Effects of relaxation interventions during pregnancy on maternal mental health, and pregnancy and newborn outcomes: A systematic review and meta-analysis

Mubarek Abera; Charlotte Hanlon; Beniam Daniel; Markos Tesfaye; Abdulhalik Workicho; Tsinuel Girma; Rasmus Wibaek; Gregers S. Andersen; Mary Fewtrell; Suzanne Filteau; Jonathan C. K. Wells

doi:10.1371/journal.pone.0278432

Peer Review History

Original SubmissionNovember 15, 2022
17 Jul 2023 Decision Letter - Fadhlun Alwy Al-beity, Editor PONE-D-22-31287Effect of relaxation interventions in pregnant women on maternal and neonatal outcomes: A systematic review and meta-analysisPLOS ONE Dear Dr. Mubarak Abera 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. ============================== ACADEMIC EDITOR: Kindly check for errors in the manuscript =========="A total of 19 studies were included in the systematic review (Error! Reference source not found.)."==================== Please submit your revised manuscript by 20 Aug 2023. 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, Fadhlun Alwy Al-beity, MD, PhD 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 https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf. 2. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability. "Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized. Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access. We will update your Data Availability statement to reflect the information you provide in your cover letter. 3. Please ensure that you refer to Figures 1-4 in your text as, if accepted, production will need this reference to link the reader to the figure. 4. 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. [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: No ****** 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: 1. Pregnant women at risk of preterm births are likely to have more anxiety , depression etc. Why were they excluded from the analysis? 2. Although methodology section mentions to study impact in early postnatal life . Details are missing . Reviewer #2: Dear authors I would like to thank you for giving me the opportunity to review the manuscript entitled “Effect of relaxation interventions in pregnant women on maternal and neonatal outcomes: A systematic review and meta-analysis”. This systematic review and meta-analysis were conducted on studies that have tested relaxation interventions to improve maternal wellbeing, and pregnancy and birth outcomes in various settings. My comments are as follows: - This study should be included in the review: Effects of Benson Relaxation Technique and Music Therapy on the Anxiety of Primiparous Women Prior to Cesarean Section: A Randomized Controlled Trial: https://www.hindawi.com/journals/arp/2022/9986587/ - Since it has been more than a year since the search, I suggest you do the search again. - Some citation did not reveal in the text such as P 9. ****** 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: Yes: DR PRAVEEN KUMAR Reviewer #2: Yes: OK ******** [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. https://doi.org/10.1371/journal.pone.0278432.r001
Revision 1
1 Sep 2023 Author Response Response to Feedback Our general response: The authors are thankful to the reviewers for taking their time to read and give us important feedback/comments on our manuscript. Now we have considered the comments and have done important edits throughout the document to improve the quality and intensity of the manuscript. Below please find point-by-point response to the issues raised. We have used track change in the main document to indicate changes. 1. Pregnant women at risk of preterm births are likely to have more anxiety, depression etc. Why were they excluded from the analysis? Response: Thank you for this comment. Now we have included those articles in to the review. 2. Although methodology section mentions to study impact in early postnatal life. Details are missing. Response: Now this is clarified that the aim of this study is to examine the effect of relaxation intervention on maternal wellbeing, pregnancy and birth and newborn outcomes. Our study does not assessed the impact during the early postnatal life. 3. This study should be included in the review: Effects of Benson Relaxation Technique and Music Therapy on the Anxiety of Primiparous Women Prior to Cesarean Section: A Randomized Controlled Trial: https://www.hindawi.com/journals/arp/2022/9986587/ Response: Now we have added this and other articles identified when we update the searching. Thus a total of 13 articles are added now. Consequently we have revised the manuscript consistently throughout the text. 4. Since it has been more than a year since the search, I suggest you do the search again. Response: Now we updated this on 26 August 2023 and made the desired revisions. 5. Some citation did not reveal in the text such as P 9. Response: Now corrected Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0278432.r002
3 Nov 2023 Decision Letter - Daniel Ahorsu, Editor PONE-D-22-31287R1Effects of relaxation intervention during pregnancy on maternal mental health, and pregnancy and newborn outcomes: A systematic review and meta-analysisPLOS ONE Dear Dr. Abera, 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 submit your revised manuscript by Dec 18 2023 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: 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, Daniel Ahorsu, PhD 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: The author must be commended for revising the manuscript according to the reviewers' comments. However, there are still minor revision that needs to be made. Major comments 1. As authors keep on revising their manuscript, they must make sure the revision is reflected throughout the manuscript such that there are no anomalies in numbers (e.g., the number of studies for stress, and anxiety) and reports. For instance, findings reported in the results section were different from the Figures (e.g., Fig 1—PRISMA flow charts, Figure 2 etc). Also, for some of the Figures (Figure 2, 3), if the reference is the same, authors may differentiate them with “a” and “b” so readers may appropriately identify the exact study being referred to. For instance, Guardinoa et al. 2014a and Guardinoa et al. 2014b. If it is the same study, the same style can be used but it may be indicated beneath the figure as note “that the Guardinoa et al. 2014a and –2014b are from the same study. Please authors should make sure they rectify all these inconsistencies. • Nine trials on maternal perceived stress during pregnancy using PSS (30–38), 12 trials on anxiety during pregnancy using the State-Trait Anxiety Inventory (S-TAI) (30,31,33,35,38–45), 7 trials on antenatal and postnatal depression using the Edinburgh Postnatal Depression Scale (EPDS) (31,37,41,42,44,46,47), and 6 trials reported birth weight in grams or kilograms (44,48–52) 2. The reviewer commented on a missing reference for a study that was added In all, I suggest that the authors thoroughly go through and revise the manuscript to make sure there are no inconsistencies or missing data/information in the manuscript. Especially, they should go through the results section once more and update the discussion section appropriately. [Note: HTML markup is below. Please do not edit.] 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 #2: All comments have been addressed ******** 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 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 #2: 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 #2: 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: Thanks for making necessary changes . This study will help in management of mothers with psychological stress. Reviewer #2: Dear authors Thank you for addressing my comments. Some studies that were added newly were not included in the reference list. For instance, Abarghoee SN, et al. 2022 ****** 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: Yes: DR PRAVEEN KUMAR Reviewer #2: Yes: OK ******** [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. https://doi.org/10.1371/journal.pone.0278432.r003
Revision 2
15 Nov 2023 Author Response Our general response: The authors are thankful to the reviewers for taking their time to read and give us important feedback/comments on our manuscript. Now we have considered the comments and have done important edits throughout the document to improve the quality and intensity of the manuscript. Below please find point-by-point response to the issues raised. We have used track change in the main document to indicate changes. 1. As authors keep on revising their manuscript, they must make sure the revision is reflected throughout the manuscript such that there are no anomalies in numbers (e.g., the number of studies for stress, and anxiety) and reports. For instance, findings reported in the results section were different from the Figures (e.g., Fig 1—PRISMA flow charts, Figure 2 etc). Also, for some of the Figures (Figure 2, 3), if the reference is the same, authors may differentiate them with “a” and “b” so readers may appropriately identify the exact study being referred to. For instance, Guardinoa et al. 2014a and Guardinoa et al. 2014b. If it is the same study, the same style can be used but it may be indicated beneath the figure as note “that the Guardinoa et al. 2014a and –2014b are from the same study. Please authors should make sure they rectify all these inconsistencies. Response: These now are corrected on the search flow diagram (fig 1), and all other figures (fig 2-5) by avoiding inconsistencies in the number and type of studies. Findings from similar studies are noted as ‘a’ and ‘b” as recommended by reviewer. 2. Nine trials on maternal perceived stress during pregnancy using PSS (30–38), 12 trials on anxiety during pregnancy using the State-Trait Anxiety Inventory (S-TAI) (30,31,33,35,38–45), 7 trials on antenatal and postnatal depression using the Edinburgh Postnatal Depression Scale (EPDS) (31,37,41,42,44,46,47), and 6 trials reported birth weight in grams or kilograms (44,48–52)? Response: this statement is now also revised and clarified in the main document as “Among the 27 RCT studies, 9 trials were on maternal perceived stress during pregnancy using PSS (35–43), 13 trials on anxiety during pregnancy using the State-Trait Anxiety Inventory (S-TAI) (35,36,38,40,43–51), 7 trials on antenatal and postnatal depression using the Edinburgh Postnatal Depression Scale (EPDS) (30,36,42,46,47,49,52), and 8 trials were on birth weight and reported weight in grams or kilograms (31,49,53–58). 3. The reviewer commented on a missing reference for a study that was added. In all, I suggest that the authors thoroughly go through and revise the manuscript to make sure there are no inconsistencies or missing data/information in the manuscript. Especially, they should go through the results section once more and update the discussion section appropriately. Response: Now missing references are included (4 studies). Moreover the result and discussion section has been thoroughly edited. 4. Some studies that were added newly were not included in the reference list. For instance, Abarghoee SN, et al. 2022 Response: now this and other missed studies are included. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0278432.r004
20 Nov 2023 Decision Letter - Daniel Ahorsu, Editor PONE-D-22-31287R2Effects of relaxation interventions during pregnancy on maternal mental health, and pregnancy and newborn outcomes: A systematic review and meta-analysisPLOS ONE Dear Dr. Abera, 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 submit your revised manuscript by Jan 04 2024 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: 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, Daniel Ahorsu, PhD 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 : The authors have appropriately revised the manuscript but more needs to be done as mentioned in my previous comments. Going through the data once more, I realized that the data were wrongly reported in Figure 2 (stress). Please recheck the mean difference for PMR/BR. It is not -13.1 but rather -8.1, (95%CI -17.80, 1.6) and this mean difference is not significant. Anytime a reader or researcher consuming your manuscript sees such an anomaly, it casts doubt on whether the whole manuscript can be trusted. This is a medical/health-related manuscript which will significantly impact how we treat people so data should be thoroughly checked before submission. Although reviewers are to help check these, the absolute responsibility rests with authors and not reviewers and editors. The same issue, especially with PMR/BR can be found in anxiety figure 3. Again, although MD was -8.61 the 95%CI contains “0” which means it is not significant. I am very sure I can get so many examples If I spend hours going through the manuscript again. So, I will entreat the authors to go through it once more or better still let another neutral person edit it before re-submission. I also noticed that there were “Trails” instead of “trials” in the results (3 times). Importantly, please prepare a response letter detailing point-by-point where the revision was made and with page numbers so I can quickly cross-check. All the best. [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.] 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. https://doi.org/10.1371/journal.pone.0278432.r005
Revision 3
24 Nov 2023 Author Response Response to review feedback Our general response: we are really very thankful to the editor for giving us this opportunity to correct and make thorough edits to the manuscript. Accordingly all the authors including neutral reader have gone through the manuscript and made a detail read and added the necessary edits and corrections. Moreover below we have indicated for specific corrections we have made. 1. Going through the data once more, I realized that the data were wrongly reported in Figure 2 (stress). Please recheck the mean difference for PMR/BR. It is not -13.1 but rather -8.1, (95%CI -17.80, 1.6) and this mean difference is not significant. Response: Again we thank you for this feedback. The confusion happen when we report finding from individual PMR/BR trial without reporting the finding from the overall subgroup analysis in the text. So now we have clarified and corrected this as follow on page 10. “In a subgroup analysis although PMR/BR as a group showed no significant association (mean difference -8.1, 95% CI: -17.8, 1.6), an individual PMR/BR trial (mean difference: -13.1; 95% CI:-15.3, -11.0) and meditation therapy (mean difference: -13.1; 95% CI:-14.0, -12.2) showed the highest effect size while music therapy as a group showed the lowest effect size (mean difference = -0.8; 95% CI:-1.5, -0.1).” 2. The same issue, especially with PMR/BR can be found in anxiety figure 3. Again, although MD was -8.61 the 95%CI contains “0” which means it is not significant. Response: We have also corrected and clarified this as follows on page 11. “In the subgroup analysis although PMR/BR trials as a group showed no association (mean difference: -8.6; 95% CI: -22.6, 5.4), individual PMR/BR trials showed the highest effect size of -15.8 (mean difference: -15.8; 95% CI: -18.3, -13.3) and lowest effect size of -1.5 (mean difference: -1.5; 95% CI: -2.9, -0.1) in reducing symptoms of anxiety.” 3. Cortical spelling errors on Trial vs Trails: Response: We are very sorry for this and we have corrected them on three different sites in the main document page 9, 11 & 12. 4. I will entreat the authors to go through it once more or better still let another neutral person edit it before re-submission. Response: Thank you for this supportive feedback. Now the paper is thoroughly read and edited by all the authors and neutral reader and made important edits as can be seen in the track changed version of the main document. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0278432.r006
30 Nov 2023 Decision Letter - Daniel Ahorsu, Editor PONE-D-22-31287R3Effects of relaxation interventions during pregnancy on maternal mental health, and pregnancy and newborn outcomes: A systematic review and meta-analysisPLOS ONE Dear Dr. Abera, 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 submit your revised manuscript by Jan 14 2024 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: 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, Daniel Ahorsu, PhD 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 : The authors have revised the manuscript which has greatly improved the manuscript. However, I noticed that although the results have changed, it did not reflect in the discussion. Hence, I have provided a few comments to help the authors reflect on the results and discussion sections. 1. Authors should be consistent in how they report the sub-group analysis. A significant MD is what is important first and then the size of the MD and not the other way round. That is, if the MD is super high but it is not significant means nothing research-wise although noteworthy. Hence, I may suggest that authors report those MDs that are significant and then the MD sizes of those significant MDs. Then other super high non-significant MD may be mentioned as noteworthy cases. 2. Authors may choose to mention that the MD of for instance PMR/BR is the highest but the point is that it is not significant and so, research-wise, it does not matter as it can be equated to the other non-significant sub-group analysis. The main point is to clearly discuss why you had these results in the discussion section. In other words, clearly discuss the reasons behind the high MD but non-significant results. This applies to stress and anxiety. 3. Again, if authors will be mentioning sub-group results, then they should be ready to discuss those results. The discussion should also mention the limitations including the effect of single studies for some sub-groups. This is to help consumers understand the results clearly and know the pros and cons of using your findings. As mentioned previously, this manuscript will go a long way to influence clinical decisions and so sentences should be constructed with great caution. 4. Limitations: single studies in some subgroups analysis and their effect [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.] 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. 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Revision 4
15 Dec 2023 Author Response Our response: Again we are very thankful to the editor for giving us these review feedback. Accordingly we have revised and made a careful necessary corrections. Below we have indicated for specific corrections we have made. 1. Authors should be consistent in how they report the sub-group analysis. A significant MD is what is important first and then the size of the MD and not the other way round. That is, if the MD is super high but it is not significant means nothing research-wise although noteworthy. Hence, I may suggest that authors report those MDs that are significant and then the MD sizes of those significant MDs. Then other super high non-significant MD may be mentioned as noteworthy cases. Response: Thank you for this comment. Now we have corrected this accordingly and followed a consistent reporting for subgroup analysis in the text. Corrections are made on page 10-12. 2. Authors may choose to mention that the MD of for instance PMR/BR is the highest but the point is that it is not significant and so, research-wise, it does not matter as it can be equated to the other non-significant sub-group analysis. The main point is to clearly discuss why you had these results in the discussion section. In other words, clearly discuss the reasons behind the high MD but non-significant results. This applies to stress and anxiety. Response: Yes we agree and accept this critical comment. Now we have chosen to report in the text only those that are statistically significant and discussed them accordingly. Corrections are made on page 10-12 and also page 14-16. 3. Again, if authors will be mentioning sub-group results, then they should be ready to discuss those results. The discussion should also mention the limitations including the effect of single studies for some sub-groups. This is to help consumers understand the results clearly and know the pros and cons of using your findings. As mentioned previously, this manuscript will go a long way to influence clinical decisions and so sentences should be constructed with great caution. Response: This is also well addressed in the discussion and limitation sections. Corrections are made on page 14-16. 4. Limitations: single studies in some subgroups analysis and their effect Response: This is now added in the limitation section as “Because of lack of literature, some of the subgroup analysis involved only single study”. Corrections are made on page 17. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0278432.r008
26 Dec 2023 Decision Letter - Daniel Ahorsu, Editor Effects of relaxation interventions during pregnancy on maternal mental health, and pregnancy and newborn outcomes: A systematic review and meta-analysis PONE-D-22-31287R4 Dear Dr. Abera, 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, Daniel Ahorsu, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0278432.r009
Formally Accepted
17 Jan 2024 Acceptance Letter - Daniel Ahorsu, Editor PONE-D-22-31287R4 PLOS ONE Dear Dr. Abera, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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. Daniel Ahorsu Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0278432.r010

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