Dignity-based care and infertility treatment: A qualitative study

Zahra Kiani; Masoumeh Simbar; Soheila Nazarpour; Vida Ghasemi

doi:10.1371/journal.pone.0334322

Peer Review History

Original SubmissionMarch 7, 2025
18 Jun 2025 Decision Letter - Sidrah Nausheen, Editor Dear Dr. Simbar, 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'. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. 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Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 5. 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 If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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 If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.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 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: No Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: few Typo Errors Data sheets were written, not able to provide? If journal need Audio with study Code. It should be provided Dignity based care/ themes generated in this qualitative research, how it is different from General care required by any health seeker including confidentiality. Social stigma can be different only. Reviewer #2: This manuscript presents a qualitative study exploring the concept and dimensions of dignity-based care in infertility treatment services in Iran. Given the complex social, psychological, and ethical challenges surrounding infertility, particularly in culturally sensitive contexts, this research fills an important gap in literature by offering a multidimensional framework for understanding how dignity can be preserved in infertility care. The study is well-structured, clearly written, and includes an extensive review of related literature. The authors employ a solid qualitative methodology grounded in content analysis, and the findings are categorized meaningfully into four central themes. The paper makes a strong case for policy-level interventions and service reforms that consider patients’ dignity across psychological, cultural, and systemic dimensions. Methodology: The methodological rigor of this qualitative study is commendable. The authors used conventional content analysis based on Graneheim and Lundman’s framework and adhered to Lincoln and Guba’s criteria for trustworthiness, which greatly enhances the credibility, dependability, confirmability, and transferability of the findings. However, there are areas where methodological transparency could be improved: • A brief table or explanation of the interview guide questions (even in supplementary material) would be helpful for reproducibility. • While the authors mention “data saturation,” more detail on how this was operationalized (e.g., at which point no new themes emerged) would strengthen the claims. • Clarification on how male and female narratives were comparatively analyzed could further enrich the gendered understanding of dignity in care. Findings: The manuscript presents four main categories that define dignity-based care in infertility services: 1. Conserving dignity in providing care 2. Access to information and informed consent 3. Providing professional care and standard services 4. Considering cultural and social aspects of infertility These categories are richly supported by direct quotations, which provide authenticity and depth. However, to improve the findings section: • The presentation of Table 3 (codes, subcategories, categories) is dense and could benefit from better visual formatting or thematic grouping for readability. Discussion: The discussion is thorough and reflective, connecting the study’s findings with broader theoretical, ethical, and policy discourses on patient dignity and infertility treatment. The authors reference a range of philosophical and practical literature, offering a thoughtful framework to interpret their results. Suggestions for enhancement: • The integration of international best practices or dignity-based models in other reproductive health contexts could offer useful comparative insights. Clarity, Style, and Organization: The manuscript is generally clear and well-organized. The narrative flows logically from introduction to conclusion. Academic tone and language are appropriate, and the use of first-hand participant quotes adds richness. A few editorial recommendations: 11categoires and 4 categories.....should be 11 sub categories and 4 categories..... in table 3 • Use consistent terminology: “dignity-based care,” “dignity-oriented care,” and “respectful care” appear somewhat interchangeably; a brief clarification of these terms early on would help. The manuscript is a valuable, original, and well-executed contribution to the literature on infertility care and reproductive health ethics. Minor clarifications and edits, particularly in formatting, methodological detailing, and some stylistic improvements, will further enhance the quality and readability of the 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 #1: Yes: Dr Farheen Yousuf. Assistant Professor Aga Khan University Reviewer #2: Yes: Dr Iffat Ahmed ******** [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-25-11046_reviewer.docx https://doi.org/10.1371/journal.pone.0334322.r001
Revision 1
2 Jul 2025 Author Response Dear Editor: Dignity-based care and infertility treatment: A qualitative study (PONE-D-25-11046) Thanks to the valuable comments of the referees and the editor. The research team tried to prepare the answers and color the correct text in red. Is the manuscript technically sound, and do the data support the conclusion?1. The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes R-Thanks 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes R-Thanks 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: No Reviewer #2: Yes R-Thanks We tried to include all available information in the methods section to maintain confidentiality. 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 R-Thanks 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: few Typo Errors Data sheets were written, not able to provide? If journal need Audio with study Code. It should be provided. R- It is Corrected. We tried to include all available information in the methods section to maintain confidentiality, Dignity based care/ themes generated in this qualitative research, how it is different from General care required by any health seeker including confidentiality. Social stigma can be different only We transcribed all interviews with women, men, and key informants and put similar codes together to arrive at the concept of a dignity-centered care unit. Reviewer #2: This manuscript presents a qualitative study exploring the concept and dimensions of dignity-based care in infertility treatment services in Iran. Given the complex social, psychological, and ethical challenges surrounding infertility, particularly in culturally sensitive contexts, this research fills an important gap in literature by offering a multidimensional framework for understanding how dignity can be preserved in infertility care. R-Thanks for the comment The study is well-structured, clearly written, and includes an extensive review of related literature. The authors employ a solid qualitative methodology grounded in content analysis, and the findings are categorized meaningfully into four central themes. The paper makes a strong case for policy-level interventions and service reforms that consider patients’ dignity across psychological, cultural, and systemic dimensions R-Thanks for the comment Methodology: The methodological rigor of this qualitative study is commendable. The authors used conventional content analysis based on Graneheim and Lundman’s framework and adhered to Lincoln and Guba’s criteria for trustworthiness, which greatly enhances the credibility, dependability, confirmability, and transferability of the findings. R-Thanks for the comment However, there are areas where methodological transparency could be improved: • A brief table or explanation of the interview guide questions (even in supplementary material) would be helpful for reproducibility R-Thanks for the comment. It is Corrected. While the authors mention “data saturation,” more detail on how this was operationalized (e.g., at which point no new themes emerged) would strengthen the claims. R-Thanks for the comment. It is Corrected. • Clarification on how male and female narratives were comparatively analyzed could further enrich the gendered understanding of dignity in care. We transcribed all interviews with women, men, and key informants and put similar codes together to arrive at the concept of a dignity-centered care unit. Findings: The manuscript presents four main categories that define dignity-based care in infertility services: 1. Conserving dignity in providing care 2. Access to information and informed consent 3. Providing professional care and standard services 4. Considering cultural and social aspects of infertility These categories are richly supported by direct quotations, which provide authenticity and depth. However, to improve the findings section: • The presentation of Table 3 (codes, subcategories, categories) is dense and could benefit from better visual formatting or thematic grouping for readability. We have provided more information in Figure 1 to make it more visual. Discussion: The discussion is thorough and reflective, connecting the study’s findings with broader theoretical, ethical, and policy discourses on patient dignity and infertility treatment. The authors reference a range of philosophical and practical literature, offering a thoughtful framework to interpret their results. R-Thanks for the comment Suggestions for enhancement: • The integration of international best practices or dignity-based models in other reproductive health contexts could offer useful comparative insights. R-Thanks for the comment. It is Corrected. Clarity, Style, and Organization: The manuscript is generally clear and well-organized. The narrative flows logically from introduction to conclusion. Academic tone and language are appropriate, and the use of first-hand participant quotes adds richness. R-Thanks for the comment. A few editorial recommendations: 11categoires and 4 categories.....should be 11 sub categories and 4 categories..... in table 3 R-Thanks for the comment. It is Corrected. • Use consistent terminology: “dignity-based care,” “dignity-oriented care,” and “respectful care” appear somewhat interchangeably; a brief clarification of these terms early on would help. R-Thanks for the comment. It is Corrected. The manuscript is a valuable, original, and well-executed contribution to the literature on infertility care and reproductive health ethics. Minor clarifications and edits, particularly in formatting, methodological detailing, and some stylistic improvements, will further enhance the quality and readability of the work. R-Thanks for the comment. Other comment in text: If the participant doesn’t know Dignity care, did you provide information? The first and second questions are contradictory. AS per the objective of the study, to know about the expectations of patients while getting care R-Thanks for the comment. We tried to fix this problem by adding more questions to the manuscript. Rephrase for more clarity R-Thanks for the comment. It is Corrected. Do you mean wife or husband as the participant is a female? R-Thanks for the comment. It is Corrected. Kindly rephrase it. The immediate concept came as same sex couples. R-Thanks for the comment. It is Corrected. Attachments Attachment Submitted filename: Response to reviwers1.docx https://doi.org/10.1371/journal.pone.0334322.r002
25 Sep 2025 Decision Letter - Stefan Schlatt, Editor Dignity-based care and infertility treatment: A qualitative study PONE-D-25-11046R1 Dear Dr. Simbar, 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, Stefan Schlatt Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes ****** Reviewer #1: The author addressed all concerns raised and answer appropriately. The flow of writing is good. All parametersare fulfilled. ****** 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 ******** https://doi.org/10.1371/journal.pone.0334322.r003
Formally Accepted
Acceptance Letter - Stefan Schlatt, Editor PONE-D-25-11046R1 PLOS ONE Dear Dr. Simbar, 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 You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. 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. Stefan Schlatt Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0334322.r004

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