Title: Evaluate The Effectiveness of Using Nonpharmacological Intervention During
Childbirth: An Improvement Project in Jordanian Maternity Hospitals
Version: 4 Date: 26 Aug 2024
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
No - there are minor issues
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are minor issues
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
No - there are minor issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
N/A - there are no statistics in this study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Probably - with minor revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: The authors have attempted to respond to the reviewers' comments
but have not always been successful. In addition, the new text introduced is not always well
expressed.
The reporting of use of nonpharmacological pain management in multigravida women is of
interest.
English expression remains an issue - particularly inconsistent use of present and past tenses.
References are not numbered in sequence in the reference list (see below) and there are details
of the study that need clarification.
REQUESTED REVISIONS:
The abstract refers to limiting vaginal examinations. This is not referred to in the body of the
paper. Was it part of the included non-pharmacological interventions? If so, include in the body.
If not, remove from the abstract. The abstract should include a statement of the study aims. Other
changes may be required to the abstract following from the suggestions below.
There are constant changes in tense in the paper between past and present tense. In general, past
tense is used to describe the research that was undertaken and present to describe the results
and interpretation.
The authors were asked to provide a clearer statement of their aims. This should reflect the focus
of the study on quality improvement - it is not examining the effectiveness of interventions that
have have already been proven by way of RCTs and systematic reviews. The aim appears to be
assessing whether the interventions as a bundle are feasible during intrapartum care and impact
on patient experience.
What is meant by ""new"" mothers? (p7)  At first reading, I assume primiparas but that clearly is
not the case. Were sequential patients recruited? What proportion of women approached agreed
to be in the study? (an element in determining the generalisability of findings). It is critically
important that usual care is described along with the role of the researcher. It appears that a
researcher was present in the birth suite for each delivery.  This is a form of intervention itself
unless this was a replacement or addition to the presence of a single health care provider as part
of usual services.
On the bottom of p7, the authors state:- ""The researcher is a maternity nurse working in a health
center, this helped ensure that the responses were honest and not influenced by “what we want to
hear.”  How does having an employee ask questions ensure that responses are not biased? This
may indeed increase the likelihood of desirability bias. Unless the researchers have evidence to
the contrary, this statement should be removed and the discussion include comment the pros and
cons of having a clinical care provider from the hospital as the researcher.
Page 8. This is not an acceptable sentence "" No previous cesarean births and finally, must agree
to participate and sign the consent form.""  What is the subject?
Table 3 (referred to on page 9). Although the reviewer requested a table with patient
demographics, this table provides so much detail that it may be possible to identify individual
study participants.  It should contained summarised, tabular data, e.g., number with university
education, median income (and range), median GA at delivery (and range).  Baby details are not
relevant. Then, in providing quotes, you can say, for example, Mother 1 (29 years old), etc.
Numbering of all references should be checked.  At present, the number in the text, e.g., 17
(Braun and Clark) is in fact number 18 in the reference list.
There is no information in the methods on the approach to quality control in the coding. Was
a single researcher responsible for all coding of transcripts or was there duplicate coding of all
or some of the transcripts?
Discussion
Page 12. A claim was made that the intervention was no cost; however, there was an individual
in the room with each patient throughout delivery. In addition, there was a birthing ball and
massage provided if needed.  This claim is unnecessary unless there is evidence to back it up. A
comparison is made with previous research. Unless it had similar aims and design, the authors
should be less definitive in their statements.
Limitations
The authors state:- ""This study population included mainly mothers who gave birth in Al Zarqa
hospital."" Earlier in the manuscript they state that all mothers were recruited from Al Zarqa
hospital.
An additional limitation is that there is no information on the engagement and response of staff
involved in usual clinical care. Future research by this group may wish to focus on whether it is
possible to get hospital clinicians to routinely offer these interventions.
ADDITIONAL REQUESTS/SUGGESTIONS:
There is a challenge with English expression. The manuscript requires careful review for
inaccuracies (e.g., in numbering of references), poor grammar, and confusing language."