Reviewer ’s report  
Title: Investigation of the association between quality of life and depressive symptoms during  
postpartum period: A correlational study.  
 
Version: 1 Date: 05 May 2017  
 
Reviewer: Catherine Acton  
 
Reviewer's report:  
Thank  you for the opportunity to review the manuscript of the paper "Investigation of the 
Association between Quality of Life and Depressive Symptoms during Postnatal Period: A 
Correlational Study.  The authors are Papamarkou, Sarafis, Kaite, Malliarou and Niakas.  
 
The study examines the correlations between depressive symptoms as defined by EPDS scores, 
and quality of life domains as defined by SF -36 subscale scores, as well as various demographic 
variables, in 145 women who had given birth within the previ ous 3 or 4 days, and who were still 
inpatients at the clinic where they gave birth.   
 
Overall there are a large number of problems with the manuscript, which I have detailed below.  
In some regards, erroneous conclusions are drawn repeatedly, such as the diagnosing of some 
women with postpartum depression based on an EPDS score alone, and that this so -defined 
postpartum depression "provokes" poorer quality of life although all data is cross -sectional.  In 
other regards, there are a lack of conclusions, suc h as the lack of inference that is drawn from the 
findings being similar or different to comparable studies cited in the Discussion.  
 
Of note and great concern are the several instances of errors in this draft that were identified by 
the reviewer of the fi rst draft submitted to BMC Women's Health.  It is of concern that in their 
response to the first review, the authors have on several occasions explicitly stated that they have 
addressed the errors found.  This led me to a general sense that the authors may  not have an 
understanding of the implications of such errors on the integrity of their research.  
 
The language and expression is clunky in many places and the meaning of several long sentences 
is not decipherable.  I assume, given the country of origin th at the authors may be from a non -
English speaking background, therefore I believe it would be important that a native English 
speaker review any further drafts of this paper prior to re -submitting it for review.  
 
The comments below detail the many errors,  inconsistencies and instances of very poor written 
expression that need to be addressed.  
  
Abstract  
 
Page 2 Line 7:  The percentages provided are different to those cited later in the paper (ie on 
page 3 line 42).  
 
In the second sentence, the phrase "thus  it constitutes…" infers that low quality of life leads to an 
incapability to care for self and others.  Depression may do this, but QOL does not.   
 
The inclusion of the phrase "care of their partners" is offensive, implying that the care of one's 
partner is a duty that new mothers must undertake.  I decline to enter into a feminist argument 
about this, but will instead encourage the authors to please consider replacing the word 'partner' 
with 'families' which at least infers care of other young children and may include partners.  
 
Abstract: Results subsection.  
Page 2, Line 46:  The statement that "9.9% of participants suffered from postpartum depression " 
cannot be made given the methodology used in this investigation.  Using the EPDS, only a 
'probable' episode of depression can be identified; you cannot state that depression is present 
based on an EPDS score.  I note that the reviewer of the first draft of this paper has pointed this 
out to you already, but you have not addressed this concern.  
Page 2 line 58: need to clarify your reference point: … "women with Primary and Secondary 
education experienced higher levels of postpartum depression symptoms" but  you have not 
explained higher than whom.  
Page 3, lines 1 -5:  the purpose of this sentence does not make sense.  
Page 3 lines 5 -12: The statement commencing with "Women with postpartum depression scored 
24.27 lower…." Requires a reference point, ie lower th an whom?  For example, women without 
symptoms of postpartum depression?  Or women who scored below a particular cut -off score on 
the EPDS?  
 
Abstract: Conclusion subsection  
Page 3 line 17 "postpartum depression provokes directly and decisively the quality o f life of 
women…" cannot be made given the methodology used.  You cannot infer causality using a 
cross - sectional design.   
 
Background  
 
Page 3 line 42: the rates provided here are different to those provided in the Abstract.  Please 
clarify if you are ref erring to the same or different phenomena here (ie first episode of 
depression, any episode of depression, recurrent episodes of depression).   
Page 3 line 56: yet another prevalence figure is being used here.  It seems clear that line 42 and 
56 are at lea st referring to any episode of PPD, but 42 states 1 in 7 (15%) whereas 56 states 20% 
(or 1 in 5).  Line 56 requires a reference for this assertion.  
Page 4, line 1: the statement about PPD having deleterious consequences in terms of infant 
development requi res a reference / attribution.  
Page 4, lines 10 - 17:  The sentence that begins with "In addition, during this period…" does not 
make sense.  I do not understand what you are trying to say at all.  
Page 5 line 2: change assesses to assess  
Page 5, lines 22 - 34:  Regarding the sentence that begins with "To be more specific, a study 
conducted by…", it is not clear what point is being made here.  At this point in your paper, I 
think you are trying to justify why your study needs to be done in your particular cu ltural 
context, but how does the data provided here do this?  Please clarify.   
 
Method  
 
Page 5 line 54: remove the word 'in'  
Page 6 line 1: Can you explain what you mean by "word of mouth"?  As a recruitment method 
this sounds very casual and the term tak en on face value suggests this would lead to a very low 
uptake rate.  More specific procedural information is needed.  
Page 7 line 7: the statement "…score of 13 and above indicates presence of PPD" is erroneous as 
the EPDS can only indicate probable presen ce of PPD.   
Page 7 line 10: please review the use of the term "borderline condition" and consider "possible 
presence of PPD"  
Page 7 line 10: please review the use of the term "absence of any PPD symptomatology."  
Page 7, line 15:  Third comma should be a f ull stop.  
Page 7, line 32: change 1000 to 100.  I note that the reviewer of the first draft of your paper also 
requested that you do this.  
Page 7, line 37 (approximately): please provide a justification for the use of the SF -36 as a 
measure of Quality of Life.  
 
Results  
 
Page 8 line 10: what is meant by the term "private employees"?  It is unclear why this is 
specified and I wonder if it is a culture bound term that wouldn't be widely understood outside of 
its cultural context.   
Table 1: The headings of the final two columns of the table should be placed below the row that 
describes 'Age' data.  The mean age and the age range should not come u nder the headings 'N' 
and '%'.  
Table 1 (page 22 line 19):  Data for the category 'divorced' should perhaps be included under 
'Marital Status', not under 'Nationality'  
Table 1 (page 22, lines 11 -17):  In the final column, the figures 15.5, 84.5, 96.5, 3.5 a ll include 
commas.  Please change these to decimal points.  
Page 8 line 13 -15: Here are the first mentions of data collected about 'Chronic Physical Disease' 
and 'Relationship with husband'.  Please describe in Methods section how these were defined and 
measured.  I note that your reviewer of your original submission also asked you to describe this.  
Page 8 line 13: the number of women with and without chronic disease should be included in 
Table 1.   
Page 8 line 37: Suggest that you more accurately describe the group of women defined as having 
'Primary and Secondary education'.  Do you mean that they have Primary and Secondary level 
education only?  Would they be more accurately described as 'women who did not undertake 
tertiary education'?   
Page 9 line 10:  Please justify why you have chosen to use Multiple linear regression analysis 
with stepwise method.  There is controversy in the literature concerning the use and abuse of a 
stepwise method (see Tabachnick and Fiddell, 2007).  Futhermore, this form of ana lysis is not 
recommended for data where assumptions of normality are violated.  Please include normality 
data for your dependent variables (Table 3) if you are using this form of multivariable analysis.  
Table 4 (Page 25 line 32): as there are only two wome n identified as positive for chronic disease, 
a very small number for including this as an independent variable in your model.  I note that the 
reviewer of your original submission has already highlighted this.  
Table 4  (Page 27): please revise whether thi s is part of Table 4 (depicted on page 25) or whether 
this is Table 6 and label correctly.  
 
Discussion  
 
Page 12 line 20: the statement "9.9% of participants suffered from post -partum depression" 
cannot be made based on the methodology used.  EPDS can only indicate 'probable' PPD; it is 
not diagnostic.  
Page 12 lines 21 -27: what is the relevance of the remainder of the remainder of the sentence 
from "whereas the study of Gonidakis…" onwards?  These figures are quite different to the 
findings of the paper.  Ca n the authors infer why this may be?  
Page 12, line 40: Can the authors please provide more information about what it means to live 
inside vs outside of Attica?  Are women outside Attica ethnically different (as the inferred 
similarity to Maori vs non -Maori  women suggests)?  I note that the reviewer of the original 
submission of this paper requested further information on the difference between women in vs 
living outside of Attica, but this has not been provided elsewhere in the paper.  
Page 12 line 49: women  with Primary and Secondary education might be better described as 
women without tertiary education (since women with tertiary education technically also do have 
primary and secondary education).  I note also that the sample studied here was very well 
educ ated overall with 77% having tertiary level qualification (Table 1 on page 22, lines 21 -26).  
Please provide some indication of how representative this sample is, therefore, of the broader 
population from which it is drawn.  If it is not representative, pl ease note this in the discussion as 
a limitation of the study.  
Page 13, line 1: how do the authors account for any differences noted between their findings and 
those of the other cited authors (Gonidakis et al and Moraitou et al)?  Please draw stronger lin ks 
as to how the current results lend support or do not support previously found associations.  What 
do these links say about your conclusions?  
Page 13 line 8: Here you could use more interpretive language to describe the findings.  A clear 
example would b e the use of the phrase "worse subjective physical functioning" rather than 
"significantly higher score on the dimension "Physical Functioning"".  
Page 13 lines 27 -34: how do the authors account for the difference between their findings and 
those cited from  Rezazei et al?  
Page 13 lines 51 -59: It is unclear whether the findings listed here relate to the study by Sadat et 
al, or the authors' own findings.  Also no interpretations of differences or similarities between the 
findings are made.  
Page 14 line 5: how  do the current findings justify the statement "there is a need for further 
training of health professionals…"?  
Page 14 line 7: I do not understand the end of this sentence.  How is quality of care inferred from 
quality of life?  These are different constr ucts.  Is this a typographical error?  
Page 14 line 22 -24: the statement that the "potential association would not be observed in all 
individuals" is redundant.  
Page 14 line 27: Please include a comment on how generalisable the findings are.  You state tha t 
a uniform ethnicity was obtained.  Please elaborate on how this is a strength.  
 
Conclusions  
 
Page 14 line 37:  As noted earlier in this review, the phrase "provokes directly and decisively" is 
erroneous.  You cannot conclude causality based on the correlational and cross -sectional 
methods used.  Indeed you do state in the previous paragraph (page 14 24 -27) that correlations 
do not identify causes, but you contradict that here.  
Page 14 line 41: the sentence "Health professionals should provide individualized care…" is 
really not a conclusion to which the results of this study uniquely contribute and  justify.  It really 
is a given in the perinatal field that individualized care should be provided.  Perhaps your 
conclusions could say something else about which particular quality of life domains could 
clinicians attend to when working with women who hav e symptoms of postpartum depression?  
 
Are the methods appropriate and well described?  
If not, pl ease specify what is required in your comments to the authors.  
No 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
No 
Are the conclusions drawn adequately suppo rted by the data shown?  
If not, please explain in your comments to the authors.  
No 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
I am able to assess the statistics  
Quality of written English  
Please indicate the quality of language in the manuscript:  
Not suitable for publication unless extensively edited  
Declaration of competing interests  
Please c omplete a declaration of competing interests, considering the following questions:  
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication o f this  
manuscript, either now or in the future?  
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
3. Do you hold or are you currently ap plying for any patents relating to the content of the  
manuscript?  
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
5. Do you have any other f inancial competing interests?  
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I decla re that I have no competing interests.  
 
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