High prevalence of cardiovascular risk factors in pregnant women in Benin

Eyram Maria Concheta Tchibozo; Yessito Corine Houehanou Sonou; Salmane Ariyoh Amidou; Fabrice Hountondji; Femi Zantou; Philippe Lacroix; Dismand Stephan Houinato; Holy Bezanahary

doi:10.1371/journal.pone.0310408

Peer Review History

Original SubmissionMarch 27, 2024
27 May 2024 Decision Letter - Yoshihiro Fukumoto, Editor PONE-D-24-09850High prevalence of cardiovascular risk factors in pregnant women in BeninPLOS ONE Dear Dr. Lacroix, 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 Jul 11 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. 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The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: Yes ****** 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 ****** 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 ****** 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: Thank you for an interesting manuscript! The study focuses on modifiable cardiovascular risk factors (CVRF) among pregnant women in Benin, a country in Sub-Saharan Africa. These risk factors include conditions like high blood pressure (HBP), obesity, and diabetes. The research aims to understand the prevalence of these risk factors before the 20th week of gestation. The study revealed that cardiovascular risk factors (CVRF) were common among pregnant women. High blood pressure (HBP) was associated with age >35 years, rural residency, and insufficient fruit and vegetable intake. Overweight was also linked to age >24 years and rural setting was protective while obesity was higher in women >35 years and rural setting was protective. 1. Can you please clarify the univariate and multivariate regression analysis and the variables that are used in the mutlivariate regression analysis? Perhaps a stepwise multivariate regression analysis would be a good approach. 2. Can you please add discussion about limitations such as sampling bias into this study? Approx., how many pregnant women in Benin fails to visit the antenatal clinic and are thus not included in this study? 3. Can you please clarify why you had no follow-up time and why you specifically set the gestational week to be less than 20? 4. Please include ethic approval numbers and dates. 5. "Blood pressure was measured by an electronic device"- for all women? None were measured manually, perhaps for instance in the setting of atrial fibrillation? Was the electrinic devices calibrated and checked for accuracy? 5. Conclusion: The frequency of CVRF in women before 20th week of gestation was high. Can you please rewrite and avoid "high" since it is subjective. Reviewer #2: Reviewer’s comments. This study investigates the prevalence of cardiovascular risk factors among pregnant women under 20 weeks of gestation in general African communities. It was found that the risk factors varied depending on the residence of the pregnant women. Additionally, it is an important issue that many pregnant women with cardiovascular risks such as hypertension and obesity are unaware of their hypertension. To reduce the mortality rates of mothers and fetuses, it is desirable to identify these risk factors early and provide appropriate interventions for pregnant women. While the purpose of this study is understandable, several points can be considered insufficient. These are outlined below. Major comments: 1. Page 6; line 119: What is the basis for the definitions of overweight and obesity in Brachial circumference? 2. The author should mention the difference between urban and rural backgrounds in the results of Table 1. 3. Page 9; line 157: Which is more accurate to say that the patient had normal blood pressure but was receiving treatment or that the patient had normal blood pressure because of the treatment? 4. In Table 2, the definition of the classification of salt intake should be clarified as to how many grams of salt or sodium it is equivalent to. 5. In Table 4, it is necessary to indicate which confounding factors were adjusted for. 6. In Table 4, it is necessary to show the relationship between overweight, obesity, smoking, and alcohol consumption as factors associated with hypertension in pregnant women. 7. Author should mention limitations and strengths in the discussion. Minor comments: 1. Page 9; line 157: Twenty-eight women (2.3%)→28 (2.3%) 2. Page 9; lines 161-163: Add (%) after the number of subjects. 3. In Table 4, the reference should be shown for each variable. ****** 6. 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. 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Revision 1
19 Aug 2024 Author Response Response to reviewers We extend our sincere gratitude to reviewers for their corrections, contributions, and recommendations, which undoubtedly enhance the quality of our work. All their suggestions have been incorporated into the revised version of the manuscript. Therefore, we will only address the points requiring clarification in the following lines. Response to reviewer #1: 1. Can you please clarify the univariate and multivariate regression analysis and the variables that are used in the mutlivariate regression analysis? Perhaps a stepwise multivariate regression analysis would be a good approach. Indeed, we performed a stepwise descending multivariable logistic regression, and the details have been provided in the revised version of the manuscript. Details have been provided in the revised version of the manuscript. 2. Can you please add discussion about limitations such as sampling bias into this study? A discussion on the potential sampling bias of the study has been added in the strengths and limitations section in the revised manuscript: In Benin, according to the latest national surveys, 48% of women of childbearing age did not make at least 4 prenatal visits during pregnancy, whereas WHO recommendations stipulate a minimum of 8 visits. This could introduce a sampling bias in this study; the results may reflect the situation in the general population, however the generalization of the results to the whole country calls for caution. 3. Can you please clarify why you had no follow-up time and why you specifically set the gestational week to be less than 20? We did not conduct follow-up as the study was a cross-sectional study, not a cohort study. The aim of this study was to determine the frequencies of cardiovascular risk factors before pregnancy that predispose to preeclampsia during pregnancy. According to the recommendations of scientific societies and as specified in the introduction, hypertension or diabetes detected in the first trimester (before 20 weeks of gestation) are due to preexisting chronic disorders. Similarly, in pregnant women, mid-upper arm circumference is a measure that does not vary significantly during the first weeks of pregnancy and can be used to assess overweight and obesity prior to pregnancy. 4. Please include ethic approval numbers and dates The study was approved by the ethics and health sciences research committee of Parakou University (Benin) on 08th January 2020 (REF:0594/CLERB-UP/P/SP/P/SA). We have included this in the revised version of the manuscript. 5. "Blood pressure was measured by an electronic device"- for all women? None were measured manually, perhaps for instance in the setting of atrial fibrillation? Was the electrinic devices calibrated and checked for accuracy? Blood pressure was measured using an electronic device for all women. We did not perform manual measurements. All measurements were conducted following the recommendations of the STEPwise approach to NCD risk factor surveillance (STEPS). The electronic devices were calibrated, and their accuracy was verified before data collection. Precisions were included this in the revised version of the manuscript. 6. Conclusion: The frequency of CVRF in women before 20th week of gestation was high. Can you please rewrite and avoid "high" since it is subjective. “High” was remplaced by “significant” in conclusion. Response to reviewer #2: Major comments 1. Page 6; line 119: What is the basis for the definitions of overweight and obesity in Brachial circumference? The definitions of overweight and obesity in Brachial circumference are based on the study published by Ahminah et al. in 2017 in the South African Medical Journal titled: "Mid-upper arm circumference: A surrogate for body mass index in pregnant women." This definition was used by authors in previous study and in the same context like us. 2. The author should mention the difference between urban and rural backgrounds in the results of Table 1. The differences between rural and urban settings have been mentioned in materials and methods sections of the study on page 5, lines 97 and 98. The title of table 1 has been corrected: Table 1: Global sociodemographic characteristics of the women according to area 3. Page 9; line 157: Which is more accurate to say that the patient had normal blood pressure but was receiving treatment or that the patient had normal blood pressure because of the treatment? In stating 'the patient had normal blood pressure but was receiving treatment,' we aimed to provide information regarding the group of hypertensive patients who were on treatment before the study and had normal blood pressure at the time of the study. The sentence was modified. 4. In Table 2, the definition of the classification of salt intake should be clarified as to how many grams of salt or sodium it is equivalent to. We are unable to provide information on the grams of salt in the context of our study (African countries with a significant frequency of illiterate women). Available resources did not allow for measurements to be taken. Therefore, data were collected based on the self-reports of patients and according to their perception, as detailed in the table. Advanced nutritional studies in this population indeed seem necessary. 5. In Table 4, it is necessary to indicate which confounding factors were adjusted for. Confounding factors were adjusted for age and place of residence in the model. This was specified in the revised version of the article (page 6, line 168) and in Table 4. 6. In Table 4, it is necessary to show the relationship between overweight, obesity, smoking, and alcohol consumption as factors associated with hypertension in pregnant women. We included theses variables in our analysis except for obesity (Supporting information), which was treated separately to avoid confounding biases. However, they did not emerge as associated with hypertension in the univariate analysis and all had p-values greater than 0.20. Therefore, we did not include them in the multivariate analysis or present them in the study, as our primary objective was to provide frequencies of cardiovascular risk factors found by other studies to be associated with preeclampsia (hypertension, diabetes, and obesity). Below are the results of analyses. - Hypertension and tobacco consumption before pregnancy: P=0.2998 - Hypertension and tobacco consumption during pregnancy: P=1.0000 - Hypertension and alcohol consumption before pregnancy: P=0.2680 - Hypertension and alcohol consumption during pregnancy: P=0.6535 7. Author should mention limitations and strengths in the discussion. Limitations and strengths were mention in revised versions (page 15, line 237). Minor comments: 1. Page 9; line 157: Twenty-eight women (2.3%) →28 (2.3%) The comment has been taken into account. 2. Page 9; lines 161-163: Add (%) after the number of subjects. The comment has been taken into account. 3. In Table 4, the reference should be shown for each variable The reference categories have been specified in the tables by indicating a value of 1 for the odds ratios (OR). Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0310408.r002
2 Sep 2024 Decision Letter - Yoshihiro Fukumoto, Editor High prevalence of cardiovascular risk factors in pregnant women in Benin PONE-D-24-09850R1 Dear Dr. Lacroix, 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. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. 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Reviewer #1: Yes Reviewer #2: 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 #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: (No Response) Reviewer #2: All of my comments in the review have been addressed. It has been demonstrated that early cardiovascular risk screening for pregnant women is crucial to ensure a healthy pregnancy and childbirth for both mother and child in African communities. ****** 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 ******** https://doi.org/10.1371/journal.pone.0310408.r003
Formally Accepted
21 Sep 2024 Acceptance Letter - Yoshihiro Fukumoto, Editor PONE-D-24-09850R1 PLOS ONE Dear Dr. Lacroix, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Yoshihiro Fukumoto Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0310408.r004

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