Factors Associated with Obstetric Violence Implicated in the Development of Postpartum Depression and Post-Traumatic Stress Disorder: A Systematic Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this paper which addresses this important aspect of reproductive health care. This important review can benefit from some clarity in definitions of OV and may also benefit from some attention to the larger structural and contextual factors where obstetric care is situated and how race/class/gender is implicated here.

There are some minor English Language grammar issues that should be easily addressed as well.

Line 44: Should “The” be here?

Line 67: this sentence is missing a linking word or statement?

Line 78: Can this sentence be broken up into two sentences instead of having the question mark in the middle?

Line 104: this sentence can be moved to the prior paragraph and delete the word “Besides”

Line 116: Can Kristeller technique be defined or just replaced with “fundal pressure” Was this technique the only physical manifestation of and OV action that you included? Episiotomy? Position in labor? Silencing?

Line 137: here you define these classifications. For those lice c-section or instrumental birth (not labor) can you delineate what makes these interventions acts of violence? I am not suggesting that they are not violent under certain circumstances, but what conditions lead to a section that is violent? Can a section not be violent at times?

Should “finished the assessment” read “finished the first assessment?”

Line 341: Would it make sense to have a section at the end of the discussion with your clinical implications or recommendations?

Line 347: Decide if “The” is needed before OV. It seems that OV can stand alone without a need for “the”

Line 348:Is the definition itself weak or misunderstood? What other factors may lead to it being poorly understood? What about the norms of obstetric care or the lack of a patient or woman-centered model of care where women and birthing people are experts in their own bodies? Is OV moderated by racism? How does race/class/gender and these intersecting identities of birthing people impact OV?

Line 365: this is an incomplete sentence

385: can you clarify whose expectations birthing people are expected to comply with? D

Line 402. Delete “in turn” This could be included in a clinical implications section of the discussion- raising the cut off to 13

Line 412? Are there other scales? Vedam et al have developed at least two scales that may work here.

Comments on the Quality of English Language

There is some editing for English language needed. This will strengthen the manuscript significantly.

Author Response

Thank you for the opportunity to review this paper which addresses this important aspect of reproductive health care. This important review can benefit from some clarity in definitions of OV and may also benefit from some attention to the larger structural and contextual factors where obstetric care is situated and how race/class/gender is implicated here.

Response: Thank you for your kind words and time spent reviewing our article. We have edited the main text and responded to your comments to make the manuscript more interesting.

There are some minor English Language grammar issues that should be easily addressed as well.

Line 44: Should “The” be here?

Line 67: this sentence is missing a linking word or statement?

Line 78: Can this sentence be broken up into two sentences instead of having the question mark in the middle?

Line 104: this sentence can be moved to the prior paragraph and delete the word “Besides”.

Response: The lines have been modified according to the reviewer´s suggestions. The line 78 was modified to remove the question mark and “Beside” word was removed, and sentences moved to the prior paragraph.

Line 116: Can Kristeller technique be defined or just replaced with “fundal pressure” Was this technique the only physical manifestation of and OV action that you included? Episiotomy? Position in labor? Silencing?

Response: This line was an example of the actions that other authors considered as OV, among which episiotomy was included and, therefore, was added. Also, the Kristeller technique has been defined as fundal uterine pressure maneuver for better comprehension. The position of labor was not a variable collected by the authors, but it is very interesting for future studies.

Line 137: here you define these classifications. For those lice c-section or instrumental birth (not labor) can you delineate what makes these interventions acts of violence? I am not suggesting that they are not violent under certain circumstances, but what conditions lead to a section that is violent? Can a section not be violent at times?

Response: This is a great comment. Sometimes, during the expulsion, the established birth plan by the woman was not followed. This causes that the woman perceived these actions as violent. Taking away that these techniques are invasive for the woman's body and that time for recovery are longer, the perception of violence of these actions determines that they are risk factors for PPD and PTSD, reason why they were included in the manuscript. If these techniques are explained in advance and the woman understands that there are some conditions that can alter childbirth, she can be prepared to undertake these techniques. This aspect was explained in the conclusions.

Should “finished the assessment” read “finished the first assessment?”

Response: The sentences were edited as finished the first assessment.

Line 341: Would it make sense to have a section at the end of the discussion with your clinical implications or recommendations?

Response: This is a great point. It was added a section “4.2. Recommendations to prevent obstetric violence or vulnerability”.

Line 347: Decide if “The” is needed before OV. It seems that OV can stand alone without a need for “the”.

Response: “The” word was removed in this sentence.

Line 348: Is the definition itself weak or misunderstood? What other factors may lead to it being poorly understood? What about the norms of obstetric care or the lack of a patient or woman-centered model of care where women and birthing people are experts in their own bodies? Is OV moderated by racism? How does race/class/gender and these intersecting identities of birthing people impact OV?

Response: This is a great point. The term “violence” denotes physical, moral, or mental harm or the intention to cause it (lines 362-366). Sometimes, this term can be attributed to medical practices that are not violent, such as the obstetrician does not show up for an examination or the woman does not resolve all doubts during childbirth. This is what leads to confusion in the term “violence”, which could be attributed to “vulnerability” (as we comment in lines 42-43). However, the appreciation of patient-centered models (in this case, women) we believe is a key point that we wanted to consider in the discussion (lines 384-385).

Social classes and racism are a very interesting aspect that modulates VO. Since minority classes are a social vulnerability factor that conditions the perception of life in pregnant women. However, these variables were not collected by the studies analyzed. It would be very interesting to perform observational studies to determine how social vulnerability influences the risk of PPD and PTSD by modulating VO.

Line 365: this is an incomplete sentence.

Response: It was a type error that was edited (line 391).

Line 385: can you clarify whose expectations birthing people are expected to comply with?

Response: The expression “labor expectations” was explained.

Line 402. Delete “in turn” This could be included in a clinical implications section of the discussion- raising the cut off to 13.

Response: “In turn” words were deleted. The use of specific scales and cut-off was added in the section 4.2. Recommendations to prevent obstetric violence or vulnerability.

Line 412. Are there other scales? Vedam et al have developed at least two scales that may work here.

Response: Yes, other scales have been described, even validated in the Spanish population such as the González-de la Torre scale. All of them have been included in the discussion (lines 443-451).

Reviewer 2 Report

Comments and Suggestions for Authors

The paper “Factors Associated with Obstetric Violence implicated in the  Develop Postpartum Depression and Post-Traumatic Stress Disorder: A Systematic Review” investigates a very important topis, which has consequencies on mothers, newbors, and families’ wellbeing. The attempt to review the increasing literature on this topic is of interest. The paper is generally well-wrtitten and organizied. Just few minor concernes:

Introduction

p. 2, line 50-51: PTSD, declare the whole acronyms here

 p.2, line 52. Why PPD had such a wide range of prevalence? I suggest to explain it

 p.2, line 53. Which risk groups?

 p.2, line 69 I suggest to modify “manifestation” with risk and protective factors”

 In general, the authors speak about PPD and PTSD during pregnancy, childbirth and post-partum. PPD in a condition which could manifests only post-partum. Differently, PTSD can occur also before childbirth (if OV could occur before childbirth, I suppose). This point needs to be clarified in the text.

 I suggest to re-organize the Introduction, speaking about PPD before and about PTSD after. The differences between PPD and PTSD (linked to OV) has to be deepen.

 Materials and method

 Sometimes the authors wrote PPD, other times PPT. Please uniform.

 p.2, line 93. Explain why grey literature was not included

 Results

 p.10, line 254. What do you mean with secondary study?

 p.11 line 289. Mode of labor, instrumental or c-section. Nor clear. A childbirth experience could be both instrumental (e.g., induction) and c-section. Maybe you mean and/or?

 Discussion

 I suggest to organize the discussion in paragraph, following the division proposed by the authors in the results

Comments on the Quality of English Language

accurate proofreading needed

Author Response

The paper “Factors Associated with Obstetric Violence implicated in the  Develop Postpartum Depression and Post-Traumatic Stress Disorder: A Systematic Review” investigates a very important topis, which has consequencies on mothers, newbors, and families’ wellbeing. The attempt to review the increasing literature on this topic is of interest. The paper is generally well-wrtitten and organizied. Just few minor concerns:

Response: Thank you for your kind words and time spent reviewing our article. We have edited the main text and responded to your comments to make the manuscript more interesting.

Introduction

1. 2, line 50-51: PTSD, declare the whole acronyms here.

Response: The PTSD acronyms was defined as the first time in the main text.

p.2, line 52. Why PPD had such a wide range of prevalence? I suggest to explain it.

Response: According to Moya et al, the theories to explain the wide variability of PPD prevalences has been postulated the use of non-validated instruments, cultural variables, differences in socio-economic environments, differences in perception of mental health, and biological vulnerability factors. These factors were included in the main text (lines 51-54).

p.2, line 53. Which risk groups?

Response: According to Grekin and O`Hara could be consider as a risk groups woman with past trauma and psychological issues, with low social support, and/or traumatic birth experience. This was incorporated in the main text to be clarify.

p.2, line 69 I suggest to modify “manifestation” with risk and protective factors”.

Response: It was modified according to reviewer´s suggestion.

In general, the authors speak about PPD and PTSD during pregnancy, childbirth, and post-partum. PPD is a condition which could manifests only post-partum. Differently, PTSD can occur also before childbirth (if OV could occur before childbirth, I suppose). This point needs to be clarified in the text.

Response: This is a very interesting and valuable comment. Although it is true that PTSD can manifest throughout pregnancy, its prevalence increases in the postpartum stage (as clarified in the main text, line 57-60). Additionally, VO was studied during pregnancy, childbirth, and postpartum, and PPD and PTSD were studied in their diagnoses during postpartum because they are clinical conditions triggered by a stressful event, such as VO. We are not exploring PPD and PTSD in pregnancy or childbirth, rather than the evaluation of risk factors during pregnancy or childbirth to develop PPD and PTSD.

I suggest to re-organize the Introduction, speaking about PPD before and about PTSD after. The differences between PPD and PTSD (linked to OV) has to be deepen.

Response: The introduction was re-organized according to reviewer´s suggestions.

Materials and method

Sometimes the authors wrote PPD, other times PPT. Please uniform.

Response: Sorry about this type error that was edited.

p.2, line 93. Explain why grey literature was not included.

Response: In this review we choose documents with the maximum rigor in the evaluation of the findings, this implies double-blind peer review of experts provided by scientific journals. Since we could not guarantee this rigor in the gray literature, it was decided to exclude it.

Results

p.10, line 254. What do you mean with secondary study?

Response: Equal or more than high-school degree. It was modified in the main text.

p.11 line 289. Mode of labor, instrumental or c-section. Nor clear. A childbirth experience could be both instrumental (e.g., induction) and c-section. Maybe you mean and/or?

Response: Our apologize for this type error that it was edited.

Discussion

I suggest to organize the discussion in paragraph, following the division proposed by the authors in the results.

Response: The authors have discussed this point and we have preferred to maintain the discussion sections and expand a new section on recommendations to prevent OV. The results section is oriented towards a sociodemographic variable of the articles, exploring the quality of the studies to talk about the prevalences found in PPD and PTSD, the prevalence of VO and to conclude related to the factors associated with VO that predispose to developing PPD and PTSD. However, the discussion section comments the results in relation to other studies and highlighting the most relevant data to draw conclusions. For this reason, we have commented the difficulties involved in the definition of VO itself, and the potential conflicts and improvements that we have been able to detect in the studies. How social variables differ in the perception of VO and that conditions the development of PPD or PSTD. As well as the difficulties in obtaining a homogeneous and rigorous methodology. For this reason, we have developed a final section of future perspectives and recommendations.