Title: Evaluation of the effectiveness of a postnatal support education program for husbands in
promotion of their primiparous wives’ perceived social support: a randomized controlled trial
Version: 3 Date: 10 Aug 2022
Reviewer:  Gretchen Bjornstad
Reviewer's report:
This paper reports the results of an interesting study examining how postpartum education might
improve social support, self-efficacy and stress for new mothers.
I have some concerns around the study methodology and reporting that I describe under each
section:
Introduction
It is important to include citations of research into the mechanisms of this type of intervention,
e.g., Haslam et al 2006.
The evidence is not as clear as presented in terms of whether social support can prevent PND,
please review further evidence, e.g. Shorey et al, 2015; Wiggins et al 2004.
The paper is written as though all mothers are married to men. The applicability to and
implications for others should be considered or at least this limitation should be acknowledged.
On p. 3, the paper says that, "A woman's husband is the most important and closest person
who can support her...". This is definitely not always the case. Similarly, on p. 4 it is said that
"husbands have a vital and decisive role in supporting their wives....". This should at least be
revised to say "many husbands", as this will not apply to all women.
Materials and methods
This section should probably be revised to be entitled 'Methods', but refer to journal guidance.
In some places, it says that the study was 'performed on' participants. This is not an appropriate
way of describing the method - the participants are taking part, not having a study performed
on them.
The inclusion and exclusion criteria are very strict and seem a little unrealistic. This should at
a minimum be justified. For example, experiencing no stressful incident over the past month
- what is meant by 'stressful incident'? Why is this a criterion? It seems unlikely that anyone
would not experience any stressful events in a month-long period.
Many of the exclusion criteria would have happened during the study - were participants
excluded after randomisation? Exclusion criteria are criteria that exclude participants before the
are eligible to consent to take part and be randomised. Participants should not be excluded after
randomisation, but any events that occur after randomisation should be recorded and reported.
Study Outcomes
This section should include the description of the measures.
CONSORT flow diagram
A large number of people (n=49) were excluded from the study for 'other reasons' - as this
number is so large, these reasons should be provided.
The first data collection point seems to be missing from the CONSORT diagram.
It is surprising that no participants were lost to follow-up at any time point. This is not a problem
per se, but just to note it is unusual.
Sample size calculation
This section needs to specify the primary outcome measure that is used in the calculation. It is
also not clear what the 'mean of social support' figures come from - are these from the study that
is cited? If so, how does that study compare to this one, particularly in terms of the population
sampled and intervention used?
Sampling and random allocation method
This method needs to be written a little bit more clearly, as it is a bit vague in places and
raises concerns about selection bias. For example, how were the geographical regions identified
and how was the socio-economic status of the residents established and rated? Why was this
selection method used? Why was only one healthcare centre per region included in the study?
Would this yield a representative sample of women meeting the inclusion criteria? Please include
more information about the convenience sampling of women within each centre - the researcher
selecting eligible women particularly may have introduced selection bias.
Please clarify whether informed written consent was collected from both mothers and their
husbands.
Intervention
Please provide a comment (possibly as a limitation) on the fact that the intervention was designed
around the planned delivery method, given that childbirth does not always go to plan.
An intervention logic model needs to be included to show how the intervention is expected
to work, with details about the expected mechanism. Is the intervention expected to work to
improve self-efficacy and stress via social support? What if change in social support is detected
but not change in self-efficacy and stress? If the primary outcome is social support, is that the
primary aim of the intervention?
Data collection tools
This section needs to be organised into primary and secondary outcomes. Please explain how the
outcome measures were completed (on paper, online, at home, with a researcher?), and whether
these were completed by mothers only, and if husbands were present, as this may bias responses.
Please also clarify whether any data were collected from fathers, and if not, why not.
Results
It is not appropriate to test statistical significance of differences in baseline characteristics - the
p-values should not be presented. What is meant by 'cross-impact' - is that an interaction?
The results of the main analyses need to include reported effect sizes with confidence intervals
to show the size and certainty of the effect. P-values alone are not sufficient. It is difficult to
judge the validity of the conclusions without these results.
Table 2
The figures presented in this table are written in an unusual format - please check against
published papers in this journal and correct to show means and standard deviations correctly.
Discussion
If husbands did not complete outcome measures, it is difficult to claim that husband's
understanding has changed. I believe that was was measured was women's report of husbands'
social support. Similarly, the couples' knowledge, attitude, and practice with respect to
postpartum health was also not measured, so change on these outcomes cannot be claimed.
The discussion of findings of studies by Mohammadpour et al and Shorey et al in the Discussion
section should be moved to the Introduction section to make the case for the need for this study
by describing what has already been done and is already known and what gaps needs to be
addressed by the current study. The Discussion section can then refer back to these references
in the paragraph starting with "The results of the present study are in line with those mentioned
above...".
The benefits of social support for husbands is mentioned in the Discussion - is there any other
evidence that could be cited here?
In the discussion, in the last paragraph on p. 14, one sentence says, "The only main difference
between this study and the present study was that in the former the training program involved a
face-to-face meeting and presentation of a booklet for primiparous women, while in our study the
training program included 4 online training sessions for primiparous women." Were the training
sessions in this study for husbands only, not women? This section discussion the effectiveness
of education for women - please discuss how the effects might differ when the intervention is
delivered to fathers.
It is also reported in the discussion, early on p. 15, that "we found the positive effect of the
relationship between husbands and a professional midwife" - is this a finding of this study? I
don't think this was measured?
The Discussion section also claims that "by motivating and encouraging the mothers to adhere
to health behaviors, husbands can change the lifestyle of mothers positively and improve their
physical and mental health". I don't think that this study provides evidence for any of this claim.
If this is an aim of the intervention, it should be included in the logic model and these mechanisms
and outcomes should be measured in this study.
The Discussion includes a list of other studies that have similar or different findings, but in some
cases have little in common with the current study - investigating the effects of interventions for
women, counselling for couples, etc. It is not clear why these are discussed.
The conclusion that mothers need to be accompanied, trained and provided postpartum
counseling to cope correctly with stress, is not supported by the design or results of the current
study as there is no comparison with an intervention for mothers, nor is postpartum counselling
part of the current intervention.
The limitations listed raise further questions about selection bias in this study. The description
of the sampling method implies that there was some attempt to include a range of participants
by socio-economic status, but this is not the case.
Conclusion
At most, this study provides preliminary evidence that this intervention may improve the
outcomes that it has measured, but a larger randomised controlled trial with an effort to eliminate
selection bias and improve sampling from the whole population is needed. The wording in
the conclusion section needs to be attenuated to avoid overclaiming based on the results.
Implications for future research should be included.