PONE-D-23-06127Women's experiences of anal incontinence following vaginal birth: a qualitative study of missed opportunities in routine care contactsPLOS ONE

Dear Dr. Parsons,

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Academic Editor

PLOS ONE

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Professor Michael Keighley is Trustee and President of the MASIC Foundation but this has not impacted on conduct of study or publication, CEO of Keighleycolo Ltd involved with medical reports for court in which OASI patients have been seen but no conflict as this simply informed me of the consequences of the injury during one to one face to face consultations. Trustee Friends of Vellore UK also has helped to understand impact of OASI in the Asian community in India. Joint holder of two i4i NIHR grants for a device for the treatment of fistula in fact of value to some OASI patients.”

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Additional Editor Comments:

The reviewers have expressed positive comments regarding your article, raising only few concerns. Considering this point, I invite authors to perform the required minor revisions.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: No

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

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Overall a well-structured, appropriately designed and original piece of research. Importantly, the value of this research in terms of the existing issue are set out clearly and potential avenues for improving experiences of women after childbirth injury are suggested without breaching the capabilities of qualitative research. An overview of the themes and subgroups in each would add clarity before the main text of the results.

Reviewer #2: PLOS ONE

Women's experiences of anal incontinence following vaginal birth: a qualitative study of missed opportunities in routine care contacts

Reviewer comments

Title P2

appropriate to the paper

Abstract P2

Clear, focused, check for unnecessary capitalisation in the results section.

Intro P3

Line 54 ‘nulliparous women’, could the authors add a brief explanation of this term please,

Line 55 ‘OASI injury’ could the authors add a brief explanation of this term please

Line 56 ‘Women of Indian and Pakistani origin are significantly more likely to sustain an OASI during childbirth (13,14, 58 15).’ Could you say briefly why this is please

Line 61, could you add a sentence adding the implications please.

Lin 67, could you add a sentence to say why this is the case please, it’s a fascinating study, and not everyone will be a medical professional, or familiar with the field.

Methods P4

P4 Line 73 date needed please

P5 line 99 ‘Participants were also recruited via five hospitals across the UK’ could you say which countries, regions please

P5 line . ‘Aiming for a maximum variation sample, women were recruited with varied backgrounds according to ethnicity, deprivation’ could you say why you wanted a variation sample, and what type of deprivation/how you were assessing deprivation please,

P5

Line 110 the PPI section is interesting, could you provide a sentence or detail about how patients were involved, and what influence this had at each level of involvement please.

There is no mention of gaining ethical approval for the study, or the approval number in the methods section, I'm sure its an oversight, could you add it please.

P6 Data analysis

Whilst the whole paper is very well written and coherent, there is not enough detail or transparency about how the stages of analysis were completed, and the results were arrived at, this needs to be more explicitly included.

Results P7

P8 Table 1 What type of deprivation is being measured here, could you add more detail to the axes please

There is some unnecessary capitalisation mid-sentence throughout this section.

Its only a small study, could the authors add in brackets where they say many participants, how many, to give an idea of context.

This whole sub-section is very well written, with clear explanation, but at the moment it is not clear where these themes came from, this needs more explanation and linkage in the Methods section, good illustrative quotes.

Discussion P20

All the comments are accurate and relate to the paper, but it feels more like a summary rather than key points arising, and their implications,

what are the competing tensions? and how these concerns might be addressed - in several areas, e.g. societally, patient information, pregnancy related services, knowledge of health professionals… policies and publicity…where are the blockages, what needs to happen for services to communicate better… I'm not saying you need to resolve everything, but going beyond, to give specific ideas, pointers for better, more joined up practice, information for women ect, would lead to a stronger discussion section

what does it add, what needs to happen, what are the implications?

Conclusion P23

A really clear paper, with quality data, it would benefit from a stronger, bolder conclusion,

Reviewer #3: I read with great interest the Manuscript titled “Women's experiences of anal incontinence following vaginal birth: a qualitative study of missed opportunities in routine care contacts” (PONE-D-23-06127), which falls within the aim of this Journal.

In my honest opinion, the topic is interesting enough to attract the readers’ attention. Methodology is accurate and conclusions are supported by the data analysis. Nevertheless, authors should clarify some point and improve the discussion citing relevant and novel key articles about the topic.

Authors should consider the following recommendations:

- Inclusion/exclusion criteria should be better clarified.

- The Authors did not mention the sample size calculation for their study. It is essential to specify this data in order to guarantee an adequate significance of the results obtained by the Authors.

- The authors have not adequately highlighted the strengths and limitations of their study.

- What are the actual clinical implications of this study? it is important to report the results obtained by the authors in the context of clinical practice and to adequately highlight what contribution this study adds to the literature already existing on the topic and to future study perspectives

- Does this manuscript conform the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) network guidelines? It would be mandatory to declare about this element.

- Authors should add further details to discuss the role of the perineum protection techniques during the management of the second phase of labour and the effect on the postpartum period (authors may refer to: PMID: 25909491; PMID: 24942141).

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes: VERONICA LUMIA

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Women's experiences of anal incontinence following vaginal birth: a qualitative study of missed opportunities in routine care contacts

PONE-D-23-06127R1

Dear Dr. Parsons,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Antonio Simone Laganà, M.D., Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors performed the required corrections, which were positively evaluated by the reviewers. I am pleased to accept this paper for publication.

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 #2: (No Response)

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: Yes

Reviewer #3: Yes

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

Reviewer #2: N/A

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: 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 #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: The revisions make this a much stronger paper, its very well written and constructed, and an important topic which would benefit from dissemination and knowledge exchange activities.

There is just one aspect that needs a little more attention, then it's good to go. The explanation of the methodology is still too limited, it would benefit from more show, not just tell- how were the thematic analysis stages applied to this work, how did the themes become arrived at? Whilst it reads well really, its not clear how the authors went from inception to findings section.

There is still some unnecessary capitalisation in sentences, but this easily fixed.

Reviewer #3: I carefully evaluated the revised version of this manuscript.

Authors have performed the required changes, improving significantly the quality of the paper.

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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 #2: No

Reviewer #3: Yes: Veronica Lumia

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