Title: Associations between mental health conditions in pregnancy and maternal socioeconomic
status: A population-based retrospective cohort study in Ontario, Canada
Version: 2 Date: 29 May 2024
Reviewer's report:
The authors sought to understand whether residential neighborhood income and neighborhood
education level are association with mental health conditions during pregnancy. They utilized
9 years of retrospective data, from April 2012 to March 2021 in Ontario, Canada. A total of 1,
202, 292 pregnant individuals were included in the analytic dataset. They found an association
between lowest neighborhood quintiles and lowest education levels and diagnoses of depression,
anxiety, or any other mental health condition among pregnant women.
While this analysis was interesting, I found that the inconsistent interpretation of neighborhood
income/education as reflective of the individual was problematic. Further, the takeaways could
be strengthened. Please see more detailed comments below.
Abstract
The conclusion could be strengthened.
Introduction
Line 70: Please clarify what is meant by “location-specific” conditions
Methods
Covariate definition, line 141: add ‘years’ for maternal age
Please explain whether maternal education or income level data were available?  It seems like
the authors could have utilized multi-level modeling.
Results
Line 164 and 167: add ‘n’ when providing the number of individuals with each condition
Line 202-204: add ‘n’ when providing the number of individuals
Discussion
Line 237: please add in ‘neighborhood’ when referring to lower SES. As I understand, maternal
SES level was not evaluated.
Line 237-249: This paragraph would benefit from distinguishing whether other studies looked
at maternal SES level or neighborhood SES level.
Line 251- 260: I find the author’s line of discussion not to match the analyses performed. The
most that can be inferred from this study is related to individuals living in impoverished areas,
not the individual’s own poverty level. I have a similar comment related to education. To speak
to both individual and neighborhood education and income levels, the authors should consider
multilevel modeling analyses. Else, please update the paragraph to reflect the current analyses
and findings of neighborhood education and income levels.
Line 270: The authors indicate that neighborhood income and education level was used to
estimate SES of individuals – this information needs to be in the exposure measurement under
Methods sections. This is a major analytic decision that informs the interpretation of the data
(see comments related to discussion above).
Conclusion: Suggest the authors either frame analyses as individual income and education level,
measured by neighborhood proxy data OR simply neighborhood income and education level.
The language alternates from one to the other and it’s unclear what the takeaway is. What do
these data mean for intervention of perinatal depression or anxiety?
The conclusion and discussion could be made much stronger. Suggest that the authors utilize
more sentences to explore the association between neighborhood income/education levels
and mental health outcomes in a location where theoretically, there is universal healthcare.
Additionally, what are Canada’s recommendations on perinatal mental health screening?