-->PONE-D-25-61419-->-->Stratified and Spatial Patterns of Depression and Anxiety in Mozambican Women: Maternal Health Policy Implications-->-->PLOS One

Dear Dr. Miah,

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.-->--> -->-->Thank you for this important work. The reviewers agree you have important information to share but have suggested many areas for revision. Please respond to each suggestion by the reviewers.-->-->

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Reviewers' comments:

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1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Partly

Reviewer #2: Partly

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: No

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-->5. Review Comments to the Author

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Reviewer #1: Thank you for the opportunity to review this manuscript. Overall this is an interesting approach to examine mental health prevalence among girls and women among reproductive age and its clear that the authors have put a great deal of work into the analysis. While I believe that the study findings may be useful, there is opportunity for clarification so that the readers can understand both the study methodology and the results. Overall, the title of the paper leads the reader to understand that this is a study specifically examining maternal mental health – but it reads as a study that examined mental health among girls and women among reproductive age, but its difficult to tease out which results specifically refer to perinatal mental health versus girls’ and womens’ mental health in general.

The manuscript will greatly benefit from much more detail within the methodology section that extends beyond the analysis used, and greater organization including sub-headings within the results as its currently quite confusing and as it currently reads, many of the results appear to be contradictory. An overall copy edit for language will also be helpful.

Thank you again for the opportunity to review and congratulations on all the work that you have done thus far.

Abstract:

Methodology:

1. It will be helpful to have age disaggregation bands available here as otherwise it is challenging to interpret the findings.

2. Also, it is clear that the DHS was used to gather PHQ-9 and GAD-7 data, were additional measures also gathered from the DHS? If yes, please specify or please include mention of other scales employed by the study team such as the scale for women’s empowerment, HH asset ownership, how internet usage was assessed.

Findings.

3. 11% anxiety and 10% depressive. It would be useful to understand the percentage comorbid depression and anxiety.

4. In your findings for the age-bands, it will be helpful to specify which group had the highest odds of anxiety, and then next highest.

Conclusions:

5. Suggest extending the conclusion beyond integrated policies. While this is an important start, without supportive health systems, skilled clinicians, and available services, the policies will not address MMH challenges experienced by Mozambican girls and women.

Introduction.

6. Suggest ending the first sentence on line 67 after disease and starting a new sentence with “In 2021…”

7. Line 69…should be “worsen” and “elevate the risk of comborbid…

8. Just a note that if you are including girls as young as 15 years old, so I would encourage the authors to refer to the study population as “girls and women of reproductive age”.

9. line 73: Depression and anxiety disproportionately affect girls and women in LMIC…

10. line 76: Would encourage including lack of supportive policies and guidelines, mental health stigma, lack of specialized services as other issues.

11. If the authors are going to discuss internet access in the introduction, also suggest drawing in specific examples from the literature in regards to MMH specifically, otherwise this doesn’t seem a natural fit within this section.

12. Note that lines 81-83 state that there is little information on mental health twice. Also be sure throughout to note that the topic is specifically maternal mental health which is even further neglected area of mental health.

13. I have yet to see information on the influence of access to media on MMH, it would be helpful to include that specific relationship on lines 90-91.

14. Suggest ending the introduction with a sentence or two on how this methodological framework may be useful for other countries interested in developing responsive and data-driven MMH policies.

Methodology.

15. Line 142, what does the two areas missed refer to?

16. To confirm, this is mental health in general among women of reproductive age? These women have not necessarily had a pregnancy?

17. How was covariate data gathered? Was this all available in the DHS? If not, please specify tools used and how data was gathered if means were required outside of standard DHS. Beyond the statistical analysis, much more information is needed on how all of these measures were collected.

18. Starting on line 174. I am curious as to whether HIV status and/or migration status was also considered as variables given these are also widely recognized risk factors?

Results.

19. Line 215. Please specify what higher education refers to.

20. Line 2016. Please clarify what “justified intimate partner violence refers to”. Did they believe that 2/3rds of women who experienced IPV thought that it was excusable? Or among women in general? More specificity here will be important to understand the statement.

21. Line 217, What are indicators of women’s empowerment (it would help if the information were available in the methods).

22. Line 218. What does improved sanitation refer to? Running water? Toilet in the house?

23. For lines 217-222, in the methodology it will be important to have the various scales that were used to understand how to interpret all of these results.

24. What was the % of comorbid anxiety and depression? If this not possible to ascertain from the DHS? If not, please include in the limitations.

25. The abstract says that women in their mid 30s and then again in their mid 40s experienced the highest odds of mental health symptoms, but lines 224-225 say that prevalence of symptoms was highest among young people. More clarification is needed to understand this conflicting data.

26. Line 226. Please clarify what ‘early childbirth’ refers to. Assume this means younger age when gave birth, and not pre-term birth?

27. Also, early childbirth (if referring to young age), early sexual debut and early cohabitation all represent a similar phenomenon – just noting that these are similar and wondering if this should be teased out any further to understand specifically if its early motherhood (adolescents are among the highest risk for a perinatal mental health disorder), or if simply cohabitating places a girl at risk.

28. Line 230. Please clarify the similar trends across partners’ education, etc. Does that mean that girls and women experienced more mental health symptoms based upon their partners education?

29. Line 234, a new paragraph should start with “Among the…

30. Line 236, aren’t three or more children and multiple pregnancies the same? Or does multiple pregnancies refer to twins and triplets?

31. Line 236, what does inadequate ANC visits refer to? Please include a number – e.g., did not meet the threshold # of…

32. Line 236-237, pressure to become pregnant from who?

33. Line 237, the sentence about previous pregnancy loss is confusing. It currently reads that women who had NOT experienced a previous loss were more likely to experience depression and anxiety. This is a surprising finding given that previous pregnancy loss and stillbirth are risk factors for perinatal mental health disorders. More clarification is needed.

34. Women abstaining from sex?

35. Please name the specific religious grouping under study.

36. Line 244, had more than twice the odds in comparison to which other age group? Again, these age groupings are confusing with the information reported in the abstract. As it reads right now, it looks as though the researchers have lumped girls and women 15-39 together to indicate twice the odds of anxiety (in comparison to who?), and higher odds of depression, and then also states that women 45-49 also have higher odds of anxiety. Again, across all of these, what is the reference or comparison group to whom the higher odds are being compared to?

37. Line 255. Internet use is stated to report higher risk of anxiety, but line 233 says that symptoms were higher among those without internet access. This seems contradictory?

38. Line 262. These findings of higher odds of anxiety correlate to what was reported in the abstract. But how is this different from the findings of anxiety reported among girls? Are there sub-headings missing by location? The results as written are quite confusing.

39. Line 279, it appears that a bracket is missing.

40. Line 287, am I understanding correctly that this data is only rural women now, and early sexual debut was protective against experiencing anxiety? I would use caution with that terminology as its not clear that having sex at a young age is protective, but rather girls who had sex at a young age in rural areas experienced lower odds of depression in comparison to who?

41. Line 293, the reference to toilet facilities is unclear.

42. Line 311. What does household division refer to?

43. Early sexual debut now appears to be the greatest risk factor, but earlier was said to be protective in rural areas?

44. Line 315-316. Unclear what AUC and ROC refers to and what it means in the context of the results. What should the reader infer from this?

45. Overall comment on the results section. It is quite long and confusing. Sub-headings are needed and a great deal of attention to clarify the different analysis which seem to currently overlap and contradict each other. There are also several spaces where the authors use “higher odds” but don’t provide a reference/comparison group.

Discussion

46. Line 322. A definition for ‘reproductive transitions’ should be included within the methodology. It will be important to understand how much of this data is actually centered around the reproductive transitions once the reader has an idea what that transition refers to.

47. Line 332. This is the first reference that I’ve read regarding poor quality care. How was this ascertained? There was earlier mention of fewer ANC visits, but this seems different.

48. I am not convinced that the internet has any meaningful impact based upon this study, it seems like a superficial measure with perhaps some correlations but not necessarily impacts – if the authors are to include internet within this study, suggest further explanation and justifications for its inclusion. Especially given internet was not necessarily widely accessible.

49. The authors indicate that early sexual debut is the main risk factor but than state here that women over age 18 were more likely to have symptoms.

Strengths and Limitations

50. Challenging to tease out actual reproductive transitions – how much of this data is associated with perinatal mental health conditions versus overall mental health among this population?

Implications

51. Line 393, suggest changing ‘introducing” to “integrating”.

52. Again, clarify what reproductive transitions are.

53. Line 396, what about activities that improve gender equity and reduce IPV?

Conclusions

54. Unsure if equity-based is the most appropriate term here. Suggest a maternal health policy that integrated mental health from pre-pregnancy through two years postpartum.

55. Line 404, and also tackles gender inequities that influence risk for mental health conditions.

Reviewer #2: Needs a thorough copy edit; in many places sentences are not complete or not clear. For example line 217, “showed indicators of women’s empowerment” is not clear. Line 284, Among rural women instead of In the rural women. Line 314, no capitalization on depression and anxiety. Lines 351, 352 need revision. And more.

"Objectives" lack references and rationale that link the covariates to the actual outcomes; while this is an observational study that cannot explore causal relationships, the first part of the paper lacks clear thought on how the risk factors can directly influence depression and anxiety. The pieces are better described in the discussion and conclusion, but need more thoughtful discussion in the motivation of the paper, the mechanisms and how they can relate to the findings. Water source and toilet type, for example, what is the framework for how these relate to depression and anxiety? The author talks about conceptual relevance last, but this should probably be first (line 130).

Sometimes the author refers to ‘mental health’ instead of symptoms of depression or anxiety (line 224 for example). Those should be corrected. Line 238, unclear what is meant by preponderance? How would that influence higher symptom prevalence? Line 333, higher symptoms isn’t clear. Make sure to clearly distinguish where necessary if it is symptoms of anxiety, depression, or both. And what is the difference, would we expect both to move in the same direction with the covariates?

If age at first sex is most salient, why? It is not just age at first sex, it is the younger a young woman is when she first has sex, the more likely she is to have anxiety and depression? Line 314. Line 319, the MDHS includes all women, not just ever married. If the sample is restricted this is not clear.

I don’t think there is any spatial analysis in this paper. The author looks at geographic differences, rural urban, etc, which are important but this is not the same as spatial analysis. I suggest changing “spatial” to “geographic” or “regional” analysis and keeping the focus on geographic comparisons which are in and of themselves interesting. In the figures, it is not spatial prevalence, it is simply regional prevalence.

I don't think the author clearly discusses the figures, and I'm not sure all of the figures are needed or particularly helpful to understand the findings. Not sure figure 1 adds much value unless there is a discussion of it and the differences observed. Figures 3 and 4 would be more useful if the covariates were ordered or grouped in some way and discussed in the results. Figure 7 could be useful for the beginning of the article. Maps are useful but could be more useful if discussed when looking at internal conflict. Color bins should be changed to quartiles or some other grouping that is easier to read. A map is not spatial prevalence.

It would be interesting to reflect on the use of the GAD7 and PHQ9 in this setting as a reliable and valid way to capture depression and anxiety in a nationally representative HH survey such as the DHS.

In the Comparison and Existing Literature, it should be noted if the studies the author is comparing were done using the GAD7 and PHQ9, same age groups, etc?

That said, the analysis is an important contribution to the literature as this is the first time the DHS has included the mental health module in any survey. The discussion summarizes these patterns; this is the best part of the paper. Need to weave that more into the beginning and justification for why the analysis is being done. What is striking is how well the findings seem to hold up. It suggests that these scales are valid for use in Mozambique (and probably other countries) given the direction of the relationships found between the covariates and the outcomes. Need further discussion of Nampula, why does this region stand out? Why more so than Cabo Delgado?

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Reviewer #1: No

Reviewer #2: No

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-->PONE-D-25-61419R1-->-->Stratified and Geographic Patterns of Depression and Anxiety in Mozambican Women:  Mental Health Policy Implications-->-->PLOS One

Dear Dr. Miah,

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 Sep 10 2026 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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We look forward to receiving your revised manuscript.

Kind regards,

Jennifer Yourkavitch

Academic Editor

PLOS One

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Additional Editor Comments:

Thank you for your thorough edits in response to reviewers' comments. My concern is with your conclusion sections. The conclusion in the Abstract comprises general statements that do not reflect your findings. Teh conclusion section in the main narrative relies too heavily on restating results. I found some statements within the "impact on public health" section that would be good in the conclusions sections.

For example, this statement: "The findings suggest that maternal mental health should be integrated into existing reproductive, antenatal, and community health services in Mozambique." is too general and not specifically tied to your findings. One of your findings is about the higher burden on a certain age group, so perhaps interventions for that specific age group would be appropriate? That is an example of a conclusion that reflects your findings.

Please revise the conclusions sections in the abstract and in the narrative.

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Stratified and Geographic Patterns of Depression and Anxiety in Mozambican Women:  Mental Health Policy Implications

PONE-D-25-61419R2

Dear Dr. Miah,

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.

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PLOS One