Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

The manuscript addresses an important and timely topic by exploring midwifery workforce preparedness and continuity of maternal care during natural disasters and climate-related emergencies. The integration of workforce resilience, disaster preparedness, and maternal care continuity provides an interesting perspective with potential relevance for public health policy and integrated care planning. The adherence to PRISMA guidance and PROSPERO registration are notable strengths. However, several methodological and conceptual issues should be addressed to strengthen the rigor and clarity of the review.

Abstract

1. The abstract is generally well structured and clearly reports the objective, methods, and main findings.
2. The inclusion of PRISMA compliance and the databases searched strengthens transparency.
3. However:
   • The review question could be formulated more explicitly.
   • The conclusions occasionally overstate the strength of the evidence considering the limited number and heterogeneity of included studies.
   • The abstract would benefit from acknowledging the predominance of qualitative and cross-sectional evidence.
4. Consider clarifying that the synthesis was exclusively narrative and that no meta-analysis was feasible.

Introduction

5. The introduction provides a relevant and up-to-date overview of the impact of disasters on maternal healthcare systems and the role of midwives in continuity of care.
6. The emphasis on equity, resilience, and workforce preparedness is appropriate and clinically relevant.
7. However:
   • Some sections are somewhat repetitive, particularly regarding workforce resilience and continuity of care.
   • The conceptual relationship between “integrated care,” “equity,” and “preparedness” could be more clearly operationalized.
   • The novelty of the review relative to previous disaster preparedness reviews involving nursing and maternity care could be more explicitly justified.
8. The final paragraph clearly states the aims of the review, which is a strength.

Materials and Methods

9. The review follows PRISMA guidance and reports PROSPERO registration, which strengthens methodological transparency.
10. Eligibility criteria are generally appropriate and clearly described.
11. The inclusion of qualitative, quantitative, and mixed-methods studies is justified given the complexity of the topic.
12. However, several methodological issues require clarification:

• The review question and eligibility framework are broad, which may contribute to substantial conceptual heterogeneity.
• The inclusion of studies involving pregnant women rather than midwives themselves should be better justified, particularly when continuity-of-care models are evaluated indirectly.
• Grey literature is mentioned, but the specific sources searched and the methods used are not described in sufficient detail.

13. The search strategy is comprehensive; however:

• Some syntax inconsistencies and formatting issues are present within the search string (e.g., perinatal care").

14. Study selection and data extraction procedures are appropriately described as independent processes conducted by two reviewers.
15. The use of MMAT is appropriate for mixed study designs.
16. However:

• The manuscript states that no aggregated MMAT scores were used, yet Table 2 reports “MMAT criteria met out of 5,” which effectively functions as a score. This should be clarified to align with MMAT guidance.
• The approach to assessing certainty of evidence remains somewhat vague and would benefit from clearer methodological justification.

Results

17. Study selection is clearly summarized and supported by the PRISMA flow diagram.

18. Table 1 provides a useful overview of study characteristics.
19. However:

• Some studies include mixed populations (nurses and midwives), which may reduce specificity regarding midwifery preparedness.
• The distinction between studies assessing workforce preparedness and those evaluating continuity-of-care outcomes could be made more explicit.

21. The methodological quality section is generally appropriate.
22. However:

• Statements such as “low to moderate methodological concerns” appear somewhat subjective and could be supported with more explicit MMAT domain interpretation.
• The narrative synthesis occasionally overgeneralizes findings despite the small number of studies and highly heterogeneous contexts.

23. The thematic synthesis regarding preparedness determinants is coherent and clinically relevant.
24. Nevertheless:

• Some assertions regarding organizational preparedness and professional equity are stronger than the available evidence may support.
• Several findings derive from qualitative perceptions rather than objective preparedness measures and should be interpreted more cautiously.

25. The section “Inclusion and Professional Equity” is conceptually interesting but relatively underdeveloped and could benefit from deeper synthesis and clearer linkage to included evidence.

Discussion

26. The discussion appropriately contextualizes the findings within disaster preparedness and maternal care resilience literature.
27. The emphasis on organizational support, simulation-based training, and integration into disaster planning is relevant and potentially valuable for policy development.
28. However:

• Some conclusions are stronger than warranted given the predominance of qualitative and cross-sectional evidence.
• Causal language should be avoided or softened, particularly when discussing preparedness determinants and continuity outcomes.
• The manuscript occasionally conflates preparedness, resilience, and continuity of care as interchangeable constructs without sufficient conceptual differentiation.

29. The policy implications are useful but could better distinguish evidence-supported recommendations from broader expert interpretation.

Strengths and Limitations

30. The strengths and limitations section is comprehensive and appropriately acknowledges several methodological constraints.
31. Important limitations are correctly identified, including:

• language restriction,
• publication bias,
• concentration in earthquake-related settings,
• predominance of qualitative and cross-sectional studies.

32. However, additional limitations should be emphasized:

• substantial contextual heterogeneity,
• lack of standardized preparedness measures,
• limited geographical representation,
• inability to perform quantitative synthesis.

33. The limitation regarding indirect linkage between preparedness and measurable maternal outcomes is particularly important and should receive greater emphasis.

Conclusion

34. The conclusions are generally aligned with the review findings.
35. However:

• The wording should be slightly more cautious given the limited strength of evidence.
• The review supports important hypotheses and policy considerations but does not establish robust causal evidence regarding preparedness and maternal outcomes.

36. The call for longitudinal and intervention-based studies is appropriate and well justified.

References

37. References are generally appropriate, recent, and relevant to the topic.
38. The inclusion of recent disaster preparedness and climate resilience literature strengthens the manuscript.
39. However:

• Some references are grey literature or organizational reports, which should be balanced with additional peer-reviewed evidence where possible.
• Several citations are used repeatedly to support broad claims despite limited empirical scope.

Overall, this manuscript addresses a highly relevant and underexplored topic with potential implications for maternal health resilience and disaster preparedness planning. The review demonstrates several methodological strengths, including protocol registration and adherence to PRISMA guidance. Nevertheless, important clarifications regarding methodology, conceptual framing, and interpretation of evidence are needed to improve the scientific rigor and transparency of the review.

Author Response

Response to Reviewer 1

1.Comment: The abstract is generally well structured and clearly reports the objective, methods, and main findings. Response: We sincerely thank the reviewer for the positive evaluation of the abstract and for acknowledging its clarity and structure.

 2.Comment: The inclusion of PRISMA compliance and the databases searched strengthens transparency. Response: We thank the reviewer for recognizing the transparency and methodological rigor of the review process, including adherence to PRISMA 2020 guidelines and the comprehensive database search strategy.

3.Comment: However:

• The review question could be formulated more explicitly. Response:
  We thank the reviewer for this important suggestion. To improve clarity, we revised the final paragraph of the Introduction and explicitly stated the review question and objectives of the systematic review.

• The conclusions occasionally overstate the strength of the evidence considering the limited number and heterogeneity of included studies. Response: We thank the reviewer for this valuable observation. The Discussion and Conclusions sections were revised to adopt more cautious wording and better reflect the limited number, heterogeneity, and predominantly qualitative nature of the included studies.

• The abstract would benefit from acknowledging the predominance of qualitative and cross-sectional evidence. Statements implying causality or strong generalizability were moderated accordingly. Response: The abstract would benefit from acknowledging the predominance of qualitative and cross-sectional evidence. Response: We thank the reviewer for this important suggestion. The abstract was revised to acknowledge that the evidence base was predominantly qualitative and cross-sectional, thereby providing a more balanced interpretation of the findings.

4. Comment: Consider clarifying that the synthesis was exclusively narrative and that no meta-analysis was feasible.

Response: We thank the reviewer for this helpful suggestion. The manuscript was revised to clarify both in the Abstract and Methods sections that findings were synthesized narratively and that meta-analysis was not feasible due to substantial methodological and clinical heterogeneity among the included studies.

5. Comment: Introduction. The introduction provides a relevant and up-to-date overview of the impact of disasters on maternal healthcare systems and the role of midwives in continuity of care.

Response: We sincerely thank the reviewer for the positive evaluation of the Introduction and for recognizing the relevance and timeliness of the literature presented regarding disaster impacts on maternal healthcare systems and the role of midwives in continuity of care.

6. Comment: The emphasis on equity, resilience, and workforce preparedness is appropriate and clinically relevant.

Response: We thank the reviewer for acknowledging the clinical relevance of emphasizing equity, resilience, and workforce preparedness within the context of maternal healthcare during disasters and climate-related emergencies.

7. Comment: However:

• Some sections are somewhat repetitive, particularly regarding workforce resilience and continuity of care. Response: We thank the reviewer for this constructive observation. The manuscript was carefully revised to reduce repetitive statements across the Introduction, Results, and Discussion sections, particularly regarding workforce resilience and continuity of maternal care. Redundant wording was streamlined to improve readability and overall flow.
• The conceptual relationship between “integrated care,” “equity,” and “preparedness” could be more clearly operationalized. Response: We thank the reviewer for this insightful comment. The Introduction was revised to clarify the conceptual relationship between integrated care, health equity, and workforce preparedness within disaster-response contexts. Additional text was added to explain how preparedness supports continuity of integrated maternal care and contributes to equitable access to maternity services during disasters and climate-related emergencies.
• The novelty of the review relative to previous disaster preparedness reviews involving nursing and maternity care could be more explicitly justified. Response:

8. Comment: The final paragraph clearly states the aims of the review, which is a strength.

Response: We sincerely thank the reviewer for recognizing the clarity of the review aims and objectives presented in the final paragraph of the Introduction.

Materials and Methods

9. Comment: The review follows PRISMA guidance and reports PROSPERO registration, which strengthens methodological transparency.

Response: We thank the reviewer for acknowledging the methodological transparency of the review, including adherence to PRISMA 2020 guidance and prospective PROSPERO registration.

10. Comment: Eligibility criteria are generally appropriate and clearly described.

Response: We sincerely thank the reviewer for recognizing the clarity and appropriateness of the eligibility criteria used in this systematic review.

11. Comment: The inclusion of qualitative, quantitative, and mixed-methods studies is justified given the complexity of the topic.

Response: We thank the reviewer for acknowledging the appropriateness of including qualitative, quantitative, and mixed-methods evidence to address the multidimensional and context-dependent nature of disaster preparedness and continuity of maternal care.

12. Comment: However, several methodological issues require clarification:

• The review question and eligibility framework are broad, which may contribute to substantial conceptual heterogeneity. Response: We thank the reviewer for this important observation. The scope of the review was intentionally broad to capture the multidimensional nature of midwifery workforce preparedness and continuity of maternal care across diverse disaster contexts. Nevertheless, we acknowledge that this approach contributed to conceptual and methodological heterogeneity. Additional clarification was added to the Methods and Limitations sections to acknowledge this issue and justify the narrative synthesis approach adopted in the review.
• The inclusion of studies involving pregnant women rather than midwives themselves should be better justified, particularly when continuity-of-care models are evaluated indirectly. Response: We thank the reviewer for this important observation. Additional clarification was added to the Eligibility Criteria section to explain that studies involving pregnant women were included only when they evaluated clearly defined midwifery-led continuity-of-care models relevant to workforce preparedness and maternal care resilience during disasters. These studies were considered important because they provided indirect evidence regarding the organizational and continuity-related dimensions of midwifery workforce preparedness.
• Grey literature is mentioned, but the specific sources searched and the methods used are not described in sufficient detail. Response: We thank the reviewer for this valuable suggestion. The Search Strategy section was revised to provide additional details regarding the grey literature search, including the specific repositories searched, the search terms used, and the purpose of including non-peer-reviewed sources relevant to disaster preparedness and maternal care continuity.

13. Comment: The search strategy is comprehensive; however:

• Some syntax inconsistencies and formatting issues are present within the search string (e.g., perinatal care"). Response: We thank the reviewer for carefully identifying these formatting inconsistencies. The search strategy was revised to correct syntax and quotation formatting errors within the reported search string.

14. Comment: Study selection and data extraction procedures are appropriately described as independent processes conducted by two reviewers. Response: We sincerely thank the reviewer for recognizing the methodological rigor of the study selection and data extraction procedures employed in this review.
15. Comment: The use of MMAT is appropriate for mixed study designs. 16. Comment: However:

• The manuscript states that no aggregated MMAT scores were used, yet Table 2 reports “MMAT criteria met out of 5,” which effectively functions as a score. This should be clarified to align with MMAT guidance. Response:
  We thank the reviewer for this important methodological observation. In accordance with MMAT guidance, Table 2 was revised to avoid the presentation of numerical summary scores that could be interpreted as aggregated quality ratings. The methodological appraisal is now described narratively using qualitative descriptors of methodological concerns.

• The approach to assessing certainty of evidence remains somewhat vague and would benefit from clearer methodological justification. Response: We thank the reviewer for this important methodological observation. The section describing confidence in the evidence was revised to provide clearer justification for the decision not to apply a formal certainty-of-evidence framework such as GRADE, given the predominance of qualitative and heterogeneous study designs. Additional clarification was added regarding the narrative approach used to interpret confidence in the body of evidence.

Results

17. Comment: Study selection is clearly summarized and supported by the PRISMA flow diagram. Response: We sincerely thank the reviewer for recognizing the clarity of the study selection process and the presentation of the PRISMA 2020 flow diagram.

18-19. Comment: Table 1 provides a useful overview of study characteristics. However:

• Some studies include mixed populations (nurses and midwives), which may reduce specificity regarding midwifery preparedness. Response: We thank the reviewer for this important observation. Additional clarification was added to the Limitations section acknowledging that several included studies involved mixed healthcare professional populations, which may reduce the specificity of findings related exclusively to midwifery preparedness. However, only studies with extractable or directly relevant midwifery-related findings were included in the review.

20. Comment: The distinction between studies assessing workforce preparedness and those evaluating continuity-of-care outcomes could be made more explicit.

Response: We thank the reviewer for this valuable suggestion. The Results section was revised to more clearly distinguish between studies focusing primarily on midwifery workforce preparedness and those evaluating continuity-of-care outcomes during disasters and climate-related emergencies.

21. Comment: The methodological quality section is generally appropriate.

Response: We thank the reviewer for the positive evaluation of the methodological quality assessment approach used in this review.

21-22. Comment: However:

• Statements such as “low to moderate methodological concerns” appear somewhat subjective and could be supported with more explicit MMAT domain interpretation. Response: We thank the reviewer for this important methodological observation. The methodological quality section was revised to provide clearer interpretation of the MMAT appraisal domains underlying the narrative quality descriptions. Additional clarification was added regarding the specific methodological aspects contributing to low, minor, or moderate concerns across study designs.
• The narrative synthesis occasionally overgeneralizes findings despite the small number of studies and highly heterogeneous contexts. Response: We thank the reviewer for this important observation. The manuscript was revised to adopt more cautious and context-sensitive language throughout the Results, Discussion, and Conclusions sections. Statements that could imply broad generalizability or causal interpretation were moderated to better reflect the limited number of included studies, the predominance of qualitative and cross-sectional evidence, and the substantial heterogeneity across disaster contexts and study designs.

23. Comment: The thematic synthesis regarding preparedness determinants is coherent and clinically relevant.

Response: We sincerely thank the reviewer for recognizing the coherence and clinical relevance of the thematic synthesis concerning determinants of midwifery workforce preparedness.

24. 24. Comment: Nevertheless:

• Some assertions regarding organizational preparedness and professional equity are stronger than the available evidence may support. Response: We thank the reviewer for this important observation. The relevant sections of the Results and Discussion were revised to adopt more cautious wording regarding organizational preparedness and professional equity. Statements implying broad generalizability were moderated to better reflect the limited and predominantly qualitative evidence base.

• Several findings derive from qualitative perceptions rather than objective preparedness measures and should be interpreted more cautiously. Response: We thank the reviewer for this important methodological observation. Additional clarification was added to the Results and Limitations sections to acknowledge that several findings were based on qualitative experiences and self-reported perceptions of preparedness rather than objective preparedness measures. The interpretation of these findings was revised accordingly using more cautious language.

25. Comment: The section “Inclusion and Professional Equity” is conceptually interesting but relatively underdeveloped and could benefit from deeper synthesis and clearer linkage to included evidence.

Response: We thank the reviewer for this insightful observation. The relevant section was revised to strengthen the synthesis linking professional equity and organizational inclusion with findings derived from the included qualitative studies. Additional clarification was added to better connect these concepts to disaster-response structures, role visibility, and continuity of maternal care during crises.

Discussion

26. Comment: The discussion appropriately contextualizes the findings within disaster preparedness and maternal care resilience literature.

Response: We sincerely thank the reviewer for recognizing the contextualization of the findings within the broader literature on disaster preparedness and maternal care resilience.

27. Comment: The emphasis on organizational support, simulation-based training, and integration into disaster planning is relevant and potentially valuable for policy development.

Response: We thank the reviewer for acknowledging the policy relevance of emphasizing organizational support, simulation-based training, and the integration of midwives into disaster planning frameworks.

28. 28. Comment: However:

• Some conclusions are stronger than warranted given the predominance of qualitative and cross-sectional evidence. Response: We thank the reviewer for this important observation. The Discussion and Conclusions sections were revised to adopt more cautious wording that better reflects the predominantly qualitative and cross-sectional nature of the evidence base. Statements implying causality or broad generalizability were moderated accordingly, and additional clarification regarding the limited and heterogeneous evidence was incorporated throughout the manuscript.
• Causal language should be avoided or softened, particularly when discussing preparedness determinants and continuity outcomes. Response: We thank the reviewer for this important methodological observation. The manuscript was revised throughout the Results, Discussion, and Conclusions sections to avoid causal interpretations not supported by the predominantly qualitative and cross-sectional evidence base. Expressions implying direct effects or causal relationships were replaced with more cautious wording such as “may influence,” “appeared to be associated with,” and “suggested.”
• The manuscript occasionally conflates preparedness, resilience, and continuity of care as interchangeable constructs without sufficient conceptual differentiation. Response: We thank the reviewer for this insightful conceptual observation. The manuscript was revised to provide clearer differentiation between preparedness, workforce resilience, and continuity of maternal care as distinct but interrelated constructs. Additional clarification was incorporated into the Introduction and Discussion sections to explain how preparedness relates to response capacity, resilience reflects sustained workforce functioning under crisis conditions, and continuity of care represents a service-level outcome during disasters and climate-related emergencies.

29. Comment: The policy implications are useful but could better distinguish evidence-supported recommendations from broader expert interpretation.

Response: We thank the reviewer for this important observation. The policy implications section was revised to more clearly distinguish recommendations directly supported by the included evidence from broader interpretive considerations derived from the synthesis of findings and the wider disaster preparedness literature. The wording of several recommendations was moderated accordingly.

Strengths and Limitations

30. Comment: The strengths and limitations section is comprehensive and appropriately acknowledges several methodological constraints.

Response: We sincerely thank the reviewer for recognizing the balanced presentation of the strengths and methodological limitations of the review.

31. Comment: Important limitations are correctly identified, including:

• language restriction,

Response: We thank the reviewer for recognizing the transparent acknowledgment of important methodological limitations, including potential language bias related to the inclusion of English-language studies only.

• publication bias

Response: We thank the reviewer for acknowledging the transparent discussion of potential publication bias as a limitation of the review.

• concentration in earthquake-related settings,

Response: We thank the reviewer for recognizing the transparent acknowledgment of the concentration of evidence within earthquake-related disaster contexts and its implications for transferability across different types of disasters and climate-related emergencies.

• predominance of qualitative and cross-sectional studies.

Response: We thank the reviewer for acknowledging the transparent discussion of the predominance of qualitative and cross-sectional evidence as an important methodological limitation of the review.

32. Comment: However, additional limitations should be emphasized:

• substantial contextual heterogeneity,

Response: We thank the reviewer for this important observation. The Limitations section was revised to further emphasize the substantial contextual heterogeneity across disaster types, healthcare systems, geographical settings, and sociocultural environments represented in the included studies, which may limit transferability and comparability of findings

• lack of standardized preparedness measures,

Response: We thank the reviewer for this valuable observation. Additional clarification was added to the Limitations section acknowledging the absence of standardized preparedness measures and the variability in assessment approaches across included studies, which limited comparability and quantitative synthesis.

• limited geographical representation,

Response: We thank the reviewer for this important observation. The Limitations section was revised to further emphasize the limited geographical representation of the included studies, with evidence concentrated in a relatively small number of countries and disaster settings, potentially limiting the broader applicability of findings.

• inability to perform quantitative synthesis.

Response: We thank the reviewer for this important methodological observation. The Limitations section was revised to explicitly acknowledge that substantial clinical, methodological, and contextual heterogeneity prevented quantitative synthesis and meta-analysis.

33. Comment: The limitation regarding indirect linkage between preparedness and measurable maternal outcomes is particularly important and should receive greater emphasis.

• substantial contextual heterogeneity,

Response: We thank the reviewer for this important observation. The Limitations section was revised to further emphasize the substantial contextual heterogeneity across disaster types, healthcare systems, geographical regions, and sociocultural environments represented in the included studies, which may limit comparability and transferability of findings.

• lack of standardized preparedness measures,

Response: We thank the reviewer for this valuable methodological observation. The Limitations section was revised to acknowledge the absence of standardized preparedness measures and the variability in preparedness assessment approaches across included studies, which limited direct comparability and quantitative synthesis.

• limited geographical representation,

Response: We thank the reviewer for this important observation. The Limitations section was revised to further emphasize the limited geographical representation of the included studies, with evidence concentrated in a relatively small number of countries and disaster settings, potentially limiting the broader applicability of findings.

• inability to perform quantitative synthesis.

Response: We thank the reviewer for this important methodological observation. The Limitations section was revised to explicitly acknowledge that substantial methodological, clinical, and contextual heterogeneity prevented quantitative synthesis and meta-analysis.

33.Comment: The limitation regarding indirect linkage between preparedness and measurable maternal outcomes is particularly important and should receive greater emphasis.

Response: We thank the reviewer for this important methodological observation. The Limitations section was revised to place greater emphasis on the indirect nature of the relationship between preparedness determinants and measurable maternal or neonatal outcomes across the included studies.

Conclusion

34. Comment: The conclusions are generally aligned with the review findings.
35. Comment: However:

• The wording should be slightly more cautious given the limited strength of evidence.

Response: We thank the reviewer for this important observation. The manuscript was further revised to adopt more cautious and context-sensitive wording throughout the Discussion, Policy Implications, and Conclusions sections in order to better reflect the limited and heterogeneous nature of the available evidence.

• The review supports important hypotheses and policy considerations but does not establish robust causal evidence regarding preparedness and maternal outcomes.

Response: We thank the reviewer for this thoughtful observation. The manuscript was revised to further clarify that the review supports important conceptual and policy implications regarding midwifery preparedness and continuity of maternal care; however, the predominantly qualitative and cross-sectional nature of the available evidence does not permit robust causal inference regarding preparedness determinants and measurable maternal outcomes.

36. Comment: The call for longitudinal and intervention-based studies is appropriate and well justified.

Response: We sincerely thank the reviewer for recognizing the importance and justification of recommending longitudinal and intervention-based research to strengthen the evidence base in this field.

References

37. Comment: References are generally appropriate, recent, and relevant to the topic.

Response: We sincerely thank the reviewer for recognizing the relevance and contemporaneity of the references included in the manuscript.

38. Comment: The inclusion of recent disaster preparedness and climate resilience literature strengthens the manuscript.

Response: We sincerely thank the reviewer for recognizing the relevance and contemporaneity of the references included in the manuscript.

39. Comment: However:

• Some references are grey literature or organizational reports, which should be balanced with additional peer-reviewed evidence where possible.

Response: We thank the reviewer for this valuable observation. While selected organizational reports and grey literature sources were included to capture current international guidance and policy frameworks relevant to disaster preparedness and maternal care resilience, additional emphasis was placed on peer-reviewed evidence throughout the revised manuscript wherever applicable.

• Several citations are used repeatedly to support broad claims despite limited empirical scope.

Response: We thank the reviewer for this important observation. The manuscript was revised to ensure that broad interpretive statements were expressed more cautiously and more closely aligned with the empirical scope of the cited studies. Citations were also reviewed to improve specificity and avoid overextension of findings from individual studies.

Overall, this manuscript addresses a highly relevant and underexplored topic with potential implications for maternal health resilience and disaster preparedness planning. The review demonstrates several methodological strengths, including protocol registration and adherence to PRISMA guidance. Nevertheless, important clarifications regarding methodology, conceptual framing, and interpretation of evidence are needed to improve the scientific rigor and transparency of the review.

Response: We sincerely thank the reviewer for the thoughtful and constructive evaluation of our manuscript. We appreciate the recognition of the topic's relevance and the review's methodological strengths, including protocol registration and adherence to PRISMA guidelines. In response to the reviewer’s comments, the manuscript was extensively revised to improve methodological transparency, conceptual clarity, and interpretation of the evidence. Specific revisions included clarifying the review question and conceptual framework, refining the narrative synthesis approach, expanding the discussion of methodological limitations and heterogeneity, moderating causal language, and adopting a more cautious interpretation of findings throughout the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you.

The manuscript has value, and the topic is interesting; however, some issues need to be addressed to bring it into consideration and boost the quality of the paper. Therefore, I recommend a major revision. Please follow my recommendation below:

1. In the conclusion part, the authors should be more cautious, and they should clearly mention that the evidence is based on only 9 heterogeneous studies, mostly qualitative/cross-sectional, and with a largely earthquake focus. It shouldn’t be a creation of the impression that a strong causal link has been established between preparedness and continuity of care.
2. Authors should clarify the actual link between preparedness and continuity of care in the discussion and conclusion sections.
3. The methods part should be improved in a way that

• In the search strategy, the authors mentioned that “considered grey literature sources when appropriate.” How literature was searched.
• Why meta-analysis wasn’t suitable.
• What exactly were the criteria used to decide on narrative synthesis

4. Authors must justify the inclusion of borderline more precisely.
5. In the limitation section, authors should bring more strength to the clarification of the findings, meaning not just in the form of a list but by wording the claims.

 

Author Response

Response to Reviewer 2

1.Comment: Cautious conclusion and mention of study heterogeneity.

Response: We agree with the reviewer that the evidence base is emergent. We have revised the Conclusion to explicitly state that our findings are based on 9 heterogeneous studies, primarily qualitative and cross-sectional, with a heavy focus on earthquake contexts. We have tempered our claims to ensure we describe "associations" rather than established "causality".

2. Comment: Clarify the actual link between preparedness and continuity. Response: We have added a dedicated subsection in the Discussion (Section 4.1) to synthesize this link. We now explicitly highlight how specific preparedness gaps—such as role ambiguity and lack of simulation-based training—directly manifest as disruptions in antenatal and intrapartum care during crises. Conversely, we highlight how continuity-of-care models serve as a structural form of preparedness that preserves infant outcomes.
3. Comment: Improve Methods (Grey literature, Meta-analysis, Narrative synthesis).

Response:

• Grey Literature: We have clarified that grey literature was searched via the WHO and International Confederation of Midwives (ICM) databases to capture policy-level preparedness frameworks.
• Meta-analysis/Narrative Synthesis: We added a statement in Section 2.8 justifying the narrative approach. Meta-analysis was precluded by the lack of comparable quantitative outcome measures and the high prevalence of qualitative data. Narrative synthesis was chosen to organize findings across multidimensional domains (individual, organizational, etc.) to capture the complexity of the workforce experience.

4. Comment: Justify inclusion of borderline studies.

Response: We have updated Section 2.2 (Eligibility Criteria) to clarify that studies with mixed populations were only included if midwifery-specific outcomes could be disaggregated. Studies involving pregnant women were included only if they specifically evaluated a "midwifery-led continuity-of-care model," as this represents a key organizational determinant of service resilience.

5. Comment: Limitations section strength. Response: We have rewritten the Limitations section to move beyond a list format. We now discuss how the lack of longitudinal designs and the geographic concentration in earthquake zones limit the immediate generalizability of the findings to different disaster types, such as wildfires or floods, and how the absence of direct neonatal outcome measures in most studies necessitates a cautious interpretation of "care continuity."

Reviewer 3 Report

Comments and Suggestions for Authors

Manuscript Revision 

1. Abstract and Introduction Alignment
   The objective stated in the introduction differs from the one in the abstract. Furthermore, the abstract mentions examining an "association," yet no such assessment was performed in the study.

• Abstract: "This review aimed to synthesize evidence on determinants of midwives disaster preparedness and examine their association with continuity of maternal care."
• Introduction: "This systematic review aimed to synthesize evidence on (a) the determinants of midwives disaster preparedness and response capacity and (b) the impact of natural disasters and climate-related emergencies on the continuity of maternal care."
• Recommendation: I suggest adopting the objective from the introduction, as it is clearer and better written.

2. Results Section
   The results section currently includes this assessment of association.

• Recommendation: Please rewrite this part to remove mentions of "association," as no association is measured in your study. (The text should instead read: "Preparedness was influenced by individual, professional, organizational, and psychosocial factors. Insufficient disaster-specific training, role ambiguity, and limited institutional preparedness were associated with reduced response capacity and disruptions across antenatal, intrapartum, and postnatal care.")

3. Formatting of Section 3.4
   In the results, specifically under section 3.4, there is only one subtopic (3.4.1).

• Recommendation: The layout would look cleaner if you removed the subtopic numbering. Keep the text exactly as it is, but delete the "3.4.1" tag.

4. Conclusion Section
   The current conclusions fail to mention the main findings for your first stated objective: (a) the determinants of midwives disaster preparedness and response capacity.

• Recommendation: I suggest revising the conclusions to start with these findings. First, cite the main findings for objective (a), and then proceed with the main findings for objective (b).

Author Response

Response to Reviewer 3

1. Comment: Alignment of objectives and use of the term "association." Response: We thank the reviewer for this insightful suggestion. We have revised the objective in the Abstract to match the clearer wording used in the Introduction. Additionally, we have removed the term "association" throughout the Abstract and Results sections to avoid the implication of statistical correlation, replacing it with more appropriate descriptive terms such as "linked to" or "reflected in."
2. Comment: Results Section wording. Response: We have updated the Results section in the Abstract as requested. The text now reads: "Insufficient disaster-specific training, role ambiguity, and limited institutional preparedness were linked to reduced response capacity and disruptions across antenatal, intrapartum, and postnatal care."
3. Comment: Formatting of Section 3.4. Response: We have removed the subtopic numbering "3.4.1" to improve the flow and cleanliness of the layout. The content regarding inclusion and professional equity remains integrated within Section 3.4.
4. Comment: Conclusion Section findings for Objective (a). Response: We have revised the Conclusion to explicitly address both objectives. The section now begins by summarizing the determinants of midwives' disaster preparedness (Objective A), followed by the impact of these factors on service continuity during disasters (Objective B). This provides a more balanced and comprehensive summary of the review’s findings.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

These comments match the type of methodological corrections I gave. Careful wording, avoiding causality, stronger methods, grey literature clarification, narrative synthesis justification, and limitations. The authors appear to have responded to all my comments; therefore, I accept the manuscript in the present form. However, the revised manuscript still contains many editing problems, repeated sentences, remnants of tracked changes, and some overly strong wording.