My Concerns About the Article “Maternal Obesity: Can Raising Awareness on Related Risks Improve Pregnancy Outcomes? A Longitudinal Study among Moroccan Pregnant Women”. 2024; 51, 263

I read the study on the effects of raising awareness regarding obesity-related risks on pregnancy outcomes with great interest [1]. However, I would like to express a few concerns about the methodology and statistical analyses presented in the article.

Although the study employed a brochure-based educational method, the inclusion of pregnant women who were unable to read or write in both groups poses a significant barrier to achieving the study’s objective and obtaining unbiased results. Similar studies have excluded participants without literacy skills [2, 3, 4].

Another important point pertains to the difference in pre-pregnancy Body Mass Index (BMI) between the two groups. Due to the relationship between BMI and eating habits, this heterogeneous distribution could directly bias the study’s findings [5, 6, 7].

Of particular concern are the statistical errors in the analysis. Despite multiple variables being compared (e.g., more than 20 p-values), no correction (such as Bonferroni or Benjamini-Hochberg) was performed, thereby increasing the risk of false positives (Type I error). The results reported as statistically significant (e.g., p = 0.004, p = 0.006) should be interpreted in this context. Moreover, the chi-square test was incorrectly employed for categories with low sample sizes. When the expected frequency in any cell is less than five, Fisher’s exact test should be used. For example, in the assessment of educational level, the expected frequency in the “University” category is 2.5 (i.e., 5 in both groups), rendering chi-square invalid. Instead, Fisher’s exact test should have been used or categories could have been combined (e.g., “Primary School + Illiterate” vs. “High School + University”). Additionally, there appears to be a typographical error in the nutritional habits assessment during the third trimester for the control group, where “Yes” is listed as 60% and “No” as 40%. Given that 20/50 = 40% and 30/50 = 60%, the correct values should be “20 (40%)” and “30 (60%)”. Furthermore, in Table 2, the percentages for “Number of Meals” in the control group also seem incorrect. For example, in the third trimester, “\ge4 meals” is listed as 6 (12%), which correctly corresponds to 6/50 = 12%, indicating a possible labeling or typographical discrepancy.

References

[1] Samim S, Loukid M, Lamtali S. Maternal Obesity: Can Raising Awareness on Related Risks Improve the Pregnancy Outcomes? A Longitudinal Study among Moroccan Pregnant Women. Clinical and Experimental Obstetrics & Gynecology. 2024; 51: 263. https://doi.org/10.31083/j.ceog5112263.

[2] Edmonds SW, Solimeo SL, Nguyen VT, Wright NC, Roblin DW, Saag KG, et al. Understanding Preferences for Osteoporosis Information to Develop an Osteoporosis Patient Education Brochure. The Permanente Journal. 2017; 21: 16–24. https://doi.org/10.7812/TPP/16-024.

[3] Protz K, Dissemond J, Seifert M, Hintner M, Temme B, Verheyen-Cronau I, et al. Education in people with venous leg ulcers based on a brochure about compression therapy: A quasi-randomised controlled trial. International Wound Journal. 2019; 16: 1252–1262. https://doi.org/10.1111/iwj.13172.

[4] Smith PJ, Clavarino AM, Long JE, Steadman KJ. The Use of a Brochure to Enable CAM-with-Chemotherapy Patient Education. Journal of Cancer Education: the Official Journal of the American Association for Cancer Education. 2017; 32: 814–819. https://doi.org/10.1007/s13187-016-1011-8.

[5] van Strien T. Causes of Emotional Eating and Matched Treatment of Obesity. Current Diabetes Reports. 2018; 18: 35. https://doi.org/10.1007/s11892-018-1000-x.

[6] Phelan S, Phipps MG, Abrams B, Darroch F, Schaffner A, Wing RR. Randomized trial of a behavioral intervention to prevent excessive gestational weight gain: the Fit for Delivery Study. The American Journal of Clinical Nutrition. 2011; 93: 772–779. https://doi.org/10.3945/ajcn.110.005306.

[7] Parker HW, Tovar A, McCurdy K, Vadiveloo M. Associations between pre-pregnancy BMI, gestational weight gain, and prenatal diet quality in a national sample. PLoS One. 2019; 14: e0224034. https://doi.org/10.1371/journal.pone.0224034.