Pregnancy Care during the COVID-19 Pandemic in Germany: A Public Health Lens

Round 1

Reviewer 1 Report

In the work presented by Leibe and collaborators, they give an accurate bibliographic review related mainly to the impact of the COVID-19 pandemic on a vulnerable population such as pregnant women in Germany. The study is well-oriented, and the authors were able to capture the effects that early vaccination, as well as the problems of not considering this population within the vaccination plan, can reduce the chances of a correct and healthy pregnancy. Additionally, the authors touch on a fascinating topic concerning mental health in pregnancy and the pandemic's effect on this population. Although it is known that pregnancy has a solid stimulus for generating stress in patients, the pandemic's additional factor was a trigger to show an effect on women's behavior during pregnancy. It is important to emphasize that the German government's recommendations generated during the pandemic in pregnant women could be considered for other nations to implement these strategies. However, although the work is of good quality, to have a better reading of it, the addition of an image that can summarize the manuscript's content in a general way is recommended since this can be more attractive to the reader. We also recommend that in the conclusions, the authors propose some additional alternatives to those already described in their text. For example, in various countries, the generation of workshops or courses can help pregnant women with information on the effect of vaccines or mental health that can bring the couple closer to preventive measures for post-pandemic stress. Perhaps these recommendations have been considered and will impact the manuscript more.

Author Response

In the work presented by Leiße and collaborators, they give an accurate bibliographic review related mainly to the impact of the COVID-19 pandemic on a vulnerable population such as pregnant women in Germany. The study is well-oriented, and the authors were able to capture the effects that early vaccination, as well as the problems of not considering this population within the vaccination plan, can reduce the chances of a correct and healthy pregnancy. Additionally, the authors touch on a fascinating topic concerning mental health in pregnancy and the pandemic's effect on this population. Although it is known that pregnancy has a solid stimulus for generating stress in patients, the pandemic's additional factor was a trigger to show an effect on women's behavior during pregnancy. It is important to emphasize that the German government's recommendations generated during the pandemic in pregnant women could be considered for other nations to implement these strategies.

However, although the work is of good quality, to have a better reading of it, the addition of an image that can summarize the manuscript's content in a general way is recommended since this can be more attractive to the reader.

Thank you for your recommendation to include a figure that summarizes the paper’s topic. We considered and discussed your recommendation within our team on how to integrate your comment in our paper. However, we decided not to include an illustration/image into the paper as the topic is too complex to depict. We did a few drafts, e.g., a version with the regulations in Germany on the one hand and the impact on mothers, newborns, and others on the other hand. However, the relationship between the points is rather complex and the impact of mothers (e.g., a missing companion of choice due to measures for infection control do have an impact on maternal mental health). We do appreciate this hint!

 

We also recommend that in the conclusions, the authors propose some additional alternatives to those already described in their text. For example, in various countries, the generation of workshops or courses can help pregnant women with information on the effect of vaccines or mental health that can bring the couple closer to preventive measures for post-pandemic stress. Perhaps these recommendations have been considered and will impact the manuscript more.

Thank you for the point. We added this recommendation to our paper: “With the discontinuation of offers in times of pandemic, including birth classes, women should still be given the opportunity to prepare for childbirth and parenthood. This can take place in the form of online offers and courses [63].”

Author Response File: Author Response.docx

Reviewer 2 Report

The paper is an interesting commentary on pregnancy management in German during the COVID-19 pandemic. It highlights the pros and cons of social measures on infectious prevention and outcomes in pregnant women and newborns. Since clinical information is lacking in pregnant women in both antenatal and postnatal periods. Correctly, the authors propose implementing clinical trials with pregnant women to increase an evidence-based approach to the problem. I have only two minor concerns. One is methodological, authors should explain better the strategy of literature inclusion or exclusion. Second, although the meta-analysis of Prasal et al. showed a reduction of stillbirth in vaccinated women, the result was limited by an elevated heterogeneity. For correctness, it should be highlighted.

Author Response

Reviewer 2:

The paper is an interesting commentary on pregnancy management in German during the COVID-19 pandemic. It highlights the pros and cons of social measures on infectious prevention and outcomes in pregnant women and newborns. Since clinical information is lacking in pregnant women in both antenatal and postnatal periods. Correctly, the authors propose implementing clinical trials with pregnant women to increase an evidence-based approach to the problem. I have only two minor concerns. One is methodological, authors should explain better the strategy of literature inclusion or exclusion.

Thank you for your comment. We considered your point that was also addressed by Reviewer 3. However, we decided to not include a method section with inclusion and exclusion criteria used for literature research, as you need to consider the form of our paper. We do not claim to write a systematic review. Rather, we want to provide a critical discussion about the topic. Even though, we focus on a German context, we also include international literature (especially when reporting the impact of the COVID-19 pandemic on maternal mental health), as the evidence from Germany is limited. Therefore, we assume that women/mothers in Germany experience similar mental health issues due to the pandemic as women/mothers in other countries (e.g., systematic review of Rouhbakhsh Zahmatkesh et al. (2020)). In conclusion, we do not have fixed criteria. However, following your recommendation, we added the following statement at the end of the introduction:

The commentary is based on a narrative synthesis of international literature concerning the health of pregnant women during the COVID-19 pandemic. This evidence has been transferred to the situation in Germany and should serve as a starting point for further discussions.

 

Second, although the meta-analysis of Prasal et al. showed a reduction of stillbirth in vaccinated women, the result was limited by an elevated heterogeneity. For correctness, it should be highlighted.

Thank you for your comment. We added a sentence informing the reader how the results should be interpreted.

Author Response File: Author Response.docx

Reviewer 3 Report

The authors have made an interesting attempt at “Pregnancy Care During the COVID-19 Pandemic in Germany: A Public Health Lens” The manuscript is interesting; however, the authors need to justify the scientific writing manuscript. Some of the general comments are provided below:
 

1.     The abstract should be refined.

2.     The authors did not explain the method of this review, what was the inclusion and exclusion criteria of studies included in this review?

3.     The research gap must clearly be stated and keeping in line with the same, the research goals for the paper are to be presented.

4.     The exact technical contribution and novelty of the work need to be stated explicitly.

5.     Interpretation and analysis of experimental observations are extremely important - authors must pay proper attention to this in the manuscripts.

6.     Further, how did the investigators gain access to these online reviews? Were they publicly accessible or were the investigators required to obtain permission to gain access?

7.     It will be interesting to include the ages of mothers.

 

8.     Another important aspect is to know the difference in vaccine-related stress among mothers having their first pregnancy compared to the mothers having their second or above pregnancies. 

Author Response

Reviewer 3:

The authors have made an interesting attempt at “Pregnancy Care During the COVID-19 Pandemic in Germany: A Public Health Lens” The manuscript is interesting; however, the authors need to justify the scientific writing manuscript. Some of the general comments are provided below:

 

1. The abstract should be refined.

We have modified the abstract and hope that this meets your expectations.

 

2. The authors did not explain the method of this review, what was the inclusion and exclusion criteria of studies included in this review?

Thank you for your comment. We considered your point that was also addressed by Reviewer 2. However, we decided to not include a method section with inclusion and exclusion criteria used for literature research, as you need to consider the form of our paper. We do not claim to write a systematic review. Rather, we want to provide a critical discussion about the topic. Even though, we focus on a German context, we also include international literature (especially when reporting the impact of the COVID-19 pandemic on maternal mental health), as the evidence from Germany is limited. Therefore, we assume that women/mothers in Germany experience similar mental health issues due to the pandemic as women/mothers in other countries (e.g., systematic review of Rouhbakhsh Zahmatkesh et al. (2020)). In conclusion, we do not have fixed criteria. However, following your recommendation, we added the following statement at the end of the introduction:

The commentary is based on a narrative synthesis of international literature concerning the health of pregnant women during the COVID-19 pandemic. This evidence has been transferred to the situation in Germany and should serve as a starting point for further discussions.

 

 

3. The research gap must clearly be stated and keeping in line with the same, the research goals for the paper are to be presented.

Thank you for your comment. As already described above, we do not claim to address a research gap, since we did not collect data and did no systematic review. This paper is a critical paper that should be considered an impulse for a discussion. We further want to point out that the aim of the work is written in the lines 56-60:

This commentary summarizes available literature on pandemic-related challenges in pregnancy care with two main aims. Firstly, we want to provide a critical overview of changes that occurred in pregnancy care due to the COVID-19 pandemic. Secondly, implications should be derived to improve pregnancy care – not only during crises but also in general. Thus, different actors can benefit from the experiences made in the last three years of the pandemic and adapt these to future similar scenarios. For doing so, we are going to take a public health lens which allows considering the weighting of benefits and harms under uncertainty, and autonomy vs. commitment to act (on individual, societal and political levels) in terms of prevention, as well as aspects of equity and equality.

 

4. The exact technical contribution and novelty of the work need to be stated explicitly.

Thanks for that hint. As mentioned above, this paper does not contribute to the current research consensus, as we neither collected data nor conducted a systematic review. Rather, it should be seen as a starting point for a critical discussion of the situation of pregnant women/new mothers during the COVID-19 pandemic in Germany.

 

5. Interpretation and analysis of experimental observations are extremely important - authors must pay proper attention to this in the manuscripts.

Thank you for that comment. We included your point by adding the following sentences to our paper:

“When analyzing the impact of the COVID-19 pandemic on mothers, one must note that a comparison of exposed and unexposed women is limited, as the pandemic affects all pregnant women equally in Germany. Therefore, further research is needed that focuses on comparing women who experienced restrictions during pregnancy and birth due to the pandemic and women who did not.”

 

6. Further, how did the investigators gain access to these online reviews? Were they publicly accessible or were the investigators required to obtain permission to gain access?

Thank you for your interest for our methodological part of the paper. We decided not to address this point due to the form of the paper (discussion paper/critical review). We assume that this information is rather necessary in a systematic review/metanalysis, and therefore do not provide information on that.

 

7. It will be interesting to include the ages of mothers.

Thank you for your interest. We tried to add your point into our paper. However, we believe that the reading flow is disturbed by adding the age of the mothers. We tried to add this information, when we especially focus on the results of one study (e.g., the study of Ercan et al.). However, the age was reported in age categories and not as a mean value. Therefore, we could not include your comment into our paper.

 

8. Another important aspect is to know the difference in vaccine-related stress among mothers having their first pregnancy compared to the mothers having their second or above pregnancies. 

Thank you for your comment and your further interest. To the authors’ knowledge, there is no study that examines differences in vaccine-related stress during the pandemic in first-time parents and parents of multiple children. The current research consensus only focuses on examining stress in first-time parents without focusing on vaccine-related stress (compare:

Ben-Yaakov, O., & Ben-Ari, O. T. (2022). COVID-19-Related anxieties and parenting stress among first-time mothers and fathers in their first year of parenthood. Psychology & Health, 37(11), 1327–1341. https://doi.org/10.1080/08870446.2021.1942875)

The only publication we found that investigates the number of children and parents’ attitudes towards vaccination is the following one:

Skjefte, M., Ngirbabul, M., Akeju, O., Escudero, D., Hernandez-Diaz, S., Wyszynski, D. F., & Wu, J. W. (2021). COVID-19 vaccine acceptance among pregnant women and mothers of young children: Results of a survey in 16 countries. European Journal of Epidemiology, 36(2), 197–211. https://doi.org/10.1007/s10654-021-00728-6

However, this publication does not address vaccine-related stress.

Author Response File: Author Response.docx

Round 2

Reviewer 3 Report

The authors have addressed my queries, the manuscript is acceptable for publication.