PONE-D-23-42108Preconception health in adolescence and adulthood across generations in the UK: findings from three British birth cohort studiesPLOS ONE

Dear Dr. Righton,

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Reviewers' comments:

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Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: The authors present an informative and timely investigation into the current state and trends in preconception health in the UK. In my view, descriptive studies like this, reporting on general population samples, are very important in guiding policymakers, for raising further, more complex research questions, and informing professionals in many fields. I think there is a strong rationale (intellectual, moral, and economic one) for improving children’s well-being by focusing on ‘upstream’ factors and by improving the health and well-being of the families they are born to. As mentioned by the authors, it is not only the children that benefit, and improvement in preconception health will benefit at least two generations. The key strength of the study has to do with using population-based studies, as other types of data sources might focus only on women or pregnant individuals, for example.

Introduction

Comment 1: The introduction section makes a strong case for the study. It highlights the impact that improving preconception health can have on multiple generations, and the authors seem to cover previous approaches to describing preconception health in the UK well. However, I wonder what the authors' rationale is for not describing findings from other countries? There are, of course, important differences in these phenomena and service systems even between European countries, but maybe there would be some previous findings from other countries that would be relevant for the current study? I appreciate that the authors might have an excellent rationale for adopting a UK-focused approach, but the rationale for that is not completely clear to me after reading the introduction section. I also think that the results will be able to inform professionals from areas outside of the UK.

Methods

Comment 2: I think the data in Table 1 would be best presented visually, or at least in a slightly different way. Although the authors have reported all relevant data in the table, currently it is somewhat difficult to read and to assess the overlap between data collection waves and the assessment ages across studies.

Comment 3: It seems to me that all three survey studies included individuals born in the UK. If this is the case, the implications of this need to be discussed clearly in the discussion section.

Comment 4: I think all in all the analysis approach is clear, and I appreciate the simplicity of it. If possible, I would prefer statistical testing that would provide estimates of the magnitude of the effect size, but of course, the magnitude of observed associations can be communicated in other ways too.

Comment 5: I think it would be important to report more information on the survey samples (e.g. missing data) for each survey in more detail than it has been done now.

Results

Comment 6: I find it somewhat hard to follow the results as they are being reported currently in the text. This might only be a matter of personal preferences, but I would consider doing some restructuring, and not reporting on each indicator separately. One thing that might simplify the results section would be that the descriptions of how the indicators were defined, and when information on each was available, would be described in a separate subsection of the results section, potentially in a table.

Comment 7: For some indicators (for example, for Ethnicity), it is not completely clear to me whether there was no significant difference found between ages/birth cohorts, or whether no statistical comparison was conducted. The reporting style could be made more clear. Otherwise the manuscript is very clearly written.

Discussion

Comment 8: I very much agree with the authors about the need for ongoing monitoring of health indicators from a public health point of view. I think the authors could describe in the discussion section what they think would be the best approach to this going forward, and what their recommendations are so that an even better monitoring can be done in the future.

Comment 9: Mental disorders are very much associated with one’s somatic health, health behaviors, ability to study and work, and importantly in the context of preconception health, they are associated with things such as the ability and willingness to take care of children, medications used before and during pregnancy, and breastfeeding. I think mental health is a very important dimension that should be considered when assessing preconception health. I appreciate that including these in the current study was not possible because of the limitations of the datasets, but I do think mentioning these factors would be important in the discussion section. Again, I don’t think this is necessarily a weakness of the current study, but given that the aim is to improve preconception health and our understanding of the current state of it, I think the importance of also assessing mental disorders could be mentioned here too.

Reviewer #2: Thanks for the opportunity to review this interesting paper which is really well written.

I have a couple of questions and suggestions I would be grateful if you could clarify please.

You reported using cohort sweeps with comparable ages of participants of 16-17 and 25-26, but this meant excluding the most recent data from MCS, where the 2023 sweep captured data from 23 year olds. I would think 23 year olds are close enough in age to 25-26 year olds to include these most up to date data which would be informative for current policy. Please could you explain why you excluded the age 23 MCS sweep? (Presumably this post-school age MCS sweep also includes the education indicator too? And including it would enable MCS to be included in Table 3?) Ideally I would recommend that the data from MCS age 23 sweep be included in the paper which is why I have recommended a major revision, my other comments are minor.

I think when referring to differences between cohorts it would be clearer to say differences across cohorts instead of across sweeps. For example at line 220, I think "Among female participants, the proportion of those aged 16/17 who smoked was significantly different across sweeps" should read different across cohorts. This occurs later too e.g. line 235. The phrase different across sweeps could then be used for change within cohorts between different sweeps.

The sentence at line 327 is not entirely clearly worded: Moreover, increases of 33-44% of pregnancies complicated by type 1 diabetes and 90-111% of pregnancies complicated by type 2 diabetes have been reported in Northern Europe (30,31).

It would be helpful to understand the exact questions that were asked for indicators where you propose differences in interpretation could have influenced the results (e,.g categorisation of termination of pregnancy as a 'complication' or not.

Thanks for your time.

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Reviewer #2: No

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PONE-D-23-42108R1Preconception health in adolescence and adulthood across generations in the UK: findings from three British birth cohort studiesPLOS ONE

Dear Dr. Righton,

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 Sep 27 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,

Katriina Heikkila, PhD

Academic Editor

PLOS ONE

Additional Editor Comments:

Thank you for submitting a revised manuscript. You have addressed many of the reviewers' comments but some of the key feedback has been incompletely addressed. I have also noted a couple of additional comments on the overall presentation of the information in the manuscript.

1. As suggested by Reviewer 1, please describe in the Introduction-section, with references, what is known about this topic in other high income countries. I appreciate the study is about the UK but it is important to provide a clear context for the investigation, explicitly explaining what this study adds to what we already know anout this topic.

2. As suggested by Reviewer 2, please add analyses using data from the MCS age 23 years sweep. You cite a paper proposing that adolescence these days extends to age 24, but life course epidemiology strongly suggests that health and outcomes in early adulthood are comparable in the early to mid-20s. Further, given the limited sample sizes, particularly on some indicators, adding MSC data from the age 23 sweep would increase the value of the study considerably.

3. As a general comment, the interpretation of the findings needs to be toned down throughout the manuscript. In multiple places the authors write about their findings revealing or showing patterns. Given the observational nature of the studies included, the modest sample sizes, attrition and missing data, these types of statements on the findings are too strong. At the most, the evidence from these studies can suggest (not reveal) associations.

4. The authors provide the total numbers of participants in each study in the abstract but the numbers of individuals included in the analyses were, in fact, considerably smaller. The abstract should be revised to give the reader a realistic idea of study sizes, as this has important implications to the interpretation of the findings in terms of generalisability and analytical power.

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[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.]

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Preconception health in adolescence and adulthood across generations in the UK: findings from three British birth cohort studies

PONE-D-23-42108R2

Dear Dr. Righton,

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Kind regards,

Katriina Heikkila, PhD

Academic Editor

PLOS ONE

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