Title: Low self-esteem is related to depression and anxiety during recovery from an ectopic
pregnancy
Version: 1 Date: 14 May 2021
Reviewer's report:
This is a clearly written paper about the relationship between self-esteem and mental health
in women with ectopic pregnancy. Although there are some interesting aspects of the study,
unfortunately I believe the paper is of limited added value to the field. I believe the most relevant
finding of the study is the very high level of distress in women experiencing ectopic pregnancy,
which (although quite understandable) stresses the urgency to monitor mental distress in those
women in the period after EP.
Major points:
1. In my opinion, the authors do not make it sufficiently clear why the relationship between
self-esteem and mental distress in this group of women is important. In general, we know
there is a relationship between self-esteem and mental health. However, why this is specifically
important in this subgroup of women remains unclear to me. There are two practical implications
of finding such a relationship: 1) screening women beforehand on their self-esteem as it may
predict development of mental health issues, 2) adjusting interventions to specifically improve
self-esteem.
However, the first goal is not very likely, because only a very small proportion of women will
develop ectopic pregnancy. Furthermore, as we can expect the great majority of those women
will experience distress, the value of screening beforehand is limited.
The second goal might be interesting, however, then it should be very clear that current mental
health interventions are not sufficiently equipped to improve self-esteem leading to lasting
mental health problems. To my knowledge, this is not the case.
2. Another aspect which puzzels me is the time point mental distress was measured. I suppose
this was just before or after surgery for the ectopic pregnancy. It is highly likely that these
women experience distress at this time, because distress is a normal reaction to such an extreme
situation. My question is how informative it is to measure mental distress (and specifically its
relationship with self-esteem) at this point. I would be more interested in mental distress after
a few weeks, in which natural recovery has run its course. This is even more important as it is
not wise to start an intervention just after the EP. The authors need to be more clear about the
time frame chosen and why.
3. The authors chose to dichotomise data. They should explain their methods better, bearing
in mind that the preferred method for analysing a non-causal relationship between continuous
variables is a correlation. The non-causality of their findings should also be discussed in more
detail in the discussion section.
Minor points:
4. I was surprised by the 100% response rate. For women in such a distressed state, filling out a
questionnaire should be considered burdensome for at least some of them. It seems unlikely that
all women who were approached, agreed to participate. Alternatively, only women who gave
informed consent were considered “responders” and subsequently filled out the questionnaire.
In that case I would not speak of “response rate” as such and leave this out.
5. There are quite some exclusion criteria. It is unclear why exclusion criteria were applied (for
example, why patients with a psychiatric disorder or a previous EP were excluded) and how
many women were excluded from the study based on each of these criteria.