PONE-D-24-11503 Prevalence of Dural Puncture headache after caesarean section at a Tertiary Hospital in the Gambia. PLOS ONE

Dear Dr. Anyanwu,

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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: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

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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: No

Reviewer #3: No

Reviewer #4: 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

Reviewer #3: Yes

Reviewer #4: 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: Dear authors, thank you for your collaboration.

I consider it to be of interest and well developed, since it addresses the issue of headache after the use of epidural anesthesia, one of the undesirable effects in such emotional moments as the birth of a new family member.

Reviewer #2: The manuscript has many major issues:

1- The language is very poor and MAJOR edits needs to be done. I suggest getting help form an expert English editor or a native speaker before trying to re-submit.

2- The methodology is unclear. I can't tell if that was truly cross-sectional, retrospective or prospective study.

3- The sample size calculation was not reproducible using the same input reported by the authors.

4- The Introduction part has a plagiarism issue with about 60% of the text being not genuine.

5- I did not understand why are you reporting participants' religion in your data. If this has any thing to do with the outcome, it must be justified.

Good luck with your next submission

Reviewer #3: Although this study is not novel, it could add to information in obstetrics practice

ABSTRACT: The authors stated:"lasting for 3hrs (18%)". Since this is a retrospective study, how did the authors document the duration of the post dural headache.

Introduction

The authors should beef up the justification for the study.

METHODS

How did the authors ensure uniformity of patient recruitment? how was the sample size calculated? Was one singe type of spinal needle used in all the participants?

What is the ethical approval number?

Reviewer #4: i have added an attachment with comments as a separate file, kindly go through the file

few of them are: keywords to be arranged alphabetically

address the typographical errors

below 18 years are considered as minor and you have included young girls of 15 years, how do you justify it?

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: Gajal Lakhe

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Attachments

Attachment

Submitted filename: PONE-D-24-11503.pdf

PONE-D-24-11503R1

Prevalence of Dural Puncture headache after caesarean section at a Tertiary Hospital in the Gambia.

PLOS ONE

Dear Dr. Anyanwu,

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 Apr 18 2025 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,

Sagar Panthi, MBBS

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:

Dear Authors,

Thank you for submitting the revision of the manuscript and addressing most of the reviewers' comments. While the manuscript has potential merits and is eligible for being accepted into publication with Plos One, few of the comments from Reviewer 4 in previous revision have not been addressed so I would request the authors to carefully see through the attached file with the comments from Reviewer 4. In addition, the language used in the manuscript is still substandard and hence I would request to get professional english editing and re-submit the revision so that we can move forward with the processing of this manuscript.

In case of any queries, please feel free to reach out to the editorial team at Plos One.

Regards,

Sagar Panthi, MBBS

Academic Editor, Plos One

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 #3: 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 #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: 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 #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 #1: Yes

Reviewer #3: 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: Dear authors, thank you for your contribution.

This is an interesting area where you have conducted an interesting local survey.

Reviewer #3: The authors have addressed the comments raised. The authors stated that they have beefed up the introduction.

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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 #3: No

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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.]

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.

Prevalence of dural puncture headache after caesarean section at a Tertiary Hospital in the Gambia.

PONE-D-24-11503R2

Dear Dr. Anyanwu,

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,

Siraj Ahmed Ali

Academic 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

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 #1: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: 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 #3: 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 #3: 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: Dear Authors, thank you for continuing to improve your paper based on the reviewers' recommendations.

I wish you success.

Reviewer #3: Overall Impression

The discussion contains important comparisons with other studies and acknowledges factors influencing PDPH prevalence (needle size, number of attempts, type of CS, sample size). However:the section is too repetitive,

Weaknesses / Issues:

Lack of thematic organization:

Needle gauge is discussed in multiple scattered places rather than consolidated into one clear sub-section.

Number of attempts is introduced twice with overlapping text.

Emergency vs elective CS is addressed abruptly without linking to needle size or operator skill level.

Excessive repetition:

The Jordan study (6.3% incidence) is mentioned twice almost verbatim.

The association between needle gauge and PDPH is described multiple times.

Weak critical interpretation:

While many external studies are cited, the discussion does not critically analyse why the prevalence in The Gambia is so much higher than in most cited studies beyond gauge and attempts.

No exploration of other possible local factors such as operator training, hydration status, BMI, or post-operative positioning.

No mention of possible biases (selection bias, recall bias for headache duration).

Limited discussion of limitations:

Small sample size is acknowledged but not fully explored in terms of its impact on confidence intervals, statistical power, and generalisability.

The potential effect of being a single-centre study is not mentioned.

Poorly structured (frequent jumping between topics without logical progression), and

Contains numerous grammatical errors and unclear phrasing that weaken clarity and impact.Language and Style Issues

Grammar: Frequent misuse of tenses (“was a similar findings” → “was a similar finding”; “dura matter” → “dura mater”).

Awkward phrasing:

“with low threshold for pain” should be scientifically supported and carefully worded to avoid assumptions or bias.

“majority of the PDPH” is unclear—should be “majority of PDPH cases.”

Run-on sentences: Many sentences are overly long, with multiple ideas strung together without proper punctuation.

Recommendations for Improvement

Restructure for clarity:

Suggested order:

Restate main finding (42.7% prevalence) and briefly summarise its significance.

Compare with other African studies (Ethiopia, Nigeria, Ghana) and discuss similarities/differences.

Compare with other international studies and analyse potential reasons for differences.

Detailed sub-section on needle gauge effect.

Detailed sub-section on number of attempts.

Discussion of CS type (emergency vs elective) and possible confounders.

Pain severity comparison.

Limitations and strengths of study.

Clinical implications and recommendations.

Eliminate duplication: Merge repeated references to the same studies into single, well-analysed points.

Improve scientific depth: Include other possible contributing factors to high PDPH prevalence (hydration, postoperative mobilization time, anaesthetist experience).

Language polishing: Shorten sentences, correct grammar, and improve transitions between ideas.

Statistical reporting: Add confidence intervals and clarify the strength of associations.

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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 #3: No

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