Postpartum-Specific Anxiety and Maternal–Infant Bonding: A Predictive Validity Study amongst Italian Women

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this paper. It addresses an important topic and can shed light on maternity care. However, the following issues may require further attention.

Title: Please revise the current title.

The title needs to be descriptive and indicative of the content. Are you studying the relationship between postpartum-specific anxiety and maternal-infant bonding?  Is it a cross-sectional study? Additionally, I would suggest that authors remove “speakers” from the title. If this study was conducted in Italy, you could say “…study in Italy” or “… study in Italian women”

Abstract: What is the major focus of your study: depression or anxiety? You began by discussing the detrimental effects of depression, which could potentially confuse readers. It's important to remain consistent with your primary focus.

Unfortunately, this manuscript did not include line numbers. Adding line numbers may make review and revision easier.

 

Introduction

Overall, the background information is clearly presented but can be further improved.

1.      The first sentence in the first paragraph requires references. Please add them. Additionally, it would be better to expand on the importance of mother-infant bonding further. In the current manuscript, you only addressed this in one sentence.

2.      Remove the extra comma after “accordingly” in the second paragraph. There should be a space before the citations [4,7].

3.      “Anxiety and depressive symptoms can affect the complex process of mother-infant boding.” Please add a reference to this statement. Additionally, it seems a bit self-conflicting here, as you mentioned later that little is known about maternal boding and anxiety in the postpartum period and ‘the lack of studies examining maternal bonding in women with anxiety’.

4.      What’s the incidence of anxiety disorders in Italy? Are there any statistics? Providing more contextual information would add value.

5.      “control subjects”? were you referring to newborns of women in the control group?

6.      “…social engagement compared to healthy newborns…” Are babies of mothers with anxiety disorders not considered healthy? What did you mean by “good effect”?

7.      “DSM-IV” write it in full when it first appears

8.      What did you mean by “a separate methodology”

9.      “Further, given the high incidence of ….” Again, the incidence was not mentioned.

10. The significance of the current study should be further stressed. For example, how could the findings from the current study benefit clinical practice?

 

Methods

1.      Did you follow any reporting guidelines? For example, The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines

2.      Available at https://www.equator-network.org/reporting-guidelines/strobe/

3.      Please provide details on sample size calculation in the Participants section.

4.      It would be better to revise the subtitle ‘Procedure’ to ‘Data Collection’.

5.      Regarding statistical analysis: Why was p <0.1 chosen? Were the assumptions for hierarchical regression satisfied?

6.      Multiple confounders might be present. For example, social support, pregnancy or childbirth complications. However, you only included age, general anxiety and depression as potential confounders.

7.      If it is an online survey, how were women with a mental illness and/or those who had experienced a traumatic event in the family within the last six months excluded? Did the women self-screen?

Discussion

1.      Pay attention to the tense. For example, ‘the results suggest high levels of specific postpartum anxiety are associated with greater difficulties in developing maternal bonding with children’. Past tense should be used here.

‘…were associated…’

2.      The implications to clinical practice should be expanded further.

Conclusion

The conclusion section should be more concise and refrain from repeating background information.

 

Author Response

Dear reviewer,

We have revised the manuscript titled "Postpartum-specific anxiety and maternal-infant bonding: A predictive validity study amongst Italian speakers” which was submitted to Pediatric Reports.

We thank you for dedicating your time to evaluate our article. Your insightful suggestions have been invaluable to us, and we are grateful for your input. In response to your comments, we have endeavored to address each point highlighted.

You can find our detailed responses below.

 

REVIEWER 1

Comment #1: Thank you for the opportunity to review this paper. It addresses an important topic and can shed light on maternity care. However, the following issues may require further attention.

The title needs to be descriptive and indicative of the content. Are you studying the relationship between postpartum-specific anxiety and maternal-infant bonding?  Is it a cross-sectional study? Additionally, I would suggest that authors remove “speakers” from the title. If this study was conducted in Italy, you could say “…study in Italy” or “… study in Italian women”

Reply #1: we thank the reviewer for the positive comment, and we have followed the suggestions on modifying the title.

Comment #2: What is the major focus of your study: depression or anxiety? You began by discussing the detrimental effects of depression, which could potentially confuse readers. It's important to remain consistent with your primary focus. Unfortunately, this manuscript did not include line numbers. Adding line numbers may make review and revision easier.

Reply #2: We have followed the reviewer’s suggestion and amended in the text

Comment #3: Overall, the background information is clearly presented but can be further improved.

1. The first sentence in the first paragraph requires references. Please add them. Additionally, it would be better to expand on the importance of mother-infant bonding further. In the current manuscript, you only addressed this in one sentence.
2. Remove the extra comma after “accordingly” in the second paragraph. There should be a space before the citations [4,7].
3. “Anxiety and depressive symptoms can affect the complex process of mother-infant boding.” Please add a reference to this statement. Additionally, it seems a bit self-conflicting here, as you mentioned later that little is known about maternal boding and anxiety in the postpartum period and ‘the lack of studies examining maternal bonding in women with anxiety’.
4. What’s the incidence of anxiety disorders in Italy? Are there any statistics? Providing more contextual information would add value.
5. “control subjects”? were you referring to newborns of women in the control group?
6. “…social engagement compared to healthy newborns…” Are babies of mothers with anxiety disorders not considered healthy? What did you mean by “good effect”?
7. “DSM-IV” write it in full when it first appears
8. What did you mean by “a separate methodology”
9. “Further, given the high incidence of ….” Again, the incidence was not mentioned.
10. The significance of the current study should be further stressed. For example, how could the findings from the current study benefit clinical practice?

Reply #3: We thanks the reviewer and we have followed his suggestions

Comment #4: Methods

1. Did you follow any reporting guidelines? For example, The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines available at https://www.equator-network.org/reporting-guidelines/strobe/
2. Please provide details on sample size calculation in the Participants section.
3. It would be better to revise the subtitle ‘Procedure’ to ‘Data Collection’.
4. Regarding statistical analysis: Why was p <0.1 chosen? Were the assumptions for hierarchical regression satisfied?
5. Multiple confounders might be present. For example, social support, pregnancy or childbirth complications. However, you only included age, general anxiety and depression as potential confounders.
6. If it is an online survey, how were women with a mental illness and/or those who had experienced a traumatic event in the family within the last six months excluded? Did the women self-screen?

Reply #4:

We thank the reviewer for the comments.

1. We have not followed these guidelines specifically, but have followed a study by our colleagues from the UK that was previously published and conducted with the same aim (Fallon et al. 2019).
2. The paper has followed the previous validation of the instrument from Ionio et al. 2023. Notably an a priori power calculation based upon a small effect for the full model (f² =.05), and the possibility of  up 8 predictors (note- predictors beyond those specifically hypothesized were added based on testing associations,  see 4 below, so the estimate is highly conservative), at 80% power with an alpha of .05, suggests that a minimum of 307 participants would be required.
3. We have modified the study
4. In the statistical analysis, we followed the study by Fallon et al. 2019, our UK colleagues, that investigated the same topic. p<.1 was selected in order to allow for the inclusion of that while not having a strong association may still be associated with some variance in the outcome in the multiple regression model. Linear regression assumptions; normality of residuals, no influential cases, homoscedasticity and no multicollinearity were met.
5. the others were (a) not measured (b) not associated with outcomes
6. There was a screening for self-assessment of the exclusion criteria

Comment #5:

1. Pay attention to the tense. For example, ‘the results suggest high levels of specific postpartum anxiety are associated with greater difficulties in developing maternal bonding with children’. Past tense should be used here.

‘…were associated…’

2. The implications to clinical practice should be expanded further.

Reply #5: We have followed the reviewer’s suggestions

Comment #6: Conclusion

The conclusion section should be more concise and refrain from repeating background information

Reply #6:

We have followed the reviewer’s suggestions

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript focus on the central idea of the work submitted. The analysis of the data and interpretation of the results are good. The author has taken care of ethical considerations while developing the manuscript. The writing style and language are good. The references are judiciously used in the manuscript. The object of study is postpartum depression, which has a negative effect on the mother-child relationship, and this study investigates how anxiety affects the mother-child bond after childbirth by comparing the Italian version of the Postpartum Specific Anxiety Scale (PSAS-IT) with generalized measures of anxiety. Their results emphasized that anxiety as measured by the PSAS is a strong predictor of bonding, even when considering maternal age, general anxiety and depression, which explain 3% of the variance in scores (β = .26, p < 0.001). This underscores the importance of early identification and intervention of postpartum anxiety to promote bonding between mother and child. And publishing this manuscript is important precisely because of its contribution. There are no negative comments or need for changes to be made.

Author Response

Dear reviewer,

We have revised the manuscript titled "Postpartum-specific anxiety and maternal-infant bonding: A predictive validity study amongst Italian speakers” which was submitted to Pediatric Reports.

We thank you for dedicating your time to evaluate our article. Your insightful suggestions have been invaluable to us, and we are grateful for your input. In response to your comments, we have endeavored to address each point highlighted.

You can find our detailed responses below.

 

Comment: The manuscript focus on the central idea of the work submitted. The analysis of the data and interpretation of the results are good. The author has taken care of ethical considerations while developing the manuscript. The writing style and language are good. The references are judiciously used in the manuscript. The object of study is postpartum depression, which has a negative effect on the mother-child relationship, and this study investigates how anxiety affects the mother-child bond after childbirth by comparing the Italian version of the Postpartum Specific Anxiety Scale (PSAS-IT) with generalized measures of anxiety. Their results emphasized that anxiety as measured by the PSAS is a strong predictor of bonding, even when considering maternal age, general anxiety and depression, which explain 3% of the variance in scores (β = .26, p < 0.001). This underscores the importance of early identification and intervention of postpartum anxiety to promote bonding between mother and child. And publishing this manuscript is important precisely because of its contribution. There are no negative comments or need for changes to be made.

Reply: We thanks the reviewer for the positive comment.

Reviewer 3 Report

Comments and Suggestions for Authors

This paper investigate how anxiety affects mother-infant bonding after childbirth, comparing the Italian version of the Postpartum Specific Anxiety Scale (PSAS-IT) with generalised measures of anxiety. I think this is a timely and current topic, and also trust this study is important to the scientific community.  Although a very well-written study, I have some points I think can be better explained.

1. We can know from the article that PSAS stands for Postpartum Specific Anxiety Scale, the Italian version of this scale has been tested for reliability and validity and is the only instrument to measure postpartum-specific anxiety. But PSAS still stands for scale, not for postpartum-specific anxiety. However, the authors use PSAS in their expressions, for example, the title of 3.2 is PSAS and mother-infant bonding, and in the discussion section it is PSAS that is used for the acronym. PSAS is an abbreviation for the name of a tool, can a tool be juxtaposed with mother-infant bonding? If the comparison is between postpartum-specific anxiety and mother-infant bonding that should be the same level.

2. As stated in the previous question, this study is both like a study of the postpartum-specific anxiety and maternal-infant bonding relationship and a validation of the Postpartum Specific Anxiety Scale instrument in Italy. For example, it is confusing to read that the Postpartum-specific anxiety and maternal-infant bonding relationship is presented in the preface section, but the PSAS and maternal-infant bonding are presented in the results and discussion sections. In addition, PSAS, the key research tool in this study, was only briefly described in the Methods section. It is recommended that a description of this tool be added to the introduction. Because as it stands, the validity of the use of this tool in Italy is also one of the research components of this study.

3. One of the important findings of this study is that anxiety measured with the PSAS is a strong predictor of bonding. But there is not enough discussiosection and it is recommended to add it.

4. The study found that the PSAS does not appear to account for the variance in scores associated with mothers' beliefs about caring for their children. But there is no explanation or speculation about this anomalous result. Although the authors state that there are limited studies of younger children, is there any research that suggests that studies of younger children may cause results that are inconsistent with unusual studies? A lack of explanation of this anomalous data could lead readers to question the scientific validity of the study as a whole.

Comments on the Quality of English Language

Acceptable

Author Response

Dear reviewer,

We have revised the manuscript titled "Postpartum-specific anxiety and maternal-infant bonding: A predictive validity study amongst Italian speakers” which was submitted to Pediatric Reports.

We thank you for dedicating your time to evaluate our article. Your insightful suggestions have been invaluable to us, and we are grateful for your input. In response to your comments, we have endeavored to address each point highlighted.

You can find our detailed responses below.

Comment #1: This paper investigate how anxiety affects mother-infant bonding after childbirth, comparing the Italian version of the Postpartum Specific Anxiety Scale (PSAS-IT) with generalised measures of anxiety. I think this is a timely and current topic, and also trust this study is important to the scientific community.  Although a very well-written study, I have some points I think can be better explained.

1. We can know from the article that PSAS stands for Postpartum Specific Anxiety Scale, the Italian version of this scale has been tested for reliability and validity and is the only instrument to measure postpartum-specific anxiety. But PSAS still stands for scale, not for postpartum-specific anxiety. However, the authors use PSAS in their expressions, for example, the title of 3.2 is PSAS and mother-infant bonding, and in the discussion section it is PSAS that is used for the acronym. PSAS is an abbreviation for the name of a tool, can a tool be juxtaposed with mother-infant bonding? If the comparison is between postpartum-specific anxiety and mother-infant bonding that should be the same level.

Reply #1: We thank the reviewer for the positive comments and we have followed his suggestions

Comment #2: 2. As stated in the previous question, this study is both like a study of the postpartum-specific anxiety and maternal-infant bonding relationship and a validation of the Postpartum Specific Anxiety Scale instrument in Italy. For example, it is confusing to read that the Postpartum-specific anxiety and maternal-infant bonding relationship is presented in the preface section, but the PSAS and maternal-infant bonding are presented in the results and discussion sections. In addition, PSAS, the key research tool in this study, was only briefly described in the Methods section. It is recommended that a description of this tool be added to the introduction. Because as it stands, the validity of the use of this tool in Italy is also one of the research components of this study.

Reply #2: We have followed the reviewer’s suggestion and add a section in the introduction.

Comment #3: 3. One of the important findings of this study is that anxiety measured with the PSAS is a strong predictor of bonding. But there is not enough discussion section and it is recommended to add it.

Reply #3: We have followed the reviewer’s suggestion and add a section in the discussion.

Comment #4: The study found that the PSAS does not appear to account for the variance in scores associated with mothers' beliefs about caring for their children. But there is no explanation or speculation about this anomalous result. Although the authors state that there are limited studies of younger children, is there any research that suggests that studies of younger children may cause results that are inconsistent with unusual studies? A lack of explanation of this anomalous data could lead readers to question the scientific validity of the study as a whole.

Reply #4: We thank the reviewer for his suggestion. Unfortunately, we found no further studies in the literature, but we implemented the discussion by adding a possible explanation of our data in light of a recent study cited. We have, in addition, emphasized the need for future research to corroborate or refute our results.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you. I appreciate the time and careful attention you have given to consider my feedback. This paper is significantly improved. However, some minor issues still require further attention.

 

Academic writing needs to be rigorous. It is recommended to review the entire manuscript thoroughly. The following are some examples:

On page 2, “In indeed, in August…” The ideas in this sentence are clear, but please consider rewriting it for better clarity.

“Despite increasing scientific evidence in …early detection (20)…” What does (20) mean here?

 

It seems that there might be some misunderstanding regarding the use of reporting guidelines (e.g., STROBE guidelines). Reporting guidelines do not guide the methodology or study design. Instead, these guidelines help researchers present their work clearly and comprehensively and facilitate peer review and publication.

 

The sample size considerations should be mentioned in the manuscript as well.

 

Author Response

Dear Reviewer,

We have revised the manuscript titled "Postpartum-specific anxiety and maternal-infant bonding: A predictive validity study amongst Italian speakers” which was submitted to Pediatric Reports.

We appreciate for dedicating your time to re-evaluate our article. Your insightful suggestions have been invaluable to us, and we are grateful for your input. In response to your comments, we have endeavored to address each point highlighted.

You can find our detailed responses below.

 

 

Comment #1: Thank you. I appreciate the time and careful attention you have given to consider my feedback. This paper is significantly improved. However, some minor issues still require further attention.

Reply #1: we thank the reviewer for the positive comment.

Comment #2: Academic writing needs to be rigorous. It is recommended to review the entire manuscript thoroughly. The following are some examples:

On page 2, “In indeed, in August…” The ideas in this sentence are clear, but please consider rewriting it for better clarity.

“Despite increasing scientific evidence in …early detection (20)…” What does (20) mean here?

 

Reply #2: we carefully revised the manuscript as suggested.

 

Comment #3: It seems that there might be some misunderstanding regarding the use of reporting guidelines (e.g., STROBE guidelines). Reporting guidelines do not guide the methodology or study design. Instead, these guidelines help researchers present their work clearly and comprehensively and facilitate peer review and publication.

Reply #3: Although not specified in the text, the manuscript was written adhering to the principles of the STROBE guidelines to ensure our work is presented clearly and comprehensively and to facilitate peer review and publication.

 

Comment #4: The sample size considerations should be mentioned in the manuscript as well.

 

Reply #4: we’ve added sample size considerations as suggested.

Reviewer 3 Report

Comments and Suggestions for Authors

Comments addressed.

Comments on the Quality of English Language

Moderate level

Author Response

Dear Reviewer,

We have revised the manuscript titled "Postpartum-specific anxiety and maternal-infant bonding: A predictive validity study amongst Italian speakers” which was submitted to Pediatric Reports.

We appreciate for dedicating your time to re-evaluate our article. Your insightful suggestions have been invaluable to us, and we are grateful for your input. In response to your comments, we have endeavored to address each point highlighted.

You can find our detailed responses below.

Comment #1: Comments on the Quality of English Language: Moderate level

Reply #1: we carefully revised the manuscript.