Title: PREVALENCE, INDICATIONS AND FETAL OUTCOME OF OPERATIVE
VAGINAL DELIVERY IN SUB-SAHARAN AFRICA, SYSTEMATIC REVIEW, AND
META-ANALYSIS
Version: 3 Date: 07 Oct 2022
Reviewer's report:
Authors have given a magnificient effort in conducting this study that is going to contribute a
lot in MCH research in sub-Saharan African countries. Though there are some major concerns
from my side those I have mentioned in the commemts.
General Comments:
1. Be careful with the spaces and symbols used
2. Be careful with the English language.
3. Be focused on the topic of discussion.
A. Abstract:
1. Background:
1.1. First line:  I think rather than defining what ‘operative vaginal deliveries’ are, it would be
better to add the rationale of this SR in the first sentence, as there are word limits in the Abstract.
2. Method:
2.1. Authors have included Google Scholar, PubMed, HINARI, Web of Science and other local
databases. To my understanding, only two of them (PubMed and Web of Science) are grossly
used. But for a systematic review, it is advised to add at least three reasonable databases, which I
don’t see here. I would like to suggest the authors to add at least one of the databases (Embase or
CINAHL) for this study. By not including these databases, I think this SR lost a lot of significant
data.
2.2. Second Line of Method: “OnLine”: Is this a typo?
3. Results:
3.1 Keep an eye on the spellings: “Unfavourable” not “unfavorable”
4. Conclusion:
4.1. First line, “OVD”: Using abbreviations in the abstract is not a good idea.
Plus, you must mention earlier which words you are trying to mention through this abbreviation.
In the first line after ‘operative vaginal deliveries’ “OVD” was not mentioned.
4.2.: The second and third sentences: No need to repeat the results here again in “Conclusion”.
Just draw a conclusion from the results, as you did in the first sentence and the last sentence.
B. Main text;
1. Introduction:
1.1. First line: While you are starting the sentence with “Nowadays”, the sentence must follow
present tense or present perfect tense.
1.2. First para, last line “Substituent”: I’m not sure about the choice of word here. Are you trying
to refer to the upcoming pregnancies? Or the birth of twins?
1.3. Page 3; “The risk of soft tissue trauma,….. was higher”: In which condition? For forceps
or vacuum delivery? The message is not clear.
1.4. Page 3, 2nd para: “rates of severe birth….”: You must mention the rates with “per 1000” as
given in the referenced article. Otherwise, the values do not make sense.
1.5. Last para of the Introduction:
a. The rationale of this SR is required to be rewritten; just one sentence is not enough.
b. Where are the objectives of this study?
2. Methods:
2.1. Research questions: Should come before Methods.
2.2. Search Strategy: Use “inverted comma” properly around the search terms. Also, I would
like to look into the search strategy before providing any decision.
2.3. Under Eligibility criteria, there are two sub headings, one is “inclusion exclusion criteria”
and the other one is “exclusion criteria”. Correct it.
2.4. Under “inclusion exclusion criteria”, the last sentence:
Did the authors want to mean, the quality of all the selected articles was found to be low-risk?
Can you please share the sheet where you did the quality check?
2.5. Quality assessment; first sentence: the reference is not for JBI checklist. This is mere
carelessness.
2.6. I don’t think a description of the eight items (from the JBI Checklist) is required here. Proper
referencing is enough.
2.7. Last sentence of “Data extraction”: “Quality and inclusion of the article…” this is to be
written under the quality assessment paragraph.
Is there anything to do with a quality check for data also? If yes, rewrite the sentence; otherwise,
remove it.
You can also write in one paragraph that “the four authors conducted the evaluation of the
articles, which ones to be included and which are not to be followed by a conflict resolution
by the other two authors. Once included, the data extraction process was again conducted
individually by the four authors, which were further validated by another two authors”…
something like this.
2.8. Measurement of outcome; last line: Did you forget to delete this line, cause it says the same.
3. Results:
3.1. First para (Characteristics of the included studies): How did the author reach from 57 full-
text articles to included 17 articles? On what basis those 40 articles were removed? This is
mentioned neither in the text nor in Figure 1.
3.2. Comments on Figure 1 (not for the manuscript):
In the 3td stage (records screened): the box showing ‘Records excluded (n=163)’ must go
between the two boxes of ‘Records after duplicates removed’ and ‘Records screened’. The
position of the ‘arrow mark’ should originate from the ‘arrow mark’, not the box.
Same for the next box too.
3.3. Prevalence of operative vaginal delivery in Africa: Make it “I square” instead of “I2”.
3.4. Comment on Figure 3 (not in the main text): Don’t write “Forest plot test”. Instead, write
just “Forest plot”. It’s a graphical presentation.
Change the title/caption to “Forest plot presenting the publication bias among the included
studies on OVD from the sub-Saharan African countries” or something like this.
4. Discussion
4.1. First para; “To save lives of more… pregnancy and childbirth”: Your study is related to
OVD; what is the requirement for these lines, then? I think this statement of death on maternal
health and hygiene practices, is completely a separate matter which is unrelated to this study.
4.2. Third para of Discussion; second sentence; “there is one study…”: Be careful with the
sentence formation. “findings from India”.
4.3. Third para of Discussion; third sentence; “this similarity might …”: Not only study design.
You can also add, both sub-Saharan countries and South-East Asian countries, belong to low-
and middle-income countries (LMICs) or low-income countries
4.4. At the end of the discussion, write a paragraph covering:
a. Magnitude of the existing problem found in this study
b. Existing policy and policy gaps could contribute to these outcomes.
c. Suggestion on how to minimise these problems.
d. And lastly, research gap that could be explored in future.
5. Conclusion:
5.1. Second & third sentence: This is the result. Conclude from the result, how good or bad is
the situation or suggestions to lessen the burden of this problem among sub-Saharan African
countries.
Like in the final sentence, you have mentioned of drafting a guideline is required, suggestions
should come like this.