Reviewer I:
Major Revisions:
1. Conclusion in Abstract: as stated it bears no relation to the study!!
Conclusion in abstract was rewritten. (page 2)
2. Introduction Par. 3: this is confusing. Is elective C/S safer than vaginal
delivery? The authors state that it is, but refer to a reference that suggests it is
not! Yes, there is conflicting evidence but the paragraph does not convey the
essence of that debate.
This confusion was corrected in Par.3 (see page3)
3. Methods section: Why do the statements here confirm that the data include all
hospital deliveries?
This was corrected . It included only CS deliveries.(page 4)
4. Data Collection: What is meant / included in the category "severe morbidity"?
An operational definition was added to define severe maternal morbidity (page 6)
I appreciate that the requirement for a "intrauterine transfusion" indicates an
anaemic fetus, but it is not by itself a fetal outcome.
This issue was described in discussion (end of page 10)
Why separate cases of "ambiguous genitalia" from other forms of "congenital
anomaly" ?
All these cases were merged together under congenital anomaly. ( Table 2 page 19)
5. Results: Confusion in the 1st paragraph wrt means and averages. (plus an
important typographical error!! It is the percentage of the cohort that are of grand
multiparity that is the issue, not the "average" parity.
This paragraph was corrected for parity and gravidity, and proportions were added
with the averages.(end of page 6)
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6. Indications for C/S: It is expected that the indications for elective C/S differ
from those for emergency C/S and I see no value in comparing the indications.
Agree. These differences were deleted, and the table for indications was replaced with
Figure 1 showing indications of emergency and elective CSs separately.
Are Sections for dystocia and cord prolapse REALLY elective?
These two conditions were included under emergency CS, and table was revised with
re-analysis as necessary.
7. Adverse Obstetrical Outcomes: Since "outcomes" are the end result of many
influences but the focus in this paper is "possible associations" perhaps it would
be better to consider a title such as "maternal and fetal morbidity". For example is
HEELP caused or prevented by the intervention of C/Section?
This issue was highlighted in the discussion (page 10)
8. Adverse outcomes: IUGR and IUFD are mentioned in the results section but
no data pertaining to them are given. Either explain why, or give figures in the
text or include in the tables.
These two conditions were included in table 2 (page 19)
ICU admission (of the newborn) is included as an adverse newborn outcome and
such are found more commonly (not surprisingly) amongst infants born preterm.
Was there any routine admission policy in place that might confound this finding.
Explain.
This issue was described in discussion (page 10)
9. Discussion: More contrary statements in Par. 3 concerning low segment C/S
and uterine rupture / dehiscence. Reword the discussion.
This confusion was corrected by revision of the sentences in the paragraph (page 9)
HEELP: Missing is any consideration that severe pre-eclampsia or HEELP may
be conditions leading to C/S. A similar comment applies to the reported
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increased maternal morbidity associated with preterm delivery.
This clarification was written in the discussion with regard to HELLP and
preeclampsia.(page 10).
The rate of blood transfusion is relatively high. It would be helpful to include
some indication of the recommended approach to transfusion inj practice within
the hospital.
It was stated that the policy may need to be revisited in the hospital ( page 10)
The paragraph on perinatal mortality is unclear and requires re wording.
This paragraph was re-written ( page 11)
10.Conclusion: The comment about "multiple repeat C/Sections is totally out of
place, a complete "non sequitur" since NO DATA on numbers of previous
sections are provided! Similarly the comment re tubal ligation!
Conclusion was revised and the repeat CS was deleted. Also the recommendation for
tubal ligation was deleted. A recommendation to support the birth control programs in
the Kingdom so as to reduce the adverse outcomes among grandigravida females for
whom these outcomes are significantly high.
Discretionary Revisions:
1. The analysis and the paper represent an audit of practice at a particular
hospital and is of value for that alone, let alone the fact that it reflects on the
issues for women of high parity. Sadly no data and therefore no analysis concerns the
issue of women who have undergone "many" previous Sections. In my opinion this
represents a missed opportunity.
These limitations were stated in the last paragraph of the discussion section.(page 11).
Also the recommendation of future prospective study addressing those with repeat
CSs was stated in the conclusion section. ( pages 11,12)
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Reviewer II
1.0 Is the question posed by the authors well defined?
The study is original and ethical. Aims of study are mentioned in the last
paragraph of the introduction and could be improved to reflect what they intended
to measure. The first objective implies that the study was community based while
it was hospital based. The second objective is not measurable. What is it that
they wanted to determine about maternal and fatal adverse outcomes? Was it
the incidence or what?
Objectives were revised to include the “incidence of adverse outcome” as the measure we
intend to determine.These revisions were done in abstract (page 2) and introduction (page
4).
2.0 Major compulsory
Are the methods appropriate and well described?
The Methods need more information and clarity:
1. It is not clear if the outcome variables i.e adverse maternal outcome and
adverse fetal outcomes were composite variables of the listed individual
outcomes or each discrete outcome was analyzed independently.
This was clarified in table 2, where it was stated as a footnote that these outcomes are not
mutually exclusive. (page 19)
It is not clear what criteria were used to select these adverse maternal outcomes
[hysterectomy, blood transfusion, ruptured uterus, retained placenta, severe
maternal morbidity, HELLP syndrome, pulmonary embolism, renal failure, heart
failure, pelvic abscess, and maternal death] since others seem to overlap.
The operational definition of severe maternal morbidity and its components was stated
with references (Ref.#24&25) in the methods section ( page 6)
2. What criteria were used to diagnose severe maternal morbidity?
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Women who experienced and survived a severe health condition during pregnancy,
childbirth or postpartum
3. The definition for emergency and elective CS was the most disturbing and
specifically needs revision. It does not sound practical to consider CS due to
antepartum hemorrhage, eclampsia, fetal distress, cord prolapsed as elective CS
(see table 2). This needs detailed and convincing explanations.
All these were corrected in figure 1 that replaced table 2. All necessary corrections of
figures in table 1 were also done.
4. The operational definition states, “ Planned operations - at a time that suited
the woman and the maternity team- were considered “elective”, How could this
be established in retrospective data analysis? How could one establish that the
CS was done at a time that suited maternity team? In Table 2 of the results, it
seems some women requested for CS and yet were grouped among emergency
CS!
Although the study is a retrospective, yet the type of CS ( emergency or elective ), with
its main indication was retrieved from individual patient chart with a specialist in
OB/Gyn. With regard to “ maternal request” as an indication, this issue was corrected and
all deliveries for which maternal request was the main indication were considered as
elective. ( Figure 1 page 21)
5. Adverse outcomes are mostly attached to the underlying reason for CS. Since
indications for elective CS and Emergency CS differ substantially and outcomes
are known to be different (refer to Reference No. 10 as cited in the introduction)
the decision to combine the two needs explanations. I strongly advise that outcomes of
elective and emergency CS should be analyzed separately.
Outcomes of emergency and elective CSs were analysed separately as shown in table 3(
page 20).
6. There was need to carefully select predictor variables either based on clinical
knowledge or statistical means. It is not news to say hemorrhage predicts blood
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transfusion or eclampsia predicts severe morbidity since eclampsia is on itself a
severe morbidity (the outcome). This means some of the independent variables
were forming part of the outcome.
All predictors of outcome were revised based on statistical analysis, were different
correlations were done between different variables to identify the confounders. Table 3
was constructed to include only variables with significant association with the outcomes
in univariate analyses.( page 20). Meanwhile, these predictors were initially allocated
based on the literature as shown in the methods section.
7. It is not clear in the analysis if interaction/colinearity were tested.
Yes it was done as described in the previous statement.
Are the data sound?
The data are not sound due to the following:
1. In Table 1 some variables are not labelled-just written Mean (SD). The
differences between elective and emergency CS in this table should alert the
Authors that they were dealing with two different groups that should have been
consistently analyzed separately (not as one CS group).
Table 1 was revised, with every quantitative variable shown in categories followed by an
average and SD.
2. Tables 1 and 2 need re-analysis after revision of the definition for emergency
and elective. Some of the variables in both tables were not planned (as per
definition) yet are included as elective. Such variables include all those that
occurred accidentally during labour (fetal distress, APH, fetal distress, cord
prolapse etc). Table 3 also needs such revision.
Table 1 was re-analysed after correction of the definition of CS based on their main
indications. Table 2 was replaced with to Figure 1 to avoid comparison between the two
types of CS as recommended by other reviewers. It is not logical to compare the two
types of CSs by indications as they are different.
3. Table 4 needs a separate analysis for Emergency and elective CS. It also
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needs careful selection of independent and outcome variables as explained
above.
Separate analyses were conducted for emergency and elective CS as shown in table 3
(page 20)
3.0 Discretionary Revisions
Tables can be re- formatted to conform with formats commonly seen in
BMC-Pregnancy and Childbirth
Tables were formatted to conform with the BMC format.
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