Reviewer's report
Title:The "MENTAL" in maternal health care: Perceptions of postnatal
depression and health care needs in a South African sample.
Version:2Date:3 February 2014
Reviewer: Alexandra Sawyer
Reviewer's report:
Thank you for the opportunity to read this paper. The paper presents some very
interesting results and I think it would be of great interest to the readers of BMC
Women's Health and to healthcare professionals and researchers working in
international perinatal mental health. However, I have a number of major
concerns which need to be addressed before the paper is suitable for publication.
Firstly, crucial methodological information is missing from the methods.
Secondly, the results are not presented in a coherent and cohesive manner, and
overall, the data is under analysed. Finally, the discussion, does not offer a
comprehensive interpretation of the findings. I feel that as a whole the paper
would benefit from a clearer set of aims and objectives.
Introduction
1. The overall aim of the study is not clear. In the abstract the aim is stated as
exploring perceptions of mental well-being and depression, however Page 4,
Paragraph 1, states that the aim is to inform the development of a counselling
intervention, and to identify appropriate counsellors. MINOR ESSENTIAL
REVISION
2. The aims/objectives stated at the end of the introduction need to be written
more concisely. As it is written it is not clear exactly what the aims are, and what
is written seems very ambitious for a small qualitative study. MINOR ESSENTIAL
REVISION
Methods
One of my main concerns with this paper is the lack of methodological detail
provided. In particular:
3. Although the setting was generally described very well there is very little
information about the birth “norms” in this region. For example it would be of
interest to note where most births take place (home/health centre), who attends
the birth, mortality rates etc. MINOR ESSENTIAL REVISION
4. The authors note that Kleinman’s concept of explanatory models of illnesses
was used to guide the interviews. For those readers who are not familiar with this
model, this needs to be outlined in more detail. MINOR ESSENTIAL REVISION
5. The recruitment section requires a lot more information. What were the
eligibility criteria (age, how many months/years since birth)? Who approached
the women and who interviewed them? It would be useful if the authors could
mention how the women were introduced to the interviewer (e.g. healthcare
worker/researcher) as this could influence their responses. MAJOR
COMPULSORY REVISION
6. 20 women were included who had screened positive for PND. But how many
were screened in the first place? And how many were approached who agreed to
participate. MINOR ESSENTIAL REVISION
7. How long did the interviews approximately last? DISCRETIONARY REVISION
8. It would be helpful if the interview schedule was included as an appendix to
provide some context to the responses given by the women. MAJOR
COMPULSORY REVISION
9. The data analysis section is not very. It is not clear how analyses could be
guided by “apriori and emergent themes”. This needs to be explained in more
detail. The authors might find the following paper on thematic analysis useful
here: Braun, V. and Clarke, V. (2006). Using thematic analysis in psychology.
Qualitative Research in Psychology,3, 77-101. MINOR ESSENTIAL REVISION
10. On page 6 it is stated that 21 women were recruited, and on page 7 it says
20 women were recruited. Please clarify. MINOR ESSENTIAL REVISION
Results
11. As they are currently presented the themes and subthemes are not clearly
described. I recommend summarising the themes before you present them, or it
would be helpful to even make a table of the themes. MAJOR ESSENTIAL
REVISION
12. There is limited analytic content, rather the basis of the analysis is frequent
use of quotes (some quotes could be shortened). For example the theme on
depressive symptoms is not very informative – there is no analysis for the
subthemes unhealthy thinking and unhealthy behaviour. MAJOR ESSENTIAL
REVISION
13. It would be really helpful to know long after the birth women were
interviewed. One of the quotes (Page 8, Quote Case 15) refers to problems with
her older child at school. I am concerned therefore that the sample is very broad,
with some women talking about “postnatal depression” and others talking about
“general depression”. MINOR ESSENTIAL REVISION
14. In the method it says that ten follow-up interviews were conducted. Are the
results combined for this sample? This needs to be made clearer. MINOR
ESSENTIAL REVISION
15. It would be interesting to see the parity of the women DISCRETIONARY
REVISION
Discussion
• Because of the large number of results presented I think it would be helpful if
the authors began the discussion highlighting the main findings.
DISCRETIONARY REVISION
• The discussion includes a lot of background information, which, whilst
interesting, is not focussed on the current study and its findings (e.g. Page 15,
Paragraphs 3 and 4). MINOR ESSENTIAL REVISION
• The authors do not discuss any limitations of their research. One relevant
limitation is that women were recruited from healthcare centres. Therefore
women who do not use these facilities are not represented. MAJOR ESSENTIAL
REVISION
• A strong conclusion is lacking from this section. The authors should use the
conclusion to make a strong specific point about maternal mental health in South
Africa, and how this study contributes to the literature. DISCRETIONARY
REVISION
• Some key references were missing. For example the authors may find the
following reference helpful: Ramchandani, P. G., Richter, L. M., Stein, A., &
Norris, S, A. (2009). Predictors of postnatal depression in an urban South Africa
cohort. Journal of Affective Disorders, 113, 279-284. DISCRETIONARY
REVISION
• The paper needs proofreading for formatting errors and typos (e.g. Page 4,
Paragraph 1, Line 1 should read “Untreated maternal depression is also a
human...”) MINOR ESSENTIAL REVISION
• The references need to be consistently formatted MINOR ESSENTIAL
REVISION
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: No, the manuscript does not need to be seen by a statistician.
Declaration of competing interests:
I declare that I have no competing interests