PONE-D-22-18105Risk of obstetric anal sphincter tear among primiparous women with a history of female genital mutilation, giving birth in SwedenPLOS ONE

Dear Dr. Eshraghi,

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Reviewer #1: Yes

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Reviewer #1: No

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Reviewer #1: No

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Reviewer #1: Review on PONE-D-22-18105 "Risk of obstetric anal sphincter tear among primiparous women with a history of female genital mutilation, giving birth in Sweden".

The paper is well written and evaluates the risk of OASI in women with a history of FGM. There has previously been described an association between FGM and OASI, and it is important to further evaluate this risk in order to decrease the risk of OASI for these women. There are, however, some main concerns regarding the study. Sicnce the study includes a large amount of women in the cohort, there are a broader range of statistical possibilities. First, it is important to evaluate many different possible risk factors of OASI and including them in the multivariable analyses. The authors only include a few, and they do not report why they present differnet models. I would suggest that more variables are added (for example maternal age, ethnicity, etc) and that the authors evaluate the risk of interaction between the different factors. Especially, the interactions between FGM, OASI and episiotomy is interesting.

Further, it would be informative if the authros present the standard indications for episiotomy. And when and how is FGM diagnosed and registered, and when and how is OASI diagnosed and registered?

Are there any codes in the used dataset, that evaluates surgery prior to the delivery to enable vaginal birth without extensive tearing or cutting?

Based on the findings, do the authors suggest a modification of guiding women with a history of FGM regarding mode of delivery?

Line 284-285, the authors state that scarring af labia and the clitoral glance should not increase the risk of OASI. However, they do not come up with an alternative biomechanical explanation for the found association? What about the elasticity in scarred tissue? What about preventive strategies, like the Finnish grip, warm cloths etc. Please elaborate further on this.

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Reviewer #1: No

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PONE-D-22-18105R1Risk of obstetric anal sphincter tear among primiparous women with a history of female genital mutilation, giving birth in SwedenPLOS ONE

Dear Dr. Eshraghi,

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 30 2022 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:

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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.

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We look forward to receiving your revised manuscript.

Kind regards,

Giovanni Buzzaccarini, M.D.

Academic Editor

PLOS ONE

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Additional Editor Comments:

Please, consider the reviewers' comments.

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Reviewers' comments:

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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 #2: All comments have been addressed

Reviewer #3: (No Response)

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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 #2: Partly

Reviewer #3: Yes

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

Reviewer #2: 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 #2: Yes

Reviewer #3: No

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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 #2: 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 #2: Dear authors,

I read with great interest the manuscript, which falls within the aim of this Journal. In my honest

opinion, the topic is interesting enough to attract the readers’ attention. Its very probably that women with a history of FGM had a significant increased risk of OASI in comparison with women without FGM when giving birth in a high income delivery setting.

Nevertheless, authors should clarify some points and improve the discussion, as suggested below. Authors should consider the following recommendations:

In my opinion auhtor's have to improve the paper refering in the text if the pregnancy came from IVF or natural conception and stress how is important the impact of assisted reproduction techniques on the neuro-psycho-motor outcome of newborns and aobut eventually congenital infections .

I suggest to read anf cite these articles:

Waterbirth: current knowledge and medico-legal issues

Congenital Zika Syndrome: Genetic Avenues for Diagnosis and Therapy, Possible Management and Long-Term Outcomes

Convalescent plasma use in pregnant patients with COVID-19 related ARDS: a case report and literature review

Neonatal Outcomes and Long-Term Follow-Up of Children Born from Frozen Embryo, a Narrative Review of Latest Research Findings

Impact of assisted reproduction techniques on the neuro-psycho-motor outcome of newborns: a critical appraisal

Reviewer #3: General Impression:

The authors conducted an interesting study to assess the risk of obstetric anal sphincter injury during normal labor in patients with a previous female genital mutilation. The research followed a robust methodology and statistical analysis, besides including a large sample size -which I believe to be representative. The manuscript is well-written, well-structured, include a comprehensive discussion of its strengths and limitations. I only have some minor comments to further improve the quality of the paper.

Comments:

1. I suppose the word “Centers” is missing from line 115 (from prenatal, delivery and neonatal care Centers”.

2. Regarding lines 133-136, I would suggest adding to the limitation that this coding weakness may lead to the inclusion of non-Swedish women who received vulvar surgery for precancerous indications, but have them classified as patients with FGM. This could lead to overestimation of the chance of having OASI in patients with FGM.

3. “Mode of delivery” is written twice in line 151. Please delete the repetition.

4. In line 159, please provide a reference that justifies the consideration of a p value equals to 0.05 as statistical significance difference,

5. There is an extra “and” in line 186. Please delete it.

6. Please delete lines 211-213 because it is a repetition of the previous two and a half lines.

7. Please include a data availability statement to comply with journal’s policy.

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Reviewer #2: Yes: giuseppe gullo

Reviewer #3: Yes: Antoine Naem

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Risk of obstetric anal sphincter tear among primiparous women with a history of female genital mutilation, giving birth in Sweden

PONE-D-22-18105R2

Dear Dr. Eshraghi,

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.

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Kind regards,

Giovanni Buzzaccarini, M.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

I thank you for having answered properly the reviewers comments.

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