Reviewer’s report
Title: 
A potential role for insulin treatment during pregnancy in reducing postpartum psychological
distress in maternal obesity: An administrative population health study
Version: 
1 
Date: 
10 Dec 2020
Reviewer's report:
Overall, I think the authors addressed the majority of the reviewers' comments adequately, I have a few
additional suggestions:
-Gestational diabetes is a risk factor for PPD and is obviously a confounding factor in the insulin vs. no
insulin comparison. Also, women with GDM are at higher risk of birth complications, which is also a
predictor of PPD. The fact that GDM diagnosis and incidence of birth complications were not assessed
should be acknowledged as a limitation. It's possible that a decline in birth complications is the
mechanism by which insulin improves PPD rates - this should be acknowledged as a possibility.
-Placental lactogen levels were not measured in this study so its potential involvement in mediating the
effects seen here need to be tempered. For example, I don't think it should appear in the abstract. Also, I
believe that it shouldn't appear in the first paragraph of the discussion section - instead, it should be
discussed in a separate paragraph as a potential mechanism among others (like decline in birth
complications). I would also like to see at least a few sentences explaining the neurobiological
mechanisms by which PL is thought to impact mood.
-Re: reviewer 2's comment #11: Though you didn't recruit these participants, you can nonetheless apply a
post hoc power calculation in this case.
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Is the study design appropriate to answer the research question (including the use of appropriate controls),
and are the conclusions supported by the evidence presented?
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