-->PONE-D-25-65361-->-->Birth in Shelters: Midwives’ Lived Experiences in providing childbirth care Amidst war in Gaza-->-->PLOS One

Dear Dr. Hassan,

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Reviewers' comments:

Reviewer's Responses to Questions

-->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: Yes

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

Reviewer #1: Yes

Reviewer #2: N/A

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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: No

Reviewer #2: Yes

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-->4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: 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: The article is well written and methodologically clear. I found the themes could be better titled for example Theme 1: Unprotected in ruthless warfare could be Midwifes Safety or something similar. There is a known war that the authors refer to but there is often a tendency to add adjectives to explain the brutality of the war e.g. ruthless war etc. I would advise the authors to consider reframing the war without adjectives. Moreover, as qualitative researchers, if there are any prior experiences or biases that may influence the interpretation of the results, that needs to be mentioned. This is often encouraged in any qualitative research. The second theme has a very large results description which either needs to be shortened or another sub theme introduced. Do the midwives receive any form of prior mental health training to provide support given there is a history of conflict in the area being served? Lastly I wondered why the midwives didn't share more insights of birth complications example PPH or eclampsia or obstructed labour as a challenge in the circumstances. The results and discussion expand on lack of services which gives the reader a sense of the challenges but I wondered if the authors can comment on this query?

Reviewer #2: Thank you, editorial team, inviting me to review this manuscript. This is a methodologically sound and ethically important qualitative study. The authors present a compelling narrative that is both scientifically rigorous and deeply human. The findings have critical implications for humanitarian policy, midwifery education, and the protection of healthcare workers in conflict zones. I have several comments and questions aimed at strengthening the manuscript's clarity, methodological transparency, and the contextualization of its findings before it is ready for publication.

1. Abstract

1.1 The abstract states, "Within two years, most of the 2.1 million inhabitants were displaced and more than 69 500 people were directly killed." The timeline in the main text (page 2) clarifies the war started in October 2023 and the study was conducted from January to April 2025. Can you please specify the exact dates for the "two years" mentioned in the abstract to ensure consistency with the detailed timeline provided in the manuscript?

1.2 In the abstract, you mention "three additional themes." Please ensure the three themes listed in the abstract ("Unprotected...", "Professional role...", "Challenges and potentials...") exactly match the themes as they appear in the results section of the main text for consistency.

2. Introduction

2.1 On page 2, you cite that "more than 69 500 people were directly killed, whom more than 70% are women and children." The data source (Jamaluddine et al., 2025) is a capture-recapture analysis. To enhance the scientific robustness of this statistic in the introduction, could you briefly add a note on the methodology used to arrive at this figure (e.g., "using a capture-recapture analysis, which accounts for underreporting...")?

2.2 On page 4, you state that "IHL... are meant to protect civilians and health care providers during war." Given the extensive documentation in your paper of attacks on healthcare, including the targeting of hospitals and the displacement of midwives, do you think a brief, explicit statement about the perceived failure of IHL in this specific context would strengthen the argument for why this study is urgently needed?

3. Material and Methods

3.1 In page 5: You mention "no personally identifiable information was recorded." However, you also state interviews were conducted "face-to-face." How did you ensure that the location and time of the interview, as well as the participants' visible characteristics, did not inadvertently compromise their anonymity, especially given the small sample size and the close-knit, displaced community context?

3.2 In page 6: You used Perplexity AI to translate the transcripts for the third author. This is a novel approach. To ensure methodological transparency and address potential concerns about accuracy or bias, could you please elaborate on how the translated English transcripts were validated against the original Arabic? You mention they were "confirmed by the co-authors," but a more detailed step (e.g., "the two Arabic-speaking authors reviewed and approved the translated transcripts for accuracy and contextual meaning before the third author began analysis") would strengthen this section.

3.3 Table 1 (page 10): The table lists years of experience, but the narrative text mentions an average of \(11.0 \pm 5.93\) years. For Midwife 9, the table lists 28 years, which appears to be a significant outlier. Is this correct? If so, its impact on the analysis and findings should be noted. Also, Midwife 2 is listed as having 5 years of experience, but her narrative (MW2) is particularly rich and central to the overarching theme. It would be useful to briefly note in the text that participants spanned a wide range of experience, which contributed to the richness of the data.

4. Results

4.1 Theme 1, subtheme "Improvised Childbirth" (page 11): MW9's story of using a blanket from a vegetable cart and a donkey cart for transport is incredibly powerful. Did any midwife recount a situation where improvisation failed, leading to a poor outcome (e.g., maternal or neonatal death, infection)? While your findings focus on successful outcomes, acknowledging the presence or absence of such stories is important for a complete picture. You mention this as a limitation, but a note in the results about the nature of the narratives (e.g., "All narratives shared by the midwives concluded with a live birth, though complications were managed") would be helpful.

4.2 Theme 2, subtheme "Improvising preparedness" (page 13): The quote about using a kitchen knife and sewing thread is stark. You mention that after some incidents, there was a focus on ensuring medical points had delivery kits. Can you provide more detail? What was the nature of this "focus"? Was it a formal initiative by the Ministry of Health, UNRWA, or a grassroots effort among the midwives themselves? This small detail adds significant depth to the theme of "challenges and potentials."

4.3 Theme 3, subtheme "Navigating high-risk pregnancies" (page 16): The quote from MW8 about the woman with a previous C-section and a "precious baby" after infertility highlights the immense pressure on midwives. Was there any instance where a midwife had to make a critical decision, such as deciding not to attempt a home birth for a clearly high-risk patient, and if so, how did they manage that situation without access to a hospital? Exploring the decision-making process in these extreme scenarios would add further depth.

5. Discussion

5.1 Page 18: You state that "midwives during the recent war did not mention fear of restrictions, which might imply a growing recognition of the profession's autonomy." This is a crucial point. Could it also be that the complete breakdown of the formal health system and the state of emergency simply rendered legal restrictions moot? The authors might explore this nuance further: was the absence of fear due to autonomy or anarchy? This distinction has significant implications for how preparedness policies are framed (i.e., empowering vs. emergency protocols).

5.2 Page 18-19: You reference the Quality Maternal and Newborn Care (QMNC) framework to highlight how midwives' care aligned with its philosophy. The most urgent missing quality was "sufficient for first line management of complications." This is a critical gap. In your discussion, could you elaborate on what specific "first-line" supplies (e.g., misoprostol for PPH, antibiotics, magnesium sulfate) were most urgently needed and how the absence of these impacted the midwives' ability to manage the high-risk cases you described? This would make the recommendation for "necessary supplies" in the conclusion more specific and actionable.

5.3 Page 20: You mention the UNRWA's role and its being targeted. This is a critical part of the context. Could you briefly expand on how the targeting of UNRWA and the subsequent disruption of its supply chains directly affected the midwives you interviewed? Did they mention a specific point at which they lost access to UNRWA supplies? This would strengthen the link between geopolitical events and the on-the-ground experiences of your participants.

6. Strengths and Limitations

6.1 Page 20: The stated limitation is that "all participating midwives shared stories that, in some way, ended well with a healthy mother and baby. Important information may have refrained from participating due to fear of being perceived as having failed." This is an important and honest limitation. Could the authors expand on this by discussing the potential impact of this selection bias on the findings? For instance, does this mean the findings represent a "best-case scenario" of midwifery response, and that the experiences of those who faced tragic outcomes might reveal different, perhaps even more critical, failures in the system? Acknowledging this gap explicitly would be valuable.

7. Conclusion and Recommendations

7.1 Based on your findings, what would be the first, most critical element of such a policy? Is it the provision of a standardized "emergency birth kit" with essential supplies? Is it a legal framework that explicitly authorizes and protects midwives practicing in community settings during declared emergencies? Prioritizing this in the final sentence of your conclusion could give your recommendation more immediate impact.

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Reviewer #1: Yes: Dr Danish Ahmad MBBS, MSc PhD,MNAMS, FRCP(Edin) FRCP(Lon) FHEA (UK)

Reviewer #2: Yes: Temesgen Anjulo Ageru

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Birth in Shelters: Midwives’ lived experiences in providing childbirth care amidst war in Gaza

PONE-D-25-65361R1

Dear Dr. Hassan,

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,

Muhammad Haroon Stanikzai

Academic Editor

PLOS One

Additional Editor Comments (optional):

This manuscript presents a timely and methodologically sound work and I congratulate the authors for their work.

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 #2: 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 #2: Yes

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

Reviewer #1: N/A

Reviewer #2: Yes

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-->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: No

Reviewer #2: 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 #2: Yes

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-->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: The authors have addressed my comments and also the 2nd reviewer points. I am largely happy to recommend the paper for publication given it is a qualitative paper with established methodology and the availability of timely results would be important from the journals perspective.

Reviewer #2: The authors' responses are respectful, evidence-based, and have genuinely improved the manuscript's rigor, transparency, and contextual depth. No outstanding issues remain from my previous review.

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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.

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Reviewer #1: Yes: Dr Danish Ahmad, MBBS,MSc,PhD, FRCP

Reviewer #2: Yes: Temesgen Anjulo Ageru

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