Optimal gestational weight gain and pregnancy outcomes, by BMI and height, in a marginalised population of women with short stature living along the Thailand-Myanmar border: A retrospective cohort, 2004–2023

Mary Gouws; Rose McGready; Wirichada Pan-ngum; Aung Myat Min; Nay Win Tun; Mary Ellen Gilder; Taco Jan Prins; Widi Yotyingaphiram; Mupawjay Pimanpanarak; Jacher Viladpai-Nguen; Nuttapol Panachuenwongsakul; François H. Nosten; Sue J. Lee

doi:10.1371/journal.pone.0330256

Peer Review History

Original SubmissionDecember 26, 2024
18 Feb 2025 Decision Letter - Vidhura Tennekoon, Editor Dear Dr. Gouws, Please submit your revised manuscript by Apr 04 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. 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'. 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Kind regards, Vidhura S Tennekoon Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Thank you for stating in your Funding Statement: “The Shoklo Malaria Research Unit is supported in part by the Wellcome-Trust Major Overseas Programme in Southeast Asia (# 220211, https://doi.org/10.35802/220211; lead applicant Nicholas Day). For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. There was no additional external funding received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” Please provide an amended statement that declares all the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement. Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf. 3. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). 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This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. 6. Please amend the manuscript submission data (via Edit Submission) to include author “Jacher Viladpai-Nguen”. Additional Editor Comments: Please pay careful attention reviewer comments and address all of them. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes Reviewer #3: Yes ****** Reviewer #1: Thank for the paper, give us a good presentation, have an excellent proposed to help a vulnerable group of pregnant women. Nevertheless, I have a few suggestions before their publication. Unify the objective (line 30-31) from the abstract with the last section of introduction (lines 71-72) Line 140. Is SES socioeconomic status? Clarify Add the information to literacy and socioeconomic status as limitation (in Discussion section), because these variables can have influence on the health and well-being of the pregnant women and affect their GWG. What is the reason to have greater intervale in those women with overweight-and obesity pregestational BMI (Table 3)? Add the information in discussion section. My final doubt is the applicability can be effective in all women with short stature? Regardless of the access to health service, and another sociocultural context? Or only those from Nepal, East Timor and Bangladesh? Reviewer #2: Dear Authors, Thank you for the opportunity to review this interesting piece of work, that highlights an under-adressed data gap in a marginalized population. However, I have a few minor concerns and queries about the article: 1) Firstly, I suggest adjustments to the wordings in the article, particularly on the usage of "short stature women", as it may come across as stigmatizing this population, taking into consideration this population may have shorter stature due to a underlying varying genetic and/or environmental reasons. I suggest adhering to person-first language i.e. "women with shorter stature" or "women with short stature" for a more neutral tone. 2) I am curious as to why neonates with major congenital abnormalities were excluded from the analysis, considering maternal obesity is a known risk factor for congenital anomalies. If there is a strong reason to this, I suggest the authors include the explanation in the main text. 3) The women in the overweight/obese BMI range were analyzed as a homogenous group rather than 2 separate groups. The authors have alluded to the inherent issue of analyzing BMI as a categorical factor rather than continuous - that it oversimplifies risk estimation for women within a broad range of profiles such as BMI. In fact, the paper by Morisaki, quoted by the authors, found rather differing optimal GWG for women in the overweight (7.7kg) vs obese (4.3 kg) category. Therefore, I suggest the authors consider splitting the analysis of overweight (BMI 23-24.9 kg/m2) and obese (>25 kg/m2) categories, for better clinical applicability. 4) I suggest p-values to be included in Tables 1 and 2, to reflect the baseline differences among different BMI categories, if any, as they may hold weight in interpreting the main outcome of the analysis. 5) The authors addressed a potential overestimation of risk of adverse outcomes using the composite score - my question is how should the reader account for this when applying the findings of the analysis in clinical practice. Should the clinician advise for a more lenient range, or perhaps upper-half of the normal range reported in this study, while advising optimal GWG for women with shorter stature? I suggest the authors to discuss the clinical implications of this. Reviewer #3: The study explored optimal gestational weight gain (GWG) by BMI and height in a marginalized migrant population along the Thailand-Myanmar border, aiming to inform more population-specific guidelines. Here are some of my concerns that require addressing: The study does not distinguish between iatrogenic (medically indicated) and spontaneous preterm birth. Iatrogenic PTB (e.g., for preeclampsia or fetal distress) is often an appropriate and protective medical intervention rather than an adverse outcome. If iatrogenic PTB is grouped with spontaneous PTB, it could misrepresent GWG’s true impact on PTB risk or the composite risk outcome. The study states that they adjusted for GDM screening method changes over time, but does not clearly define how GDM itself was accounted for in their models. A sensitivity analysis excluding women with GDM could strengthen the findings. This is hared across the other pregnancy complications including Malaria, and hypertensive disorder. Parity status - intriguing the majority of women were obese were multiparous. Nulliparity is what essentially creates a "unknown" risk - if you had "normal deliveries/pregnancies" before then that is the best predictor about cows in future pregnancies. I would be interested in a nulliparous analysis being highlighted. Similarly, inter pregnancy weight gain - if that is something that can be teased out and its associated risk with the composite risk - that is very interesting. I assume - although. this is not spelt out by the authors - that some women here would feature multiple times? If you only included one pregnancy which one? Or how were the repeat pregnancies handled—were they accounted for in the statistical models? The authors use the Perinatal Institute’s Gestation Related Optimal Weight (GROW) customised bulk centile calculator V.8.0[18]. They state: GROW offers the advantage of region-specific classification and has coefficients to represent over 100 country-of-origin groups. -> which ethnic group did you choose? and do justify the choice. Strength Addresses a population often underrepresented in research. Attempts to tailor GWG recommendations to short-stature women, which is clinically relevant. Uses GROW centiles, which allow for ethnicity-specific fetal growth assessment. Utilizes modern statistical methods (natural cubic splines) to model nonlinear relationships. Key Limitations to Address Before Publication: Clarify whether multiple pregnancies from the same individuals were included and account for within-subject correlation. Differentiate between iatrogenic vs. spontaneous PTB. Explicitly describe how GDM was adjusted for in the analysis. Provide further justification for cubic spline modeling choices and potential overfitting concerns. ****** 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: Yes: Quan-Hziung Lim Reviewer #3: 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. 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Revision 1
4 May 2025 Author Response Dear Dr Tennekoon Re: Response to reviewer comments PLOS ONE-D-24-59010 Optimal gestational weight gain and pregnancy outcomes, by BMI and height, in a marginalised population of women with short stature living along the Thailand-Myanmar border: a retrospective cohort, 2004-2023. On behalf of the authors of the above manuscript, I would like to submit a revised version of this manuscript. We thank the reviewers for their constructive comments which we feel has strengthened our manuscript. We have addressed all comments as specified in the bullet points overleaf. We have uploaded 2 new versions of the manuscript: one with tracked changes and one unmarked, and labelled them as prescribed by PLOS ONE. The requested amended funding statement is as follows: The Shoklo Malaria Research Unit is supported by the Wellcome-Trust Major Overseas Programme in Southeast Asia (#220211, lead applicant Nicholas Day) and in the years prior to that (WT-106698). MG was supported by a Rhodes Scholarship. For the purposes of Open Access, the author has applied a CC BY public copyright license to any Author Accepted Manuscript version arising from this submission. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There was no additional external funding received for this study. We hope very much that this revised and improved manuscript will be acceptable for publication. Yours sincerely, Mary Gouws DPhil Candidate, University of Oxford. MSc International Health and Tropical Medicine, University of Oxford. MBChB, University of Cape Town. EDITORS' SPECIFIC POINTS: Please find responses to comments in blue. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at The manuscript has been updated to meet PLOS ONE’s style requirements and figures and supporting information have been saved with appropriate names and are now uploaded separately as individual files. 2. Thank you for stating in your Funding Statement: “The Shoklo Malaria Research Unit is supported in part by the Wellcome-Trust Major Overseas Programme in Southeast Asia (# 220211, https://doi.org/10.35802/220211; lead applicant Nicholas Day). For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. There was no additional external funding received for this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” Please provide an amended statement that declares all the funding or sources of support (whether external or internal to your organization) received during this study, as detailed online in our guide for authors at http://journals.plos.org/plosone/s/submit-now. Please also include the statement “There was no additional external funding received for this study.” in your updated Funding Statement. Please include your amended Funding Statement within your cover letter. We will change the online submission form on your behalf. We have amended the funding statement (below) and have included this revised version in the cover letter. “The Shoklo Malaria Research Unit is supported by the Wellcome-Trust Major Overseas Programme in Southeast Asia (#220211, lead applicant Nicholas Day) and in the years prior to that (WT-106698). MG was supported by a Rhodes Scholarship. For the purposes of Open Access, the author has applied a CC BY public copyright license to any Author Accepted Manuscript version arising from this submission. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There was no additional external funding received for this study.” 3. We note that you have indicated that there are restrictions to data sharing for this study. For studies involving human research participant data or other sensitive data, we encourage authors to share de-identified or anonymized data. However, when data cannot be publicly shared for ethical reasons, we allow authors to make their data sets available upon request. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Before we proceed with your manuscript, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information, data are owned by a third-party organization, etc.) and who has imposed them (e.g., a Research Ethics Committee or Institutional Review Board, etc.). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of recommended repositories, please see https://journals.plos.org/plosone/s/recommended-repositories. You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. Please update your Data Availability statement in the submission form accordingly. The data availability statement now reads: “The data cannot be shared publicly due to ethical restrictions: this data was routinely collected from a marginalized population of undocumented refugees and migrants and the women have not consented for the data to be shared. These restrictions are in keeping with the policy of the Oxford Tropical Research Ethics Committee. However, de-identified data is available from the Mahidol-Oxford Research Unit institutional data access committee upon reasonable request from researchers who meet the criteria for access to confidential data (contact Rita Chanviriyavuth, email rita@tropmedres.ac).” 4. For studies involving third-party data, we encourage authors to share any data specific to their analyses that they can legally distribute. PLOS recognizes, however, that authors may be using third-party data they do not have the rights to share. When third-party data cannot be publicly shared, authors must provide all information necessary for interested researchers to apply to gain access to the data. (https://journals.plos.org/plosone/s/data-availability#loc-acceptable-data-access-restrictions) For any third-party data that the authors cannot legally distribute, they should include the following information in their Data Availability Statement upon submission: 1) A description of the data set and the third-party source 2) If applicable, verification of permission to use the data set 3) Confirmation of whether the authors received any special privileges in accessing the data that other researchers would not have 4) All necessary contact information others would need to apply to gain access to the data This is not applicable for our study: third-party data was not involved in this analysis. 5. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Rose McGready is the corresponding author, with ORCID iD: 0000-0003-1621-3257. 6. Please amend the manuscript submission data (via Edit Submission) to include author “Jacher Viladpai-Nguen”. This has been updated accordingly, as requested. RESPONSES TO REVIEWER COMMENTS Reviewer #1: Thank for the paper, give us a good presentation, have an excellent proposed to help a vulnerable group of pregnant women. Nevertheless, I have a few suggestions before their publication. Unify the objective (line 30-31) from the abstract with the last section of introduction (lines 71-72) Amended as suggested. Line 140. Is SES socioeconomic status? Clarify SES is socioeconomic status and this is now spelled out in the methods. Add the information to literacy and socioeconomic status as limitation (in Discussion section), because these variables can have influence on the health and well-being of the pregnant women and affect their GWG. Amended as suggested (lines 285-288). What is the reason to have greater intervale in those women with overweight-and obesity pregestational BMI (Table 3)? Add the information in discussion section. This wider interval can be attributed to the wide variation of first trimester BMI in this overweight and obese group, ranging from 23 to 43kg/m² (a total range of 20 kg/m²). In the underweight BMI group, the range was only 4.9 kg/m² (13.5 to 18.4 kg/m²) and the range for the normal BMI category was bound at 4.4 kg/m² (18.5-22.9 kg/m²). We have added a few lines to discuss this, as suggested (lines 277-280) of the manuscript. My final doubt is the applicability can be effective in all women with short stature? Regardless of the access to health service, and another sociocultural context? Or only those from Nepal, East Timor and Bangladesh? There are limited data globally on women with short stature and as far as we are aware, no guidelines for GWG currently exist for these groups. Thus, the findings from our study currently provide the only insight for any pregnant woman with short stature, regardless of access to health services and sociocultural contexts. This has been clarified in the manuscript (lines 73-74 and 328-329). Reviewer #2: Dear Authors, Thank you for the opportunity to review this interesting piece of work, that highlights an under-adressed data gap in a marginalized population. However, I have a few minor concerns and queries about the article: 1) Firstly, I suggest adjustments to the wordings in the article, particularly on the usage of "short stature women", as it may come across as stigmatizing this population, taking into consideration this population may have shorter stature due to a underlying varying genetic and/or environmental reasons. I suggest adhering to person-first language i.e. "women with shorter stature" or "women with short stature" for a more neutral tone. Thank you for this suggestion. Have amended the manuscript throughout to adhere to first person language. 2) I am curious as to why neonates with major congenital abnormalities were excluded from the analysis, considering maternal obesity is a known risk factor for congenital anomalies. If there is a strong reason to this, I suggest the authors include the explanation in the main text. Thank you for raising this. The primary reason for this exclusion is that neonates with major congenital abnormalities often present with skewed birth weight distributions, such as being small or large for gestational age, which could confound the assessment of the relationship between maternal weight gain and neonatal outcomes. Additionally, certain congenital abnormalities can directly or indirectly influence gestational weight gain (GWG), further complicating the interpretation of results if included. As there was a relatively small number of neonates with congenital abnormalities, we anticipate that excluding this group should not substantially affect the results in any case. As suggested, we have added an explanation of this to the methods section (lines 109-112). 3) The women in the overweight/obese BMI range were analyzed as a homogenous group rather than 2 separate groups. The authors have alluded to the inherent issue of analyzing BMI as a categorical factor rather than continuous - that it oversimplifies risk estimation for women within a broad range of profiles such as BMI. In fact, the paper by Morisaki, quoted by the authors, found rather differing optimal GWG for women in the overweight (7.7kg) vs obese (4.3 kg) category. Therefore, I suggest the authors consider splitting the analysis of overweight (BMI 23-24.9 kg/m2) and obese (>25 kg/m2) categories, for better clinical applicability. This is an important issue and we thank the reviewer for raising it. Although growing, the overweight and obese groups are still relatively small populations in this area. The small numbers meant that when separated, the samples were underpowered and we were not able to produce meaningful results. To demonstrate this more clearly, we have added Table 1 and 2 repeated but separated into overweight and obese groups in the supplementary materials (Table S1 and Table S2). The number of overweight BMI women was 2085 and 1975 for obese women. Additionally, the Asia-pacific classification of overweight BMI (BMI 23-24.9 kg/m2) is very narrow. We have mentioned this as a limitation in the discussion section. 4) I suggest p-values to be included in Tables 1 and 2, to reflect the baseline differences among different BMI categories, if any, as they may hold weight in interpreting the main outcome of the analysis. Thank you for this suggestion. After consulting with the study statistician and in accordance with the STROBE guidelines for observational studies (section 14, 2007 Explanation and Elaboration by Vandenbroucke et al.) we note that descriptive tables are recommended to summarize participant characteristics without inferential statistics such as p-values. The rationale is to prevent any implication that these tables test hypotheses or draw conclusions about the data beyond simple description. 5) The authors addressed a potential overestimation of risk of adverse outcomes using the composite score - my question is how should the reader account for this when applying the findings of the analysis in clinical practice. Should the clinician advise for a more lenient range, or perhaps upper-half of the normal range reported in this study, while advising optimal GWG for women with shorter stature? I suggest the authors to discuss the clinical implications of this. We would suggest that a clinician in this setting should advise the same GWG range for all women within each BMI group, based on height. Because two thirds of our pregnancies had no adverse outcomes (n=11,309, 65.8%), these would have had the largest influence on the GWG estimations. Less than 6% had more than 1 of the adverse outcomes indicating not only that it was uncommon for women to experience more than 1 adverse outcome, but also that those who did would have minimal impact on the estimated GWG recommendation. The frequencies of pregnancies experiencing no adverse outcome, 1 adverse outcome and 1 or more adverse outcomes is also now included in the results and more explanation has been included in the discussion as well. Reviewer #3: The study explored optimal gestational weight gain (GWG) by BMI and height in a marginalized migrant population along the Thailand-Myanmar border, aiming to inform more population-specific guidelines. Here are some of my concerns that require addressing: The study does not distinguish between iatrogenic (medically indicated) and spontaneous preterm birth. Iatrogenic PTB (e.g., for preeclampsia or fetal distress) is often an appropriate and protective medical intervention rather than an adverse outcome. If iatrogenic PTB is grouped with spontaneous PTB, it could misrepresent GWG’s true impact on PTB risk or the composite risk outcome. Thank you for raising this point. In order to avoid the issues you mention, we have removed iatrogenic PTBs from the dataset (N=174) and rerun the analyses (N=17194). The study states that they adjusted for GDM screening method changes over time, but does not clearly define how GDM itself was accounted for in their models. A sensitivity analysis excludin Attachments Attachment Submitted filename: Reviewer_rebuttal_letter_May2025_FINAL.docx https://doi.org/10.1371/journal.pone.0330256.r002
12 Jun 2025 Decision Letter - Vidhura Tennekoon, Editor Optimal gestational weight gain and pregnancy outcomes, by BMI and height, in a marginalised population of women with short stature living along the Thailand-Myanmar border: a retrospective cohort, 2004-2023. PLOS ONE Dear Dr. McGready, In particular, please address the remaining additional concerns of Reviewer 2. Please submit your revised manuscript by Jul 27 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, Vidhura S Tennekoon 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. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 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??> Reviewer #1: Yes Reviewer #2: Partly ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> 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 Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Thank you again for the opportunity to read your article. The authors responded satisfactorily to all my comments. I have no further suggestions. Reviewer #2: Thank you for addressing my previous comments. However, I have further concerns about certain points in the study. 1) As the main focus on this study is on women with short stature - there should be an explicit statement of why 153 cm was taken as the threshold in this study. 2) There should be discussions on the differential background metabolic risks of populations with short stature, in relation to BMI, compared to taller populations. Underlying genetic, environmental, and socioeconomic factors that may confound short stature and adverse pregnancy outcomes should be highlighted as well. 3) The authors should caution from stating that these findings can be generalized to other populations. 4) There are other minor formatting issues highlighted in comments in the document. ****** 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: Yes: Quan Hziung Lim ******** [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 Attachments Attachment Submitted filename: PONE-D-24-59010_R1_Reviewer 2.pdf https://doi.org/10.1371/journal.pone.0330256.r003
Revision 2
25 Jul 2025 Author Response RESPONSES TO COMMENTS from REVIEWER 2 1) As the main focus on this study is on women with short stature - there should be an explicit statement of why 153 cm was taken as the threshold in this study. The height of <153cm was chosen as the cut-off because ≥153cm was used by the INTERGROWTH-21 project as one of the factors “commonly used to identify women who would benefit from low-risk, routine antenatal care”: • Cheikh Ismail L, Bishop DC, Pang R, et al. Gestational Weight Gain Standards Based on Women Enrolled in the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project: A Prospective Longitudinal Cohort Study. BMJ 2016, 352, i555, doi:10.1136/bmj.i555 • Villar J, Altman DG, Purwar M, et al. International Fetal and Newborn Growth Consortium for the 21st Century. The objectives, design and implementation of the INTERGROWTH-21st Project. BJOG 2013;120(suppl 2):9-26, v. doi:10.1111/1471-0528.12047 To clarify why this cut-off was chosen, we have added the following line in the methods: “Similar to the IG-21study, short stature was defined as maternal height less than 153cm.” 2) There should be discussions on the differential background metabolic risks of populations with short stature, in relation to BMI, compared to taller populations. Underlying genetic, environmental, and socioeconomic factors that may confound short stature and adverse pregnancy outcomes should be highlighted as well. Thank you for this suggestion. We agree that the relationship between maternal height, BMI and adverse pregnancy outcomes is complicated. We have added a paragraph to the discussion to highlight the complexity that needs to be considered, The relationship between maternal height, birth outcomes and BMI is complex. The women in this study represent a marginalised population where nutrition may be compromised but there is also an increasing proportion of women with overweight or obese BMIs[35]. This “double burden of malnutrition”[36] combined with short stature may impact the outcomes considered in this study, including caesarean section[37,38], small for gestational age and large for gestational age[39]. Indeed, Rahman et al reported that maternal overweight combined with short stature was associated with a higher risk of caesarean section regardless of socio-economic status which usually predicts risk for this outcome[37]. Yearwood et al found maternal height modified the association between SGA and LGA and risk of adverse outcomes; increased maternal height was associated with increased adverse outcomes in SGA babies but decreased risk in LGA babies[39]. Although we know that all women in this cohort were seeking services in a humanitarian healthcare setting, data on literacy and socioeconomic status, which can influence health and well-being of pregnant women and affect the GWG, was limited for this cohort, thus could not be adjusted for in the analysis.” 3) The authors should caution from stating that these findings can be generalized to other populations. We agree that readers should be cautious about the generalisability of our results. For this reason we have purposefully used cautious language such as “The findings from our study MAY also be applicable…”. However, we also believe it is important to note that there are limited data globally on women with short stature and as far as we are aware, no guidelines for GWG currently exist for these groups. Therefore, the findings from our study currently provide the only insight for any pregnant woman with short stature, regardless of access to health services and sociocultural contexts and we have presented our results in this context. 4) There are other minor formatting issues highlighted in comments in the document. Apologies for the formatting errors. The extra table that was inserted between the Figure headings/legends has now been removed. The table title for Table 3 has been modified to “Calculated optimal GWG ranges based on minimisation of composite risk of adverse outcomes, per Asia-Pacific BMI category, by height (<153cm vs. ≥153cm) and compared with NAM GWG recommendations”. The n for the full cohort has been added to Table 3. All abbreviations are now defined for all tables. In the discussion, where there was repetition of the previous sentence, we have removed “where only a small proportion of women fall into the overweight/obese category”. In addition, a sentence has been added to the discussion stating that another reason for the differences found may be due to the pregnancy outcomes that were considered in our study compared with those considered for the NAM GWG recommendations, “One reason for this difference may be because while this study considered the outcomes of HDoP, GDM, CS, spontaneous preterm birth, SGA and LGA, the NAM GWG recommendations additionally considered postpartum weight retention and childhood obesity, but not GDM [7]. Data on postpartum weight retention and childhood obesity were not available for analysis in this study.” Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0330256.r004
30 Jul 2025 Decision Letter - Vidhura Tennekoon, Editor Optimal gestational weight gain and pregnancy outcomes, by BMI and height, in a marginalised population of women with short stature living along the Thailand-Myanmar border: a retrospective cohort, 2004-2023. PONE-D-24-59010R2 Dear Dr. McGready, 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. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. 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. Kind regards, Vidhura S Tennekoon Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #2: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #2: Yes ****** Reviewer #2: Dear authors, thank you for addressing all the comments I highlighted previously. I have no further comments and congratulations on the great work. ****** 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: Yes: LIM QUAN HZIUNG, MBBS, MMed ******** https://doi.org/10.1371/journal.pone.0330256.r005
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