Title: Low self-esteem is related to depression and anxiety during recovery from an ectopic
pregnancy
Version: 1 Date: 16 May 2021
Reviewer's report:
Thank you for the opportunity to review the manuscript “Low self-esteem is related to depression
and anxiety during recovery from an ectopic pregnancy”.
I believe the manuscript can make a relevant contribution to the body of knowledge on the
psychological effects of experiencing an ectopic pregnancy. However, I think that the manuscript
can benefit from revision. Please see my suggestions/comments below:
In the background section, I felt that some linkage is missing between the 2nd and 3rd paragraphs
of page 4. And in the same 3rd paragraph, I believe that the connection between mental health
and self-esteem should be further developed.
The authors hypothesize that self-esteem can mediate the effects of ectopic pregnancy on mental
health. I don’t think that the authors are referring to the statistical effect of mediation. Still,
instead, they want to emphasize that the impact of ectopic pregnancy on women’s mental health
can differ according to their self-esteem.
When defining the purpose of the study, the authors state that “our research team aimed to
determine the relationship of self-esteem with mental health and its subscales in order to explore
strategies to improve mental health problems among women with ectopic pregnancy after losing
their pregnancy.”
I believe this sentence should be rewritten because mental health does not have subscales.
Perhaps instead, the authors could state, “The purpose of the current study was to determine
the relationship of self-esteem with mental health (describe the constructs evaluated through
the different subscales) in order to explore strategies to improve mental health problems among
women with ectopic pregnancy after losing their pregnancy”. Regarding the second part of this
last sentence, the authors inform the reader that they will explore strategies to improve mental
health problems among women with ectopic pregnancy. Do they really do this in the manuscript?
And in the last sentence of the section, the authors state that “We hope that the results of this study
will form the basis for future”. Perhaps they mean something like this instead: “The results of the
current study are expected to contribute to the body of knowledge of the psychological impact
of experiencing an ectopic pregnancy, and also to the development of interventions targeting the
promotion of self-esteem and mental health in women who suffer an ectopic pregnancy.”
Please note that the authors’ writing style alternates between active and passive writing. This
should be focus of attention and revision.
Materials and methods. Which were the inclusion criteria? How was the ectopic abortion treated
(e.g., through surgery or medication)? At which week of gestation was the ectopic pregnancy
diagnosed? Were the pregnancies planned? How was the sample size estimated? Did the authors
use a software as the G*Power? Which were the parameters through which the sample size was
estimated?
Were all women evaluated at hospital discharge? Which was the number of average days spent
in the hospital? Which were the consequences of the ectopic pregnancies on the participants’
reproductive health?
When describing the statistical procedure, the authors should avoid referring to “mental health
and its subscales”. Instead, they should explain the constructs evaluated by the different
subscales.
Please present the reliability for each measure used.
Results: Can the authors please provide the t-test results for the results presented in Table 3?
Did the authors perform independent sample t-tests, to evaluate the effect of different mental
health symptoms on self-esteem?
The logistic regressions were performed one per dependent variable? Besides the predictors,
each model also included nine covariates? Perhaps the authors should conduct a preliminary
power analysis to guarantee that the sample size is adequate for such analysis. The authors should
present the models’ adjusted R2.
Did the authors consider evaluating the reciprocity between self-esteem and the different mental
health factors? The question arises since self-esteem can act as a buffer in the prevention of
mental health problems, but also, good mental health promotes one’s self-esteem.   Based on the
studies described in the background and the discussion sections, is it possible that the impact
of ectopic pregnancy on mental health is worse for those with prior experience of abortion
and that women with higher self-esteem are more protected? Of course, the study can only be
correlational since the design is cross-sectional.
Overall, I believe the manuscript can make a relevant contribution to this field of research.
However, I strongly suggest the authors to revise the document, rethink and clarify the purpose
of the study, the statistical analysis, and adjust the discussion section accordingly.