on the study outcomes clearly?

RESULTS

21. Line 218: The study was not about "pregnant women", so please revise

DISCUSSION

22. Line 276: which is the former publication??? any citations?

23. Line 281: "Newborn death" is not a maternal characteristic

24. Line 286: What are you implying with the statement "our material"???

25. Line 293: The statement is contrary to that of the first sentence in the conclusion of the abstract...

26. Line 299: Check your grammar

27. Line 360: the available "study population" was used... why not state that instead of "adequate sample size"?

28. Line 366: is it "prevalence of PPD" or "risk of PPD" or "prevalence of risk of PPD"???? Please be consistent all through the manuscript...

CONCLUSION

29. Line 381: Should the initial part of the sentence not be "the prevalence of PPD" or "risk of PPD at an EPDS score of 9 or more"???? Thought it was the "prevalence of PPD being measured with the EPDS" and "not the prevalence of EPDS".

30. Line 384: In place of "had a substantial impact", why not state clearly that "there was a drop in prevalence rates with higher cut-offs for EPDS"??? That would be much more to the point

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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

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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

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

Reviewer #1: 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

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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

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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: (No Response)

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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

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Attachments

Attachment

Submitted filename: PONE-D-21-20712_R1.pdf

Mothers at risk of postpartum depression in Sri Lanka: A population-based study using a validated screening tool

PONE-D-21-20712R2

Dear Dr. Solås,

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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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,

Yeetey Akpe Kwesi Enuameh, MD, MSc, DrPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors have addressed the issues raised. Just one final suggestion, could you replace "crosstabulation" on line 26 of the abstract with "univariate" and change "regression" to plural?

Congratulations and thanks for your patience.

Reviewers' comments: