Influence of Physical Activity on Self-Esteem and Anxiety during Pregnancy: A Longitudinal Prospective Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

 

The authors present a prospective study regarding the effect of physical activity on self-esteem and anxiety during pregnancy.

 

My comments for the article are:

-              Avoid single sentences as paragraphs.

-              Please clarify the meaning of the sentence in lines 94 – 95

-              The authors should include in the results section the total number of the recruited women, the number of the excluded and the total number of the included women.

-              The authors should also in the materials and methods section the language of the three questionaries and comment if they were standardized for the Portuguese language.

-              The results should be reported in more clear and concise manner.

Comments on the Quality of English Language

Minor editing of English language required

Author Response

Reviewer 1

Avoid single sentences as paragraphs.

Please clarify the meaning of the sentence in lines 94 – 95

The authors should include in the results section the total number of the recruited women, the number of the excluded and the total number of the included women.

The authors should also in the materials and methods section the language of the three questionaries and comment if they were standardized for the Portuguese language.

The results should be reported in more clear and concise manner.

 

Thank you very much for your review. We appreciate your feedback and have made the necessary changes throughout the text.

______________________________________________________________________

Reviewer 2

The study features a robust design that allows observation of changes over time, providing valuable information about the dynamic nature of self-esteem, anxiety and AF during pregnancy. The relatively large sample size (n=152) enhances the generalizability of the results. The study complies with ethical guidelines, and ethics committee approval and informed consent were obtained from participants. The use of validated questionnaires to assess self-esteem, anxiety and AF increases the reliability of the results. The study offers practical recommendations for health care professionals, supporting the psychological well-being of pregnant women through tailored interventions.

 Thank you very much for your comments

Please state the research hypotheses after the objectives discussed.

 We add the sentences “We hypothesize that there is a positive correlation between PA levels and self-esteem among healthy pregnant women across the three GTs. Specifically, higher levels of physical activity are associated with higher self-esteem”

The study methodology should be located after the study introduction

Thank you for your comment. We have placed the methods section after the results section in accordance with the journal's guidelines

Clarity of statistical reporting needs improvement. The mention of "satisfactory internal consistency with α = 0.75" is unclear and it should be clarified to which measure this refers. 

This value referred to the questionnaire; however, we understand that it should be removed from the text as it was causing confusion.

It would also be useful to provide more details about the recruitment process, including the number of women invited, response rates, and reasons for non-participation or exclusions. 

We add the sentence “Two hundred forty-eight women were initially invited to participate in the study. However, only 152 completed the questionnaires throughout the different gestational trimesters, resulting in a follow-up loss of 38.7% (96 participants). Losses during the follow-up were primarily due to incomplete questionnaire responses”.

 

Clarifying the data collection procedures, especially how the questionnaires were administered, will be helpful. 

We add the sentence “After the medical consultation, pregnant women followed at hospital, in the first GT (< 12 weeks of gestation), were referred by the nurse to an office. The principal investigator checked the eligibility and exclusion criteria and gave general information about the study. The principal investigator scheduled the follow-up evaluation”.

Exclusion criteria need further clarification, especially "cognitive inability." 

Thank you. We change the sentence “cognitive impairment that precludes comprehension of the questionnaire to answer a questionnaire”

Conclusions should be written in impersonal form, please add practical implications.

Thank you. We made the changes in the manuscript.

______________________________________________________________________

Reviewer 3

The study's design, which includes its longitudinal prospective nature and the sample size of 248 pregnant Portuguese women, is briefly described in the abstract. It is appropriate and explicitly specified that self-reported surveys and particular scales be utilized (Pregnancy Physical Activity Questionnaire, Zung Anxiety Scale, and Rosenberg's Self-Esteem Scale). The methodology section, however, would benefit from a summary of the statistical techniques applied to the data analysis to give a more thorough explanation of how the outcomes were arrived at.

Thank you very much for your comments

• The abstract could improve by specifying the magnitude of changes (e.g., the percentage decrease in physical activity) and including confidence intervals to provide a clearer picture of the data's reliability.
• The relevant keywords cover a broad spectrum related to the study's focus. However, including terms like "gestational trimesters," "prospective study," and "mental health" might enhance searchability and relevance.

Thank you, we accept the suggestion and add in keywords.

1. Introduction:

• The introduction gives a general overview of the situation by emphasizing how stressful and difficult pregnancy may be for women, which raises their risk of anxiety and depression. It would, however, be beneficial to concentrate more on the distinct physiological and psychological changes that take place during pregnancy and how these, in turn, connect to anxiety and self-esteem. A quick rundown of hormone fluctuations, issues with body image, and the significance of physical pain throughout pregnancy may be included in this.
• Although the introduction cites a number of studies, a more thorough discussion of the body of research on the connection between physical exercise and mental health during pregnancy would be beneficial. The authors ought to provide a more thorough analysis of earlier research, especially that which points out contradictions or gaps in our knowledge. This would give a clearer explanation and more convincing justification for the current study's necessity.
• Near the conclusion of the introduction, the study's objectives are stated. Nonetheless, a clearer explanation of the research questions or hypotheses would improve the section. Elucidating them would facilitate readers' comprehension of the precise goals and anticipated results of the study from the beginning.

 

• The introduction could be improved by emphasizing the practical implications of the research. While it mentions the importance of understanding the relationship between physical activity, self-esteem, and anxiety, it should also discuss how these findings could influence clinical practice, public health policies, or interventions to improve maternal mental health.
• The flow of the introduction could be improved to enhance readability. For example, the paragraph discussing the benefits of physical activity (lines 67-77) seems slightly disjointed from the preceding discussion on mental health risks. A smoother transition between these topics, perhaps by discussing the potential of PA as an intervention, would create a more cohesive narrative.
• The mention of screening for prenatal mental health (lines 57-60) is relevant but could be expanded. Discussing the effectiveness of different screening tools and interventions and barriers to their implementation would provide a more comprehensive background for the study.

 

2. Results:

The section begins with an internal consistency measure (α = 0.75) without context. It would be beneficial to specify which scale or measurement this refers to.

This value referred to the questionnaire; however, we understand that it should be removed from the text as it was causing confusion.

The flow of the section could be improved by structuring it more logically, starting with a brief overview of the key findings before delving into specific results.

The use of the Kolmogorov-Smirnov test to assess normality is appropriate, but the results are presented in a manner that could be clearer. For example, stating "All variables did not present normality, except for pre-pregnancy body mass and height" can be confusing. It would be better to state which specific variables failed the normality test and their implications.

We change the sentence “Physical activity, self-esteem, anxiety, body mass and height variables did not present normality and non parametric tests were used”

• The results mention significant differences in PA levels and self-esteem across GTs but do not provide detailed statistical values for these comparisons. Including exact p-values, confidence intervals, and effect sizes for each comparison would enhance the section's robustness.

Table 1 provides baseline characteristics but lacks a clear connection to the narrative. It would be helpful to reference the table more explicitly in the text and explain its relevance to the study's findings.

Thank you, we change in the main text.

Figures 1 and 2 are mentioned but not included in the provided text. The text should clearly describe these figures, indicating what each figure illustrates and how it supports the findings. Ensure that all figures are labeled accurately and referenced appropriately.

Thank you, we change in the main text.

 

• The section states that "Anxiety scores were not modified throughout the three GTs" and that "self-esteem was significantly reduced in the 2nd and 3rd GT." While these findings are clear, the discussion around these results is minimal. Providing more context or hypotheses for these findings would be valuable. For instance, discussing potential reasons for the stability of anxiety scores despite changes in physical activity and self-esteem could provide deeper insights.

 

• The mention of ES is good practice, but the interpretation of these sizes could be expanded. For instance, stating "Only self-esteem, from the 1st to the 2nd GT, showed a large ES of 1.7" should be followed by a brief explanation of what this large effect size implies in the study context.

We add “Only self-esteem, from the 1st to the 2nd GT, showed a large ES of 1.7, indicating that this result has clinical significance.”

3. Discussion:

thank you very much for all your comments. we have revised the document and changed all the points suggested in the text

• The discussion mentions hormonal changes as a factor but lacks depth in explaining how specific hormonal shifts during pregnancy may influence anxiety and self-esteem. A more detailed analysis of hormonal mechanisms could provide a richer understanding.
• While physical discomfort is noted, it would be beneficial to delve into specific types of discomfort (e.g., musculoskeletal pain, fatigue) and their direct impact on PA and mental health.

Thank you. We change in the main text

•  
• While the need for interventions is highlighted, more specific recommendations on the nature and timing of these interventions would be beneficial. For instance, what types of PA are most effective in different trimesters? How can healthcare providers tailor interventions based on individual patient needs and preferences?

Thank you for your comments. We add the information in the text.

The authors acknowledge several limitations, including the reliance on self-reported data and the specific regional focus of the study. It would be helpful to discuss how future studies could address these limitations. For example, using objective PA measures (e.g., wearable devices) or expanding the study to diverse populations could enhance the robustness of future research.

Thank you for your comments. We add the information in the text.

4. Materials and Methods:

The study's longitudinal prospective design is appropriate for investigating changes over time, crucial in understanding the dynamic nature of self-esteem, anxiety, and PA levels throughout pregnancy. The inclusion and exclusion criteria are clearly defined and justified, ensuring a homogeneous sample that minimizes confounding variables. 

Thank you for your comments.

The detailed procedure section outlines the evaluation stages and methods for ensuring participant follow-up. This thorough description enhances the reproducibility of the study. Using a unique identification code for each participant is a commendable practice that ensures data integrity and accurate tracking. However, the section could benefit from a more explicit explanation of the measures taken to mitigate potential biases, such as how the researchers addressed possible variations in health professional assessments or the impact of home visits on participant responses.

Thank you. We add the information throughout the text

 

The choice of questionnaires (Rosenberg's Self-Esteem Scale, Zung Self-rating Anxiety Scale, and Pregnancy Physical Activity Questionnaire) is appropriate and relevant to the study's objectives. Each tool's reliability and validity are well-documented, and their adaptation to the Portuguese population is a critical strength. However, the section could be improved by providing more detail on the psychometric properties of these adapted versions, including any reliability and validity tests conducted specifically for the study sample.

We add the information throughout the text

Reviewer 2 Report

Comments and Suggestions for Authors

The study features a robust design that allows observation of changes over time, providing valuable information about the dynamic nature of self-esteem, anxiety and AF during pregnancy. The relatively large sample size (n=152) enhances the generalizability of the results. The study complies with ethical guidelines, and ethics committee approval and informed consent were obtained from participants. The use of validated questionnaires to assess self-esteem, anxiety and AF increases the reliability of the results. The study offers practical recommendations for health care professionals, supporting the psychological well-being of pregnant women through tailored interventions.

 

Please state the research hypotheses after the objectives discussed.

 

The study methodology should be located after the study introduction

Clarity of statistical reporting needs improvement. The mention of "satisfactory internal consistency with α = 0.75" is unclear and it should be clarified to which measure this refers. 

It would also be useful to provide more details about the recruitment process, including the number of women invited, response rates, and reasons for non-participation or exclusions. 

Clarifying the data collection procedures, especially how the questionnaires were administered, will be helpful. 

Exclusion criteria need further clarification, especially "cognitive inability." 

Conclusions should be written in impersonal form, please add practical implications.

Author Response

The study features a robust design that allows observation of changes over time, providing valuable information about the dynamic nature of self-esteem, anxiety and AF during pregnancy. The relatively large sample size (n=152) enhances the generalizability of the results. The study complies with ethical guidelines, and ethics committee approval and informed consent were obtained from participants. The use of validated questionnaires to assess self-esteem, anxiety and AF increases the reliability of the results. The study offers practical recommendations for health care professionals, supporting the psychological well-being of pregnant women through tailored interventions.

 Thank you very much for your comments

Please state the research hypotheses after the objectives discussed.

 We add the sentences “We hypothesize that there is a positive correlation between PA levels and self-esteem among healthy pregnant women across the three GTs. Specifically, higher levels of physical activity are associated with higher self-esteem”

The study methodology should be located after the study introduction

Thank you for your comment. We have placed the methods section after the results section in accordance with the journal's guidelines

Clarity of statistical reporting needs improvement. The mention of "satisfactory internal consistency with α = 0.75" is unclear and it should be clarified to which measure this refers. 

This value referred to the questionnaire; however, we understand that it should be removed from the text as it was causing confusion.

It would also be useful to provide more details about the recruitment process, including the number of women invited, response rates, and reasons for non-participation or exclusions. 

We add the sentence “Two hundred forty-eight women were initially invited to participate in the study. However, only 152 completed the questionnaires throughout the different gestational trimesters, resulting in a follow-up loss of 38.7% (96 participants). Losses during the follow-up were primarily due to incomplete questionnaire responses”.

 

Clarifying the data collection procedures, especially how the questionnaires were administered, will be helpful. 

We add the sentence “After the medical consultation, pregnant women followed at hospital, in the first GT (< 12 weeks of gestation), were referred by the nurse to an office. The principal investigator checked the eligibility and exclusion criteria and gave general information about the study. The principal investigator scheduled the follow-up evaluation”.

Exclusion criteria need further clarification, especially "cognitive inability." 

Thank you. We change the sentence “cognitive impairment that precludes comprehension of the questionnaire to answer a questionnaire”

Conclusions should be written in impersonal form, please add practical implications.

Thank you. We made the changes in the manuscript.

Reviewer 3 Report

Comments and Suggestions for Authors

Abstract:

·         The study's design, which includes its longitudinal prospective nature and the sample size of 248 pregnant Portuguese women, is briefly described in the abstract. It is appropriate and explicitly specified that self-reported surveys and particular scales be utilized (Pregnancy Physical Activity Questionnaire, Zung Anxiety Scale, and Rosenberg's Self-Esteem Scale). The methodology section, however, would benefit from a summary of the statistical techniques applied to the data analysis to give a more thorough explanation of how the outcomes were arrived at.

·         The abstract could improve by specifying the magnitude of changes (e.g., the percentage decrease in physical activity) and including confidence intervals to provide a clearer picture of the data's reliability.

·         The relevant keywords cover a broad spectrum related to the study's focus. However, including terms like "gestational trimesters," "prospective study," and "mental health" might enhance searchability and relevance.

1. Introduction:

·         The introduction gives a general overview of the situation by emphasizing how stressful and difficult pregnancy may be for women, which raises their risk of anxiety and depression. It would, however, be beneficial to concentrate more on the distinct physiological and psychological changes that take place during pregnancy and how these, in turn, connect to anxiety and self-esteem. A quick rundown of hormone fluctuations, issues with body image, and the significance of physical pain throughout pregnancy may be included in this.

·         Although the introduction cites a number of studies, a more thorough discussion of the body of research on the connection between physical exercise and mental health during pregnancy would be beneficial. The authors ought to provide a more thorough analysis of earlier research, especially that which points out contradictions or gaps in our knowledge. This would give a clearer explanation and more convincing justification for the current study's necessity.

·         Near the conclusion of the introduction, the study's objectives are stated. Nonetheless, a clearer explanation of the research questions or hypotheses would improve the section. Elucidating them would facilitate readers' comprehension of the precise goals and anticipated results of the study from the beginning.

·         The introduction could be improved by emphasizing the practical implications of the research. While it mentions the importance of understanding the relationship between physical activity, self-esteem, and anxiety, it should also discuss how these findings could influence clinical practice, public health policies, or interventions to improve maternal mental health.

·         The flow of the introduction could be improved to enhance readability. For example, the paragraph discussing the benefits of physical activity (lines 67-77) seems slightly disjointed from the preceding discussion on mental health risks. A smoother transition between these topics, perhaps by discussing the potential of PA as an intervention, would create a more cohesive narrative.

·         The mention of screening for prenatal mental health (lines 57-60) is relevant but could be expanded. Discussing the effectiveness of different screening tools and interventions and barriers to their implementation would provide a more comprehensive background for the study.

2. Results:

·         The section begins with an internal consistency measure (α = 0.75) without context. It would be beneficial to specify which scale or measurement this refers to.

·         The flow of the section could be improved by structuring it more logically, starting with a brief overview of the key findings before delving into specific results.

·         The use of the Kolmogorov-Smirnov test to assess normality is appropriate, but the results are presented in a manner that could be clearer. For example, stating "All variables did not present normality, except for pre-pregnancy body mass and height" can be confusing. It would be better to state which specific variables failed the normality test and their implications.

·         The results mention significant differences in PA levels and self-esteem across GTs but do not provide detailed statistical values for these comparisons. Including exact p-values, confidence intervals, and effect sizes for each comparison would enhance the section's robustness.

·         Table 1 provides baseline characteristics but lacks a clear connection to the narrative. It would be helpful to reference the table more explicitly in the text and explain its relevance to the study's findings.

·         Figures 1 and 2 are mentioned but not included in the provided text. The text should clearly describe these figures, indicating what each figure illustrates and how it supports the findings. Ensure that all figures are labeled accurately and referenced appropriately.

·         The section states that "Anxiety scores were not modified throughout the three GTs" and that "self-esteem was significantly reduced in the 2nd and 3rd GT." While these findings are clear, the discussion around these results is minimal. Providing more context or hypotheses for these findings would be valuable. For instance, discussing potential reasons for the stability of anxiety scores despite changes in physical activity and self-esteem could provide deeper insights.

·         The mention of ES is good practice, but the interpretation of these sizes could be expanded. For instance, stating "Only self-esteem, from the 1st to the 2nd GT, showed a large ES of 1.7" should be followed by a brief explanation of what this large effect size implies in the study context.

3. Discussion:

·         The discussion mentions hormonal changes as a factor but lacks depth in explaining how specific hormonal shifts during pregnancy may influence anxiety and self-esteem. A more detailed analysis of hormonal mechanisms could provide a richer understanding.

·         While physical discomfort is noted, it would be beneficial to delve into specific types of discomfort (e.g., musculoskeletal pain, fatigue) and their direct impact on PA and mental health.

·         The discussion notes that anxiety scores did not change significantly across trimesters, yet anxiety is still discussed as a relevant factor. Clarifying this apparent contradiction would enhance coherence. If anxiety did not change, why is it still considered a significant factor? More precise language or additional analysis might be necessary.

·         The discussion rightly points out that sedentary behavior remains constant while PA decreases. However, a deeper comparison with studies focusing on sedentary behavior during pregnancy could strengthen this argument. How does this constancy of sedentary behavior compare to other populations or similar studies?

·         While the need for interventions is highlighted, more specific recommendations on the nature and timing of these interventions would be beneficial. For instance, what types of PA are most effective in different trimesters? How can healthcare providers tailor interventions based on individual patient needs and preferences?

·         The authors acknowledge several limitations, including the reliance on self-reported data and the specific regional focus of the study. It would be helpful to discuss how future studies could address these limitations. For example, using objective PA measures (e.g., wearable devices) or expanding the study to diverse populations could enhance the robustness of future research.

·         The discussion could benefit from a deeper exploration of the long-term implications of reduced PA during pregnancy. How might these findings affect postpartum recovery and long-term maternal health?

4. Materials and Methods:

·         The study's longitudinal prospective design is appropriate for investigating changes over time, crucial in understanding the dynamic nature of self-esteem, anxiety, and PA levels throughout pregnancy. The inclusion and exclusion criteria are clearly defined and justified, ensuring a homogeneous sample that minimizes confounding variables. However, the sample size calculation could be expanded to include more details on the statistical power and ES considerations, providing a stronger justification for the chosen sample size.

·         The detailed procedure section outlines the evaluation stages and methods for ensuring participant follow-up. This thorough description enhances the reproducibility of the study. Using a unique identification code for each participant is a commendable practice that ensures data integrity and accurate tracking. However, the section could benefit from a more explicit explanation of the measures taken to mitigate potential biases, such as how the researchers addressed possible variations in health professional assessments or the impact of home visits on participant responses.

·         The choice of questionnaires (Rosenberg's Self-Esteem Scale, Zung Self-rating Anxiety Scale, and Pregnancy Physical Activity Questionnaire) is appropriate and relevant to the study's objectives. Each tool's reliability and validity are well-documented, and their adaptation to the Portuguese population is a critical strength. However, the section could be improved by providing more detail on the psychometric properties of these adapted versions, including any reliability and validity tests conducted specifically for the study sample.

Comments on the Quality of English Language

The language is generally clear and understandable, though occasional grammatical issues and awkward phrasing could benefit from some refinement to enhance readability and flow.

Author Response

The study's design, which includes its longitudinal prospective nature and the sample size of 248 pregnant Portuguese women, is briefly described in the abstract. It is appropriate and explicitly specified that self-reported surveys and particular scales be utilized (Pregnancy Physical Activity Questionnaire, Zung Anxiety Scale, and Rosenberg's Self-Esteem Scale). The methodology section, however, would benefit from a summary of the statistical techniques applied to the data analysis to give a more thorough explanation of how the outcomes were arrived at.

Thank you very much for your comments

• The abstract could improve by specifying the magnitude of changes (e.g., the percentage decrease in physical activity) and including confidence intervals to provide a clearer picture of the data's reliability.
• The relevant keywords cover a broad spectrum related to the study's focus. However, including terms like "gestational trimesters," "prospective study," and "mental health" might enhance searchability and relevance.

Thank you, we accept the suggestion and add in keywords.

1. Introduction:

• The introduction gives a general overview of the situation by emphasizing how stressful and difficult pregnancy may be for women, which raises their risk of anxiety and depression. It would, however, be beneficial to concentrate more on the distinct physiological and psychological changes that take place during pregnancy and how these, in turn, connect to anxiety and self-esteem. A quick rundown of hormone fluctuations, issues with body image, and the significance of physical pain throughout pregnancy may be included in this.
• Although the introduction cites a number of studies, a more thorough discussion of the body of research on the connection between physical exercise and mental health during pregnancy would be beneficial. The authors ought to provide a more thorough analysis of earlier research, especially that which points out contradictions or gaps in our knowledge. This would give a clearer explanation and more convincing justification for the current study's necessity.
• Near the conclusion of the introduction, the study's objectives are stated. Nonetheless, a clearer explanation of the research questions or hypotheses would improve the section. Elucidating them would facilitate readers' comprehension of the precise goals and anticipated results of the study from the beginning.

 

• The introduction could be improved by emphasizing the practical implications of the research. While it mentions the importance of understanding the relationship between physical activity, self-esteem, and anxiety, it should also discuss how these findings could influence clinical practice, public health policies, or interventions to improve maternal mental health.
• The flow of the introduction could be improved to enhance readability. For example, the paragraph discussing the benefits of physical activity (lines 67-77) seems slightly disjointed from the preceding discussion on mental health risks. A smoother transition between these topics, perhaps by discussing the potential of PA as an intervention, would create a more cohesive narrative.
• The mention of screening for prenatal mental health (lines 57-60) is relevant but could be expanded. Discussing the effectiveness of different screening tools and interventions and barriers to their implementation would provide a more comprehensive background for the study.

 

2. Results:

The section begins with an internal consistency measure (α = 0.75) without context. It would be beneficial to specify which scale or measurement this refers to.

This value referred to the questionnaire; however, we understand that it should be removed from the text as it was causing confusion.

The flow of the section could be improved by structuring it more logically, starting with a brief overview of the key findings before delving into specific results.

The use of the Kolmogorov-Smirnov test to assess normality is appropriate, but the results are presented in a manner that could be clearer. For example, stating "All variables did not present normality, except for pre-pregnancy body mass and height" can be confusing. It would be better to state which specific variables failed the normality test and their implications.

We change the sentence “Physical activity, self-esteem, anxiety, body mass and height variables did not present normality and non parametric tests were used”

• The results mention significant differences in PA levels and self-esteem across GTs but do not provide detailed statistical values for these comparisons. Including exact p-values, confidence intervals, and effect sizes for each comparison would enhance the section's robustness.

Table 1 provides baseline characteristics but lacks a clear connection to the narrative. It would be helpful to reference the table more explicitly in the text and explain its relevance to the study's findings.

Thank you, we change in the main text.

Figures 1 and 2 are mentioned but not included in the provided text. The text should clearly describe these figures, indicating what each figure illustrates and how it supports the findings. Ensure that all figures are labeled accurately and referenced appropriately.

Thank you, we change in the main text.

 

• The section states that "Anxiety scores were not modified throughout the three GTs" and that "self-esteem was significantly reduced in the 2nd and 3rd GT." While these findings are clear, the discussion around these results is minimal. Providing more context or hypotheses for these findings would be valuable. For instance, discussing potential reasons for the stability of anxiety scores despite changes in physical activity and self-esteem could provide deeper insights.

 

• The mention of ES is good practice, but the interpretation of these sizes could be expanded. For instance, stating "Only self-esteem, from the 1st to the 2nd GT, showed a large ES of 1.7" should be followed by a brief explanation of what this large effect size implies in the study context.

We add “Only self-esteem, from the 1st to the 2nd GT, showed a large ES of 1.7, indicating that this result has clinical significance.”

3. Discussion:

thank you very much for all your comments. we have revised the document and changed all the points suggested in the text

• The discussion mentions hormonal changes as a factor but lacks depth in explaining how specific hormonal shifts during pregnancy may influence anxiety and self-esteem. A more detailed analysis of hormonal mechanisms could provide a richer understanding.
• While physical discomfort is noted, it would be beneficial to delve into specific types of discomfort (e.g., musculoskeletal pain, fatigue) and their direct impact on PA and mental health.

Thank you. We change in the main text

•  
• While the need for interventions is highlighted, more specific recommendations on the nature and timing of these interventions would be beneficial. For instance, what types of PA are most effective in different trimesters? How can healthcare providers tailor interventions based on individual patient needs and preferences?

Thank you for your comments. We add the information in the text.

The authors acknowledge several limitations, including the reliance on self-reported data and the specific regional focus of the study. It would be helpful to discuss how future studies could address these limitations. For example, using objective PA measures (e.g., wearable devices) or expanding the study to diverse populations could enhance the robustness of future research.

Thank you for your comments. We add the information in the text.

4. Materials and Methods:

The study's longitudinal prospective design is appropriate for investigating changes over time, crucial in understanding the dynamic nature of self-esteem, anxiety, and PA levels throughout pregnancy. The inclusion and exclusion criteria are clearly defined and justified, ensuring a homogeneous sample that minimizes confounding variables. 

Thank you for your comments.

The detailed procedure section outlines the evaluation stages and methods for ensuring participant follow-up. This thorough description enhances the reproducibility of the study. Using a unique identification code for each participant is a commendable practice that ensures data integrity and accurate tracking. However, the section could benefit from a more explicit explanation of the measures taken to mitigate potential biases, such as how the researchers addressed possible variations in health professional assessments or the impact of home visits on participant responses.

Thank you. We add the information throughout the text

 

The choice of questionnaires (Rosenberg's Self-Esteem Scale, Zung Self-rating Anxiety Scale, and Pregnancy Physical Activity Questionnaire) is appropriate and relevant to the study's objectives. Each tool's reliability and validity are well-documented, and their adaptation to the Portuguese population is a critical strength. However, the section could be improved by providing more detail on the psychometric properties of these adapted versions, including any reliability and validity tests conducted specifically for the study sample.

We add the information throughout the text

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

 

The authors adequately replied to all comments and issues raised. I believe that this version of the manuscript is more comprehensible and reflects better the work and effort of the authors.

Comments on the Quality of English Language

Minor editing of English language required.

Author Response

Thank you very much for your suggestions.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for applying the corrections. I recommend the study for publication.

Author Response

Thank you

Reviewer 3 Report

Comments and Suggestions for Authors

1. Abstract:

·         The abstract still lacks specific statistical details such as confidence intervals and the magnitude of changes, particularly the percentage decrease in physical activity. This limits the clarity and comprehensiveness of the data's reliability.

2. Introduction:

·         While the introduction has been expanded, the discussion on the specific hormonal shifts during pregnancy and their precise impact on anxiety and self-esteem could be further detailed. This would provide a deeper understanding of the physiological underpinnings of the study's findings.

·         The practical implications discussed in the introduction could benefit from more concrete examples of how the study's findings could influence clinical practice or public health policies. The discussion remains somewhat general.

3. Results:

·         Although the internal consistency measure (α = 0.75) is now specified, there is still a lack of context about how this consistency compares to similar studies or what it implies for the reliability of the measurements used.

·         While improved, the presentation of the Kolmogorov-Smirnov test results could be clearer regarding the implications of the non-normality of variables on the overall analysis and conclusions of the study.

·         Including detailed statistical values (e.g., exact p-values and effect sizes) is a positive addition, but the interpretation of these statistics could be expanded. Specifically, these findings' relevance and practical significance could be better explained.

·         Figures 1 and 2 are now referenced, but these figures' visual clarity and labeling could still be improved to ensure they effectively communicate the results to the reader.

4. Discussion:

·         The discussion on the hormonal changes affecting anxiety and self-esteem lacks depth. A more thorough analysis of how specific hormones, such as cortisol or progesterone, interact with mental health variables during pregnancy would provide a richer discussion.

·         The treatment of sedentary behavior in the discussion is somewhat superficial. There is a need for a more detailed comparison with existing literature on sedentary behavior during pregnancy, which could strengthen the manuscript's arguments about its constancy.

·         The recommendations for interventions are still relatively general. More specific guidelines on physical activity types and timing during different trimesters would make the discussion more actionable and valuable for practitioners.

·         The long-term implications of reduced physical activity during pregnancy are not fully explored. The potential effects on postpartum recovery and long-term maternal mental health need further discussion to highlight the importance of maintaining activity levels during pregnancy.

5. Materials and Methods:

·         The sample size calculation, while expanded, could still be more detailed, especially in terms of the assumptions made for the effect size and how these assumptions align with the study's aims.

·         The explanation of bias mitigation techniques is still somewhat lacking. A more explicit discussion of how the researchers controlled for potential biases, such as the impact of the home visits on participant responses, would strengthen the methodology section.

·         Although the psychometric properties of the adapted questionnaires are mentioned, the discussion remains brief. Further details on the validation process and how these tools performed specifically in the Portuguese population would enhance the measurements' credibility.

6. Figures and Tables:

·         The integration of tables and figures into the narrative has improved, but the manuscript could benefit from more explicit references to these elements within the text. This would help the reader understand their relevance to the study's findings.

·         While now described, the figures still require better visual clarity and more detailed captions to ensure they effectively support the text.

Comments on the Quality of English Language

The text is generally understandable, but there are several instances where the grammar, sentence structure, and phrasing need improvement for clarity and readability. Some specific areas that might require attention include consistency in tense, proper use of articles, and refining complex sentences to improve flow and comprehension.

Author Response

1. Abstract:

• The abstract still lacks specific statistical details such as confidence intervals and the magnitude of changes, particularly the percentage decrease in physical activity. This limits the clarity and comprehensiveness of the data's reliability.

ANSWER: We added this information in the abstract section. Thank you.

 

2. Introduction:

• While the introduction has been expanded, the discussion on the specific hormonal shifts during pregnancy and their precise impact on anxiety and self-esteem could be further detailed. This would provide a deeper understanding of the physiological underpinnings of the study's findings.

ANSWER: Done.

 

• The practical implications discussed in the introduction could benefit from more concrete examples of how the study's findings could influence clinical practice or public health policies. The discussion remains somewhat general.

ANSWER: Done.

 

3. Results:

• While improved, the presentation of the Kolmogorov-Smirnov test results could be clearer regarding the implications of the non-normality of variables on the overall analysis and conclusions of the study.

ANSWER: Done.

 

• Including detailed statistical values (e.g., exact p-values and effect sizes) is a positive addition, but the interpretation of these statistics could be expanded. Specifically, these findings' relevance and practical significance could be better explained.

ANSWER: The full interpretation is presented in the discussion section. The results should be clear and show the reader only real statistical values. This is the step-by-step when researchers are writing an article (https://doi.org/10.1016/j.eurger.2015.08.005).

 

4. Discussion:

• The discussion on the hormonal changes affecting anxiety and self-esteem lacks depth. A more thorough analysis of how specific hormones, such as cortisol or progesterone, interact with mental health variables during pregnancy would provide a richer discussion.

ANSWER: Done.

 

• The treatment of sedentary behavior in the discussion is somewhat superficial. There is a need for a more detailed comparison with existing literature on sedentary behavior during pregnancy, which could strengthen the manuscript's arguments about its constancy.

ANSWER: We added this sentence in the section.

 

• The recommendations for interventions are still relatively general. More specific guidelines on physical activity types and timing during different trimesters would make the discussion more actionable and valuable for practitioners.

ANSWER: We added this sentence in the section. Thank you!

 

• The long-term implications of reduced physical activity during pregnancy are not fully explored. The potential effects on postpartum recovery and long-term maternal mental health need further discussion to highlight the importance of maintaining activity levels during pregnancy.

ANSWER: We added this sentence in the section. Thank you!

 

5. Materials and Methods:

• The sample size calculation, while expanded, could still be more detailed, especially in terms of the assumptions made for the effect size and how these assumptions align with the study's aims.

ANSWER: Done.

 

• The explanation of bias mitigation techniques is still somewhat lacking. A more explicit discussion of how the researchers controlled for potential biases, such as the impact of the home visits on participant responses, would strengthen the methodology section.

ANSWER: Done.

 

• Although the psychometric properties of the adapted questionnaires are mentioned, the discussion remains brief. Further details on the validation process and how these tools performed specifically in the Portuguese population would enhance the measurements' credibility.

ANSWER: We added the sentence for a better understanding of the readers.

 

6. Figures and Tables:

• The integration of tables and figures into the narrative has improved, but the manuscript could benefit from more explicit references to these elements within the text. This would help the reader understand their relevance to the study's findings.

ANSWER: We added this sentence in the discussion section.

 

Round 3

Reviewer 3 Report

Comments and Suggestions for Authors

1. Introduction

Changes:

·         The revised introduction has expanded the discussion on the mental health risks during pregnancy, adding more detailed information on the relationship between hormonal changes and mood fluctuations. Adding current guidelines on PA during pregnancy is a positive enhancement, adding context to the study's rationale.

·         The updated introduction also includes new references to support the claims made, which improves the credibility and relevance of the background information provided.

Feedback:

·         The additions strengthen the manuscript by providing a more comprehensive background. However, ensure that all newly added references are the most current and directly related to the context discussed.

·         The structure and flow of the introduction have improved, but consider further refining the connection between the discussion of mental health risks and the rationale for studying PA's effects on self-esteem and anxiety.

2. Methodology

Changes:

·         Minor changes in terminology have been made to clarify the statistical methods used. The explanation of effect size (ES) calculations has been rephrased for clarity.

·         Including a more detailed description of the statistical tests used (e.g., Dunn post-hoc test) provides a clearer understanding of the analytical approach.

Feedback:

·         These changes have improved the clarity and accuracy of the methods section. The revised explanations are more precise and accessible to readers.

·         Consider adding a brief justification for choosing specific statistical tests to strengthen this section further.

3. Results

Changes:

·         The results section now clearly distinguishes between statistical and clinical significance, particularly in discussing effect sizes. This is an important clarification that helps readers interpret the findings more accurately.

·         Minor textual adjustments have been made to improve the readability of the presentation of the results.

Feedback:

·         The revision enhances the reader's ability to understand the practical implications of the findings. The distinction between statistical and clinical significance is crucial and well-executed.

·         Ensure all figures and tables referenced in this section correctly label and correspond to the text.

4. Discussion

Changes:

·         The revised discussion includes additional references to previous research, supporting the findings related to sedentary behavior and its impact on mental health during pregnancy.

·         The authors have added a discussion on the need for targeted interventions to address the reduction in PA and its impact on self-esteem during pregnancy. This is a valuable addition that aligns well with the study's aims.

Feedback:

·         The added content strengthens the discussion by linking the findings to broader public health implications. However, ensure that the discussion remains focused and avoids unnecessary repetition.

·         The implications for practice and future research are well articulated, but consider expanding on specific recommendations for interventions based on the study's findings.

5. Conclusion

Changes:

·         The conclusion has been slightly rephrased for clarity, emphasizing the study's main

Feedback:

 

·         The revised conclusion is succinct and effectively summarizes the study's contributions. Ensure that it aligns with the newly added content in the discussion.

Comments on the Quality of English Language

The manuscript is generally understandable, but several areas need improvement in phrasing, grammatical issues need correction, and clarity could be enhanced. A thorough review would ensure that the language is clear and professional throughout.

Author Response

1. Introduction

Changes:

• The revised introduction has expanded the discussion on the mental health risks during pregnancy, adding more detailed information on the relationship between hormonal changes and mood fluctuations. Adding current guidelines on PA during pregnancy is a positive enhancement, adding context to the study's rationale.
• The updated introduction also includes new references to support the claims made, which improves the credibility and relevance of the background information provided.

Feedback:

• The additions strengthen the manuscript by providing a more comprehensive background. However, ensure that all newly added references are the most current and directly related to the context discussed.
• The structure and flow of the introduction have improved, but consider further refining the connection between the discussion of mental health risks and the rationale for studying PA's effects on self-esteem and anxiety.

 

Reply:

Dear Reviewer,

Thank you very much for your careful review. We have taken your comments into consideration and made the necessary revisions to the main text.

2. Methodology

Changes:

• Minor changes in terminology have been made to clarify the statistical methods used. The explanation of effect size (ES) calculations has been rephrased for clarity.
• Including a more detailed description of the statistical tests used (e.g., Dunn post-hoc test) provides a clearer understanding of the analytical approach.

Feedback:

• These changes have improved the clarity and accuracy of the methods section. The revised explanations are more precise and accessible to readers.
• Consider adding a brief justification for choosing specific statistical tests to strengthen this section further.

Thank you. We add the justification of using the e Dunn post-hoc test.

3. Results

Changes:

• The results section now clearly distinguishes between statistical and clinical significance, particularly in discussing effect sizes. This is an important clarification that helps readers interpret the findings more accurately.
• Minor textual adjustments have been made to improve the readability of the presentation of the results.

Feedback:

• The revision enhances the reader's ability to understand the practical implications of the findings. The distinction between statistical and clinical significance is crucial and well-executed.
• Ensure all figures and tables referenced in this section correctly label and correspond to the text.

Thank you. We add the information in main text

4. Discussion

Changes:

• The revised discussion includes additional references to previous research, supporting the findings related to sedentary behavior and its impact on mental health during pregnancy.
• The authors have added a discussion on the need for targeted interventions to address the reduction in PA and its impact on self-esteem during pregnancy. This is a valuable addition that aligns well with the study's aims.

Feedback:

• The added content strengthens the discussion by linking the findings to broader public health implications. However, ensure that the discussion remains focused and avoids unnecessary repetition.
• The implications for practice and future research are well articulated, but consider expanding on specific recommendations for interventions based on the study's findings.

5. Conclusion

Changes:

• The conclusion has been slightly rephrased for clarity, emphasizing the study's main

Feedback:

 

• The revised conclusion is succinct and effectively summarizes the study's contributions. Ensure that it aligns with the newly added content in the discussion.

Thank you

Comments on the Quality of English Language

The manuscript is generally understandable, but several areas need improvement in phrasing, grammatical issues need correction, and clarity could be enhanced. A thorough review would ensure that the language is clear and professional throughout.

Thank you. We made the grammatical correction

Round 4

Reviewer 3 Report

Comments and Suggestions for Authors

All my concerns have been thoroughly addressed in the revised version of the manuscript.

Author Response

Thank you very much for your suggestions.