Title: Prevalence and Risk Factors of Postpartum Depression among Women Attending Primary
Healthcare Centers in Northern of West Bank/ palestine : A cross-sectional study, 2022
Version: 4 Date: 02 Jul 2023
Reviewer:  Akihiro Seita
Reviewer's report:
Dear authors,
Thank you so much for this very stimulating manuscript on postpartum depression (PPD) among
Palestine Women in the West Bank. I read it with interest. I found it well-written and should
be published in the journal.
I am not an expert in PPD or mental health, and I have a few fundamental questions, as well
as some minor ones.
Firstly, I would like to inquire about the methodology you employed. I understand that you
used a "self-administered questionnaire," which consists of internationally recommended and
standardized questions. Nonetheless, I am uncertain about how you ensured a high level of
completion and accuracy among the respondents. Did any health or research staff cross-check
the questionnaire responses with the mothers immediately after they completed them? Were
there any mechanisms in place to ensure the completeness and accuracy of their responses? It
would be helpful if you could address this in your manuscript.
Furthermore, in the Data Analysis chapter, you mentioned that "incomplete questionnaires were
discarded." However, you did not provide any details or numbers regarding the "discarded"
questionnaires. I suggest including some information on this aspect.
Moreover, it is important to consider the reliability of a dataset composed solely of self-
administered questionnaires without any verification by researchers or data collectors. Are there
any existing literature or evidence indicating that self-administered datasets are as reliable as
those collected by trained data collectors? I am curious why you did not employ trained data
collectors to gather information from the mothers. It would be beneficial if you could address
these two points, namely dataset reliability and the chosen data collection method, in your
manuscript.
Secondly, I would like to discuss the care provided to mothers identified with PPD. In your
ethical considerations, you did not mention the care provided to mothers who were found to
have PPD. Did you inform healthcare providers and the mothers themselves about the results?
Did you offer any specific care or support to the mothers? This aspect is crucial in any research
involving human subjects, and it would be valuable to include a description of these procedures
in your manuscript.
The following are minor issues on your manuscript.
1. Limitations in the recruitment strategy
The possibility of selection bias should be discussed in the limitation section. Your study
selected Palestinian women attending vaccination clinics at primary health care centres. This
point can imply that the participant women might have higher health literacy to bring the child
to vaccination clinics than those women who did not bring children there. Also, the participants
might reside nearby the primary health care centre and have more geographical advantage to
attend the routine vaccine program than those who were not included in the study. Section
3.1.1 (Description of participants) can reinforce these concerns (having parents with high health
literacy and geographical accessibility) as it says the majority (84%, n=319) were city dwellers,
highly educated (studied beyond secondary school) (70.3%, n=267), and married to highly
educated men (47.6%, n=181).
2. Transparency of study procedure
2-1) Regarding the seven primary MoH health centres you included in the study, what was the
distribution across the four governorates? Namely, the number of the MoH PHCs chosen from
each governorate should be also written.
2-2) Your result mentioned, “The predictors of postpartum depression were stressful life events
during pregnancy”. This point is a very vague statement. In general, it is easy to imagine having
stressful life events can deteriorate/increase PPD. Therefore, it is important which events were
used as predictors in your study since various types of stressful events exist, and the severity of
the perceived stress can depend on each pregnant woman. To investigate what kind of stressful
life events the study participants ever had, I assume you used the first part self-administered
questionnaire which you described in section 2.4 (; A pre-defined checklist used to collect data
about socio-demographic factors, pregnancy and birth-related factors, baby-related factors, and
psychological history). However, the abovementioned points are not clear. You drew some
relevant examples from the reference (29), but please describe your own cases.
3. Clear presentation of sufficient data and findings
3-1) In most tables, you presented the percentage only for the total column. The percentages of
all columns should be also calculated and presented. Otherwise, it is hard to compare the results
at a glance.
3-2) The Table 3 data was not presented in the manuscript.
4. Other limitations
4-1) An additional point to limitation; Based on section 3.1.1 (Description of participants) and
the fact that your study was unable to assess mothers across all areas of Palestine and the
UNRWA refugee clinics, your study participants may live in better living conditions than the
other Palestinian mothers and the prevalence of PPD may be higher in the remaining Palestinian
mothers.
4-2) There is a confusing expression; “The risk of postpartum depression/PPD risk” and “Risk
factors of PPD”. You should change the expression to distinguish these two differences.
Overall, I appreciate your contribution to the field of PPD research and believe that addressing
these questions and concerns will enhance the manuscript's quality.