Title: Evaluate The Effectiveness of Using Nonpharmacological Intervention During
Childbirth: An Improvement Project in Jordanian Maternity Hospitals
Version: 3 Date: 07 Jun 2024
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
No - there are major issues
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are major issues
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
No - there are minor issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
N/A - there are no statistics in this study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: The use of non-pharmacologic modalities in labor and birth is an
interesting topic and I commend the authors for their commitment to physiologic birth and
respectful maternity care. However, I believe this is a quality improvement project rather than
a qualitative research study and should be written as such. There is need of additional English
language editing. The authors did address the previous reviewers comments.
REQUESTED REVISIONS:
Overall, I agree that exploring non-pharmacologic modalities for comfort in labor is important
and I applaud the authors commitment to providing labor support and non-pharmacologic
comfort measures. This manuscript seems less like a qualitative research study and more
like a quality improvement project was an “intervention” per se in that the participants were
given information and support about using non-pharmacologic modalities for pain relief. My
suggestion would be that the authors rewrite it as such using the SQUIRE guidelines
https://www.squire-statement.org/index.cfm?fuseaction=Page.ViewPage&PageID=471
The introduction needs more refining
Particularly when women don’t have the option for pharmacologic pain relief or are desirous of
a non-medicated birth having a toolkit of non-pharmacologic methods is very helpful. However,
I think the authors need to acknowledge that epidurals, while not without risk, not always
available, and potentially costly are considered the “gold standard” for pain relief in labor.
There are some English language issues – primarily missing articles like “a” for example “and
birth of depressed baby” needs to be written as  “and birth of a depressed baby”
Another example:  “Also, our data is considered reliable because we research saturation into
the research as responses became consistent across most participants.” Did you mean that you
reached saturation?
Well-intentioned interventions can lead to unintended emergencies or even harm, such as
elective amniotomy to speed labor progress followed by prolapsed umbilical cord, cesarean
under general anesthesia, and birth of depressed baby [3]. Other procedures should be likewise
eliminated as routine, and rather used sparingly on an individual as needed basis, such as
episiotomy, bedrest “visitor control”, and stirrups. The WHO stresses the importance of
intervening in the process of childbirth only if there is tangible evidence that indicates the need to
interfere due to certain risk factors [4]. – this doesn’t really apply to the significance of reviewing
non-pharmacologic methods of pain relief in labor
A meta-analysis study from Australia that systematically searched articles published between
1989 and 2020 in six electronic databases included eight studies with 713 participants with nine
different nonpharmacological strategies for reducing labor pain. The traditional meta-analysis
demonstrated that nonpharmacological coping strategies were effective in reducing labor pain
[2]. Of these interventional strategies, the ranking probabilities analysis of the network meta-
analysis suggested that the Bonapace Method (massage on pressure points including the sacrum,
hand, and calf) may be the most effective strategy in reducing labor pain. This systematic review,
by synthesizing the body of evidence, demonstrated that nonpharmacological interventions are
effective in enhancing satisfaction and reducing labor pain among participants [2].
Introduce various methods of non-pharmacologic strategies rather than giving a synopsis of the
meta-analysis
some may opt to go through high-risk labor experiences [4]. Can you explain this?
These interventions are better in managing low-risk childbirth because midwives and nurses
assume responsibility for managing the childbirth process [3]. This needs more explanation
as studies have proven that the adopted practices of the medical system in Jordanian hospitals –
Avoid the word proven as nothing is ever really proven in science
Jordan is no exception, as studies have proven that the adopted practices of the medical system
in Jordanian hospitals and in maternity clinics are not aligned with the WHO recommendations
for application of natural childbirth, especially low risk mothers [4]. As a matter of fact, it
has been observed that many interventions are being implemented and the process, more than
there should be, and in so many cases in unnecessary situations and circumstances. Even more,
some interventions took place in some cases that are low risk cases rather than only interfering
with the high-risk childbirth cases [9]. – can you be more specific about what interventions and
circumstances?
Some reasons were found behind the low usage of nonpharmacological pain management
interventions in Jordan [14]. – what were the reasons?
Methods:
the abstract includes: Finally, the midwife tries to conduct childbirth without an episiotomy. But
then there is nothing about this in the actual body of the paper and I would suggest taking it
out of the abstract
The new Zarqa Governmental Hospital is considered one of the largest hospitals in
Jordan. There is a Department of Neonatology and Prematurity at Al Zarqa Governmental
Hospital. This hospital has passed the requirements for success in the Excellence Program for the
year 2018, thus it deserved the shields for its excellence in providing mothers and child health
services. The new Zarqa Governmental Hospital has obtained the international accreditation
certificate after applying all the requirements of the hospital accreditation standards of the Health
Care Accreditation Council.
This is not really relevant
The researcher is a maternity nurse working in a health center, this helped ensure that the
responses were honest and not influenced by “what we want to hear.”
Does this mean that the researcher does not provide direct patient care for any of the research
participants?
A total of eighteen mothers agreed to participate in our research study. Their ages ranged
between 22 and 37 with an average of 29.4 years. The age ranges of their husbands were between
26 and 39, with an average of 32.9. At the time of marriage, their ages were between 19 and 26,
with an average of 22.5. The duration of marriage time ranged between two years and 12 years,
with an average of 6.9 years. Three of our participants had a bachelor's degree. Five of them were
high school graduates, while two of them graduated with a diploma. Only three of them were
employed (those who had a bachelor's degree). Six of the husbands were high school graduates,
and three of them had a bachelor's degree, while one of them graduated with a diploma. Most
were employed, and some had their own businesses as drivers, farmers, etc. Their salary ranged
from 250 JD to 700 JD, with a maximum value for family income of 700 JD. Eleven of our
participants live in rented houses, and seven own their homes; eleven of them live with family in
the same building. Regarding the number of pregnancies for the mothers, including the present
pregnancy (G), the maximum number was six, while the minimum number of pregnancies was
two. The maximum number of term births was five, while the minimum was one.
This can all go in a Table and be summarized in the text
In general, our findings suggest that our participants were satisfied with their experience
of using non-pharmacological interventions for the management of pain during labor and
birth. Compared to their previous experiences of childbirth, our participants felt relaxed and
autonomous.
This summary should go after the results – in the discussion
Create a table with the participant demographics and identify which of the participants you are
quoting – it adds context to know if it is a participant who is 20 versus 35 and having their first
baby versus their 4th.
ADDITIONAL REQUESTS/SUGGESTIONS:
Rewrite as a quality improvement project using SQUIRE guidelines. The intervention being
labor support and use of non-pharmacologic comfort measures."