Title: Posttraumatic stress symptoms and postpartum anxiety among Palestinian women: The
mediating roles of self-esteem and social support
Version: 1 Date: 27 Apr 2023
Reviewer's report:
Stressful life events and postpartum anxiety among Palestinian women: The mediating roles of
self-esteem and social support
Abstract:
• No background
• It is not clear why this study is important to be conducted in Palestine in the abstract
• Methods: no mention of the instruments
Theoretical Background
• In the sentence below, the risk factors of PPA are mentioned along with PPA itself as a risk
factor: The risk factors should be revised and organized.
During the postpartum period, four categories were identified as predicted risk factors for PPA
including demographic factors (e.g, having more education,  being a young mother  and being
employed); childbirth experiences (e.g. having a cesarean delivery, and having fear of death
during delivery, having fear of the birth, less self-confidence for the delivery); social support
problems (e.g. family conflicts and lack of family support); and psychological history problems
including postpartum anxiety and depression [9, 15].
• They don't explain in their literature review why they looked into postpartum anxiety or why
they thought it was a problem for women after giving birth.
• It's unclear why the reference numbers were listed at the beginning of sentences rather than
the authors' names and the year.  For instance:
[21] found that exposure to traumatic experiences among Palestinian women was positively and
significantly associated with complications during pregnancy and increased postpartum anxiety
symptoms [28, 21].
The addition of references number is known to occur at the end of sentences rather than the
beginning. Verify and properly rewrite all of your references in the article.
Stressful life events, Postpartum Anxiety and Self-esteem
• The definitions of the terms in this section's title—stressful life events, postpartum anxiety,
and self-esteem—are missing. Give each concept a detailed definition.
• The literature review in this paragraph deals with postpartum depression, whereas the authors'
study is focused on postpartum anxiety. In place of postpartum depression, you should include
studies and information about postpartum anxiety.
Stressful life events, postpartum anxiety and social support
• This section of your literature review is still unclear. While studying PPA, you concentrated
on PPD. You stated, for instance:
• A  cross sectional study that was conducted in the city of Nablus in the West Bank, found
that exposure to two  or more stressful events during pregnancy, poor satisfaction with the
marital relationship, low support and help from husband, and perceived low social support, were
strongly associated with PPD [6]. In another study in refugee camps in the West Bank that aimed
to explore the risk factors for depression during pregnancy, the results showed that exposure
to violence and the unavailability of support from others are considered as a risk factor for
depression [3].
In place of postpartum depression, you should include studies and information about postpartum
anxiety.
Current study : Setting
• The authors are still unable to explain why it is crucial to investigate postpartum anxiety among
Palestinian women.
Methodology: Participants
• What was the size of your target population overall, and how did you  calculate the sample size?
• The authors list a few participant characteristics in this section. It is well known that these
results belong in the result section and not the methodology.
• Please include a table in your results section that lists the sociodemographic variables and other
variables you looked at in your research, along with frequency and percentages for each variable.
• Participants were mothers of infants ranging in age from one day to six months for the
assessment of PPA, according to the authors.
From a scientific standpoint, evaluation of PPA should take place between six weeks and six
months after delivery. Actually, your study may not accurately assess PPA because it is common
for women to experience anxiety during the first month following delivery. However, if it
persists for more than a month, it is viewed as a problem. So I'm not sure if your result regarding
this point is accurate. The data of the women who were evaluated less than six weeks after
delivery may need to be deleted.
Measures
• Mention the  developer  of the scales and cited them in your references:
Berlin Social Support Scales (BSSS)
The Impact of the Event Scale (IES-R): The IES-R
The Rosenberg self-esteem scale (RSES)
• The Impact of Event Scale measures symptoms of posttraumatic stress disorders , so why  the
authors  use it? in  the study aim  and the findings the authors did not mentioned symptoms
of PTSD
• Did  the authors use a scale such Combat Exposure Scale or Life Stressors Checklist to assess
traumatic or stressful  events and their duration? I   know  that the  scale  "The Impact of Event
Scale"  evaluates symptoms of PTSD  one month after a traumatic event. Your assessment
of PTSD is inaccurate because you evaluated women one day after delivery. If you asked the
participants to list specific traumatic events they had experienced along with the date, please
specify.
• The authors did not present the results of The Impact of Event Scale in their  findings to show
how  they assess  traumatic events.
• What is  the validity for  all the  scales  the authors used in their  study
Ethical consideration:
• Mention whether you followed international ethical standards while conducting your research.
• Are any of your participants under the age of 18?
Findings
• The absence of the prevalence of PPA in your findings is one of your study's key findings.
Please include it in the findings section.
• According to the results of  the  study, what are the main traumatic events that these women
are exposed to?
• Have the authors  examined any PPA risk factors?
• Add the table with the sociodemographic data and other factors you considered in the study.
• What are the stressful life events that the authors  identified and evaluated their relationship
with self-esteem and social support as the authors measured PTSD symptoms using the Impact
of the Event Scale (IES-R), but not traumatic events. Have the authors ever used a scale to rate
different types of stressful life events in your research?
• Presenting only the connections between PPA, self-esteem, and social support is not very
informative because earlier studies had similar findings. What new information do the authors
of this study hope to provide?
• Did the authors  employ any multiple regression analysis to demonstrate the variables that
influence the relationship between the key concepts in your study?
Discussion
• The authors mentioned that
One possible explanation of our results is that Palestinian women with newborn infants
experience the same as the majority of Palestinian people who are exposed to ongoing traumatic
experiences due to Israeli occupation.  This leads to a very negative impact on mental health,
and may increase postpartum anxiety among those women [31].
I'm not sure how they were able to draw this conclusion because they did not measure the
prevalence of PPA and did not include in their findings information about the main traumatic
events to which these participants had been exposed. In particular, they did not make use of
scales that measure traumatic events, such as the Combat Exposure Scale or the Life Stressors
Checklist.
• The discussion of the findings has no bearing on the research findings. They examined how
PPA, self-esteem, social support, and stressful events are related in their study. Their discussion
centered on the elements that could make these women's postpartum anxiety worse. Their
findings also failed to identify the variables that influence PPA among Palestinian women.
• For the discussion of  the relationship between high level of self-esteem stressful events, they
just present their point of view without a comparison with other studies in literature review