revisions but before transmittal to production for composition and copyediting:
• Comments from the reviewers and editors (email to author requesting revisions)
• Response from the author (cover letter submitted with revised manuscript)*
*The corresponding author has opted to make this information publicly available.
Personal or nonessential information may be redacted at the editor’s discretion.
Questions about these materials may be directed to the Obstetrics & Gynecology editorial office:
[email protected].
Date: Sep 23, 2022
To: "Kristin Julianna Konnyu"
From: "The Green Journal" [email protected] Subject: Your Submission ONG-22-1517
RE: Manuscript Number ONG-22-1517
Perspectives on fewer visits and televisits for routine antenatal care: A qualitative synthesis Dear Dr. Konnyu:
Thank you for sending us your work for consideration for publication in Obstetrics & Gynecology. Your manuscript has been reviewed by the Editorial Board and by special expert referees. The Editors would like to invite you to submit a revised version for further consideration.
If you wish to revise your manuscript, please read the following comments submitted by the reviewers and Editors. Each point raised requires a response, by either revising your manuscript or making a clear argument as to why no revision is needed in the cover letter.
To facilitate our review, we prefer that the cover letter you submit with your revised manuscript include each reviewer and Editor comment below, followed by your response. That is, a point-by-point response is required to each of the EDITOR COMMENTS (if applicable), REVIEWER COMMENTS, and STATISTICAL EDITOR COMMENTS (if applicable) below.
The revised manuscript should indicate the position of all changes made. Please use the "track changes" feature in your document (do not use strikethrough or underline formatting).
Your submission will be maintained in active status for 21 days from the date of this letter. If we have not heard from you by Oct 14, 2022, we will assume you wish to withdraw the manuscript from further consideration.
Please note the following:
*** Help us reduce the number of queries we add to your manuscript after it is revised by reading the Revision Checklist at https://journals.lww.com/greenjournal/Documents/RevisionChecklist_Authors.pdf and making the applicable edits to your manuscript.
EDITOR COMMENTS:
1. Thank you for submitting this work to Obstetrics and Gynecology. If you opt to submit a revision, please make it clear in the manuscript that this is a shortened version of something previously published on line
https://effectivehealthcare.ahrq.gov/products/schedule-visits-antenatal-care/research.
2. Include that this was a systematic review in the title of the manuscript. Perhaps something like "Patient and Provider Perspectives on Changing Prenatal Care Delivery: A Systematic Review"?
REVIEWER COMMENTS:
Reviewer #1:
Summary:
This is a systematic review of qualitative studies evaluating patient and provider perspectives regarding modified prenatal visit schedules as well as televisits. Four studies addressing reduced visits and five studies addressing televisits were included (9 total), and barriers and facilitators of reduced visits/televisits were analyzed according to established thematic domains.
Major comments:
View Letter
1 of 3 10/18/2022, 9:12 AM
authors do an excellent job describing methodology (in accordance with established practices for systematic review and qualitative synthesis) and results. However, the primary challenge facing this systematic review is lack of restriction to U.S.
based studies. As the goal of the review is to synthesize qualitative data regarding patient and provider experiences with alternate prenatal care models, it is problematic to combine data from different countries/patient populations/health systems, as these factors are highly contextual. This limits the ability of the reader to draw any actionable conclusions from an already limited data set (only 9 total included studies).
Minor comments:
Introduction:
-Very nice introduction.
-In the final paragraph of the paragraph, I am unclear about the relationship between this systematic review and the project commissioned by ACOG/SMFM/AHRQ. Please clarify this or omit this context if it is not necessary for the paper.
Methods:
-Sources: Were studies from outside of the U.S. included? This should be stated explicitly.
-Sources: Where is the search strategy/terms? This should be described here.
-Was there any a prior plan to account to differentiate studies pre/post the COVID-19 pandemic? This should be mentioned in the methods section.
Results
-The results are organized well and easy to follow, particularly the tables.
-As the tables are very "text heavy," it might be helpful to the reader to also include a summary figure inclusive of barriers/facilitators of modified prenatal care, perhaps broken down by patient and provider.
Discussion/Conclusion:
-It would be helpful to contextualize the results more broadly in terms of what is known (or not known) about reduced visits/telemedicine and maternal/neonatal outcomes, as well as any qualitative data that exist regarding patient/provider ambulatory telemedicine experiences outside of obstetrics.
Reviewer #2:
Applaud the group for applying rigorous methods to perspectives.
Very timely topics in these of both covid concerns and budget cuts, thus it is understandable why ACOG and SMFM want to study these
Authors acknowledge the pacity rigorous studies.
Would suggest addressing the lack of timely studies on visit frequency, only one is in the covid era. One must consider the potential for different motivations in a different time and how applicable these are our current time.
The telemed are all in the time of covid thus more applicable to study the question.
Concern on different countries may lead to different perspectives in different reimbursement models.
Value of this study is in identifying beliefs or perceptions that maybe barriers to success.
Once identified these can be addressed to hopefully lead to interventions and educations to improve implementation Presentation: maybe a table to clearly present provider perspectives or beliefs concisely to aid in reader learning
Table 3: Title is antenatal televisits- but most or all of the studies are related to visit frequency, did they do televists in the sanders study?
Reviewer #3:
This manuscript outlines a systematic review of qualitative studies of patient preference regarding antenatal care visit schedules and use of telehealth. The methodology is rigorous and thoroughly described, and the topic was deemed important by ACOG and SMFM. The results are extensive but also appropriately brief.
1. Precis is unfocused.
2. Consider using gender inclusive language, e.g. "pregnant people", when referring to populations.
3. Introduction, lines 44-46: Clarify when these recommendations were made and in what context - were these meant to be broad or during COVID-19?
4. Methods, lines 101-105: it may be helpful to describe what is meant by reflexivity. This is described a bit more in results, but I suspect that this concept is not familiar to much of our readership.
5. Results, lines 170-171: in some ways, this belongs in the discussion, but I'll admit I kind of enjoyed the punch it packs here.
6. Table 1: You appropriately note the necessity of evaluating preferences of diverse populations. Is there a way Table 1 could give more detail on the demographics of the included studies?
--
Torri D. Metz, MD, MS Associate Editor, Obstetrics
The Editors of Obstetrics & Gynecology
__________________________________________________
In compliance with data protection regulations, you may request that we remove your personal registration details at any time. (Use the following URL: https://www.editorialmanager.com/ong/login.asp?a=r). Please contact the publication office if you have any questions.
View Letter
3 of 3 10/18/2022, 9:12 AM
necessary for the paper. Research and Quality (the full report is available at
https://effectivehealthcare.ahrq.gov/produc ts/schedule-visits-antenatal-care/research).”
Methods:
-Sources: Were studies from outside of the U.S. included? This should be stated explicitly.
• We have added the following clarification to the methods: “Studies had to be conducted in the United States or another high-income country as defined by the World Bank at the time of our review.”
Methods:
-Sources: Where is the search strategy/terms?
This should be described here.
• We report the full search strategy in the Appendix. We have added text to make this more explicit “The full search strategy, including key terms used, can be found in Appendix A.”
Methods:
-Was there any a prior plan to account to differentiate studies pre/post the COVID-19 pandemic? This should be mentioned in the methods section.
• Differentiating studies pre/post the COVID- 19 pandemic was beyond the scope of the review (n.b. the review was conducted during the pandemic and as such, studies conducted during the pandemic were still emerging). In our results, we noted studies (for telemedicine) that were conducted during the pandemic in our overall introduction to the evidence, but the synthesis that follows reflects the findings obtained from all studies and does not differentiate based on those obtained pre/post the pandemic.
Results
-The results are organized well and easy to follow, particularly the tables.
• Thank you
Results
-As the tables are very "text heavy," it might be helpful to the reader to also include a summary figure inclusive of
barriers/facilitators of modified prenatal care, perhaps broken down by patient and
provider.
• We experimented with a figure, however believe the tables convey the most accurate depiction of the evidence without too much of a loss of detail. We would be happy to discuss options with the editor if there is further interest in replacing the table with a figure.
Discussion/Conclusion:
-It would be helpful to contextualize the results more broadly in terms of what is known (or not known) about reduced visits/telemedicine and maternal/neonatal outcomes, as well as any qualitative data that exist regarding patient/provider ambulatory telemedicine experiences outside of
obstetrics.
• We have added further details about the benefits and harms of reduced
visits/telemedicine from our systematic
review of this literature, as well as
experiences with telemedicine in general
outside of obstetrics.
suggests that providers and patients saw potential benefits but also had some concerns with reduced visit schedules and use of televisits for routine antenatal care]
present precis is sufficient given the complexity of the findings.
Consider using gender inclusive language, e.g.
"pregnant people", when referring to populations.
• We have chosen to report the study participants as “women” as this is the term used by the studies. Within the studies there was no suggestion that the focus groups included antenatal individuals who did not identify as women. However, we defer to the editor about preferred language.
Introduction, lines 44-46: Clarify when these recommendations were made and in what context - were these meant to be broad or during COVID-19?
• We have clarified that the recommendations were published between 1989 and 2019.
Methods, lines 101-105: it may be helpful to describe what is meant by reflexivity. This is described a bit more in results, but I suspect that this concept is not familiar to much of our readership.
• We have added a definition of reflexivity to the sentence.
Results, lines 170-171: in some ways, this belongs in the discussion, but I'll admit I kind of enjoyed the punch it packs here.
• The line in question (“Notably, across studies, most patient-related themes were collected from providers, and few were based directly on patient-reported
perspectives”) is a result as it describes the type of perspectives represented in the participants and whose perspectives are missing, prior to summarizing the themes identified.
• We note this finding as well in our discussion as it highlights the need for further research among clinic leadership and partners (lines 381-384).
Table 1: You appropriately note the necessity of evaluating preferences of diverse
populations. Is there a way Table 1 could give more detail on the demographics of the included studies?
• Unfortunately, studies were very limited in
their reporting of participant characteristics
beyond generalities already described. As a
result, a detailed table of demographics of
participants does not add much information.
