Title: Women's Worries about Prenatal Screening Tests Suspected of Fetal Anomalies: A
Qualitative Study
Version: 1 Date: 13 Oct 2022
Reviewer:  Neeltje Crombag
Reviewer's report:
Thank you for the opportunity to read this interesting manuscript. I have read it with great
interest, but feel it needs major revisions for it to be published:
Background
line 2-4, I would suggest rephrasing: 'Over the recent decades, prenatal screening for the
diagnosis of fetal anomalies has been recommended to all pregnant women as a part of prenatal
care services' I don't think it is correct to say 'Prenatal screening is recommended', I would
suggest 'Prenatal screening is offered as an option....'
2nd paragraph:
Additionally, there is the problem of long-term uncertainty from the time of the suspected
diagnostic test to the definitive diagnosis. I think the 'long-term uncertainty' is an incorrect term.
Long-term to me indicates a period of years.
I would recommend rephrasing: 'losing an abnormal fetus by having a selective abortion or
accepting an abnormal child' into 'losing a fetus with congenital anomalies by having a selective
abortion or accepting a child with special needs'.
3rd paragraph: Evidence has shown that this group of women experiences the highest level of
worry twice, once immediately after the diagnosis of anomalies by the physician, and another
time, during the termination of pregnancy (10). A study emphasized that hospitalized women
experienced strong feelings of sadness and guilt for termination of pregnancy with abnormal
fetuses (11).
Which group is meant by 'this group'?
Also, I am not sure if your reference 11 indicates 'guilt of women', and besides I doubt whether
guilt is so profound. I think it is often 'loss' and 'grief' See for example the work of Stina Lou.
I think if you want to describe guilt, be more precise on guilt towards what/ whom etc. See for
example the work of Marijke Korenromp.
5th paragraph: what is meant by 'quality of worry'?
Also, I think there is already some work  related to 'experiences of women with suspected fetal
anomalies to detect various aspects of their worries' See for example the earlier mentioned work
of Stina Lou, Marijke Korenromp, but I think some of your references also consider this topic.
I would suggest being more specific on what exactly your study adds to the existing literature.
Also I would end the background part with a clear aim, and not on what this study may add for
practice. I believe it would be better to take that towards the discussion.
Methods:
The aim is too wide in my opinion, try to narrow it down to what was your main focus in this
study. Also as suggested above I would expect the aim at the end of your introduction.
setting and participants
Please add your eligibility criteria
Do you know why  people refused to participate? May be of interest for your data.
Data collection:
2nd paragraph
'Various tools and approaches were used for data collection, including semi-structured
interviews, observation, recording, transcription, taking notes during the interviews, and
documenting evidence'. Can you please be more specific what and how you used your 'tools'
and 'approaches'
I think the interview is your main method. The rest that you describe is how you have conducted
your research method.
Next, I'd suggest you refer to your interview guide (add as appendix) in stead of mentioning how
you have probed. Also I think your initial question is not clear to me (probably translation issue):
What are your worries about the possibility of fetal anomalies--> How do you feel about ....Can
you describe your worries?
I would suggest using COREQ for reporting on your research (https://www.equator-
network.org/reporting-guidelines/coreq/)
Results
Your results are very interesting, it reveals also socio-context specific issues.
Discussion:
"medical diagnostic processes" would that implicate logistic challenges. Can you maybe
elaborate on what the background is of this? It is indeed known that incorrect information, delay
in referral causes additional stress (see also Marokakis 2016). Could this be related to type
of centre (specialised versus local clinics). Specialised information and support is often much
appreciated in case of prenatal diagnosis as it is often relatively rare, and high-level knowledge
can be centralised in specialised centres.
Also in this first paragraph you touch upon family, which is one of your sub-themes. I would
expect a further elaboration on this, and potentially a recommendation how this can be improved.
It seems to me a very lonely situation in an already stressful period. May reflect on this
from specific socio-cultural aspects: why is there a lack of understanding, support, not taking
the diagnosis and further research seriously. What could be an explanation for this reaction?
Probably grief or disbelief of the family? And how can the family play a more supportive role?
Financial concerns: this is very interesting. But it might be of interest to elaborate more on why
there are financial constraints: is the system not equal accessible? Therefore I would suggest
elaborating more on equity aspects, and less on the effect of stress on birth weight. In case
of a fetal anomaly, if if there are no financial contrasts, this will add stress to the pregnancy
regardless. What I think is important is how this financial stress can be decreased? Maybe be
more specific on your countries insurance/ medical/ financial context.
Coping strategies through religion, I think this is a very relevant and import finding of your
study. Can you be more explicit on how this can help parents? Undergoing prenatal screening
tests and receiving non-reassuring test results very much touch upon essential life question (a life
with special needs, abortion etc)  for which religion (for religious people) may provide guidance:
I think it would be very interesting to elaborate further on how is 1) the decision to undergo
prenatal screening is linked with these life-questions and religion, and how this can be helpful
in case of diagnosed anomalies. So I would suggests putting it in a different perspective. 'the
quality of life and coping strategies can be ameliorated by improving an individual's religious
attitude ' is unclear for me. I would want to know how this can work, and what exactly.
Visiting other physicians as a coping strategy links with the need for reliable information. See
for example the work on spina bifida and Congenital  diaphragmatic hernia by Crombag. I would
try to put this more in this context of need for a profound understanding.
6th paragraph, linked with family, would move up and discus as suggested (why does this
reaction exist, how can this be altered into more helpful and causing less stress?)
7th paragraph, would also suggest to discuss this guilt more in depth, why guilt, towards whom
and how can women be supported in this?
Conclusion:
I think your recommendations can become more specific if related to the above suggestions.