PONE-D-21-28982Maternal characteristics as indicators of referral to obstetric-led care in low-risk pregnant women in the Netherlands a retrospective cohort studyPLOS ONE

Dear Dr. Niessink-Beckers,

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.

 As you were informed, there was a change of academic editor prior to evaluation. After reassignment, two reviewers experts in the field have provided their detailed comments that suggest the need of changes, particularly in terms of interpretation of results. Note also that, in order to ensure completeness of reporting, PLOS ONE recommends the use of checklists such as the Strobe checklist for cohort studies, https://www.strobe-statement.org/download/strobe-checklist-cohort-studies-pdf  and the RECORD checklist for REporting of studies Conducted using Observational Routinely-collected Data, https://www.record-statement.org/ ​Please submit your revised manuscript by Jun 10 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.

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Academic Editor

PLOS ONE

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Reviewers' comments:

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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

Reviewer #2: Partly

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

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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: Overall

This is a retrospective cohort study in one midwifery practice in the Netherlands, which investigates the association of various maternal characteristics (including psychosocial and lifestyle characteristics) with the chance on a referral from primary midwifery to secondary obstetric care. The strength of the study is the richness of the dataset, in comparison with the national perinatal database in the Netherlands. The associations found are informative for professionals as well for pregnant women and underpins that certain psycho-social and lifestyle factors are associated with referrals to obstetric care.

The reason for a higher chance on referrals is of course, that such problems affect her medical risks in pregnancy. A referral indicates that such a medical problem has indeed arisen. After the referral, her medical/obstetrical problem will be addressed, but this will probably not resolve or reduce the psycho-social or lifestyle issue.

Major issues

First, I express my concern about the general purpose of this article. By using the word ‘indicator’, and by presenting sensitivity and specificity, the authors suggest that they want to predict referrals based on medical and non-medical characteristics, in order to support midwives in decisions on referrals (so called ‘risk assessment’). However, I doubt whether better prediction of referrals benefits the care for women. In the Dutch context, a referral to secondary care is needed if a problem arises that need attention of an obstetric professional. Even when a woman is at elevated risk for obstetric problems based on her psycho-social or life style characteristics, an actual referral is needed only when this obstetric problem becomes evident. The prediction can be false, (total accuracy is lower than 70% in table 3), even if sensitivity and specificity are improved. Predicting a referral and acting on it by referring a woman based on the prediction creates a self-fulfilling prophecy.

In my opinion, the strength of this article is not that it may contribute to better prediction or risk assessment, but that it shows once more that certain non-medical issues have impact on the course of pregnancy and birth. These issues need the attention of the midwife, mainly because these issues are in itself important for the well-being of the mother and her family. The midwife can support women with these issues, or she eventually can suggest the help of a psychologist, dietitian or welfare worker. In my opinion, this should be discussed more extensively in the section on implications for practice (Line 264), instead of the current focus on improving risk assessment. For instance, it would be interesting to know how the midwifery practice in this study deals with such issues or what they think is necessary to improve midwifery care for women with psycho-social or life-style issues.

Selective group in intrapartum care

You present the association of characteristics with antepartum referrals and with intrapartum referral. Every women that experienced an antepartum referral, is no longer in midwifery care and therefor is no longer ‘at risk’ for an intrapartum referral. As the antepartum referrals are associated with certain characteristics, the intrapartum group (table 1b) has a different composition. For instance, in the antepartum group 12,5% of women have a BMI > 30 , and in the intrapartum group this is 9.1%. This selection process may partly explain some of your results in the intrapartum analyses, as you state in Line 219 for the characteristic ‘preconception period > 1yr’. But also education levels (Line 231) and sexual violence (Line 236) show unexpected results. Perhaps because the women with the most serious impact on their health were already referred in the antepartum period? Please elaborate on this in the discussion.

L224 You elaborate on the mixed / reverse relationship in the antepartum model for women with one or more consultations. Multiparous women with one or more consultations with obstetricians had a lower chance on an antepartum referral. That is contra-intuitive because consultations indicate that some kind of medical problem was present. Can this be explained by the way consultation are registered? Consultations that end up in a referral are probably not counted as a consultation but as a referral. If that is the case, please explain how this result should be interpreted in the antepartum analysis. In the intrapartum analyses the use of this variable make sense: it indicates that there was some kind of (medical) problem, but not severe enough to arrange a referral to obstetric care.

Minor issues

L 124 Maternal age is a continuous variable. Did you consider categorising this variable? There may well be a non-linear or (u-shaped) relation in your data, with higher complications and referrals for young (teens) and older women (> 35 or 40 yrs)

L 144 Among the 617 women who started labour in midwifery led care, 287 (47%) were referred to obstetric-led care, 62% of nulliparous and 33% of multiparous women. In the introduction, you describe percentages of 21%, probably with another denominator (all women, instead of women who started labour in midwifery led care). This is somewhat confusing.

Other:

Table 1: consider to organise the columns differently and group them by parity. This makes it easier to compare women of the same parity without referral with women with referral.

Line 239 “We cannot explain the results as research has consistently shown that a history of sexual violence is associated with perinatal outcomes (41).” Reference 41 (van der Hulst ea, 2006 ) is perhaps not the best study to refer to, as it is not an example of a study that show this association. On the contrary, this study shows no important differences in referrals and birth-interventions for women with a history of sexual violence who were in primary midwifery care in the Netherlands.

Reviewer #2: Please see my review in the attachement for more details. The paper could benefint from both textual and English laguage editing. My knowledge on statistical analysis is not brilliant but I do miss a statistical comparison of groups (see letter).

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Review PONE-D-21-28982_april 2022.docx

PONE-D-21-28982R1Maternal characteristics associated with referral to obstetrician-led care in low-risk pregnant women in the Netherlands: a retrospective cohort studyPLOS ONE

Dear Dr. Niessink-Beckers,

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 same two experts from the first round accepted to review the revised version. Reviewer 1 notes specific minor points to be enhanced. Reviewer 2 acknowledges that the suggested revisions have been implemented, but suggests rejection. This is mostly based on perceived contribution to the literature which is not one of PLOS ONE criteria. The manuscript could benefit, anyway, from a clearer explanation of its purpose and contribution. Note that reviewer 2 also provides, in a separate file, detailed feedback on specific points to improve in the manuscript.

Please submit your revised manuscript by Sep 12 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.

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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.

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,

José Antonio Ortega, Ph.D.

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 #2: 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 #2: No

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #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: No

**********

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: All comments are addressed in this new version. It is now an interesting paper, creating awareness for non-medical issues that need attention in perinatal care.

I only have some minor remarks:

Line 80:

insert: "Primary care midwives" instead of) 'Midwives' are not qualified taking care of women who receive an epidural in the Netherlands, therefor they are referred to obstetrician-led care (instead of "the obstetrician').

Line 87

To be able to intervene on those factors, we need to know which kind of non-medical factors are increasing (Insert: "the chance of") referral to obstetrician-led care

Line 172; table 2a/2b

Please replace ‘Indicators for referral’ with "association with referral "

Line 196

Remove the ; in this line after "or they had ; "

Lin2 271 “Lack of social support is associated with adverse perinatal outcomes and should be considered as an opportunity to intervene on psychosocial and lifestyle maternal characteristics [48, 49].”

This is a bit confusing. I suggest splitting this sentence and changing it a little into:

Lack of social support is associated with adverse perinatal outcomes. For these women, pregnancy should be considered …etc.

Line 287 “care systems” seems not the appropriate concept, I suggest “care models” .

Line 289: Do you really mean “all characteristics” or do you want to focus on non-medical modifiable characteristics (since medical characteristics already have the attention of maternity care professionals) ?

Reviewer #2: You have addressed all the comments diligently, thank you and I appreciate the change of tone in the discussion section. towards how we can best support women during pregnancy and labour.

I am still not clear what your aim was with this study and I am in doubt whether it will add anything substantial to the current discussion about referral rates, and my impression is that you fail to rise above the collected data.

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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 #2: No

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Attachments

Attachment

Submitted filename: Review-2 PONE_D-21-28982_juli 2022.docx

PONE-D-21-28982R2Maternal characteristics associated with referral to obstetrician-led care in low-risk pregnant women in the Netherlands: a retrospective cohort studyPLOS ONE

Dear Dr. Niessink-Beckers,

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.

Thank you very much for attending to all previous reviewer queries. Both reviewers are happy with the revisions, but have offered some additional very minor suggestions on the latest version, which you can find below. We wanted to give you a chance to address these comments, as we feel that doing so would further strengthen the manuscript.

Please submit your revised manuscript by Mar 02 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,

Hanna Landenmark

Staff 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.

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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 #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: I Don't Know

**********

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: I thank the authors for addressing all comments, the article is almost ready for publication. I have only one small remark: would you please check the subtitles in table 1a and 1b, where the % in the columns is explained?

Reviewer #2: Thank you for sending me this much improved paper on the study of maternal characteristics in primary midwifery care. I would really like to compliment the authors. The text reads much better and I am especially pleased with the improvements in the discussion and conclusion.

I still have a few minor remarks that I trust won’t take much effort to adjust:

Page 4, last Alinea of introduction: Your focus and your reasons for wanting to carry out this study are now much better explained. However I still have some trouble with the first 2 sentences of this Alinea, they seem to be contradictory. Are lifestyle factors (mentioned in the 2nd sentence) not factors such as BMI and maternal age? And there have been quite few studies so far that have shown an association between stress (psychosocial) and perinatal outcomes.

Moreover l87: …and maternal characteristics on non-medical factors > I think it should be: … and non-medical maternal characteristics?

P5 L101: I think there are words missing after “and”: Those who had a miscarriage were excluded and were referred to obstetrician-led care in the first trimester etc. This should read: and those who were referred to obstetrician-led care

P5 115/116: please change psychological problems into past (or previous) or current psychological problems and sexual abuse into a history of sexual abuse

P10, L172 Please finish the sentence … whilst those who were overweight or obese were more likely to be referred.

P12 L185 … and lived in deprivation. You do not know if they actually lived in deprivation, this is an assumption based on their zip/postal code. I suggest this should be changed to …and lived in a deprived area.

P15 L 268-270: During our study period, all women with gestational diabetes were referred to obstetrician-led care, when only a diet was applied to stabilise their glucose values. This sentence seems to have words missing after the 2nd comma? > I think you need to insert the following words: …apart from when only a diet etc etc.

P16 L 274-275: Please be aware of the limitations of your study. Therefor insert “in this particular midwifery practice.” At the end of the sentence.

P16 L286: I think you mean continuity of care instead of Continuous care?

P16 L286-287: is this also the case for women with the described characteristics in your study? Do we know this?

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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 #2: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Attachments

Attachment

Submitted filename: Review 3_PONE-D-21-28982R2_Maternal characteristics associated with obstetric referral.docx

Maternal characteristics associated with referral to obstetrician-led care in low-risk pregnant women in the Netherlands: a retrospective cohort study

PONE-D-21-28982R3

Dear Dr. Niessink-Beckers,

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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Hanna Landenmark

Staff Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: 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

**********

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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Reviewer #1: No

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