Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study

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Nonpharmacological approaches such as music therapy and hypnobirthing are developing as alternatives that are considered safe, inexpensive, and minimal in side effects, but the effectiveness of the combination of the two methods has not been widely studied in the context of pregnancy in Indonesia Methods This quasi-experimental study aimed to examine the effectiveness of hypnobirthing, music therapy, and their combination in alleviating LBP among third-trimester pregnant women. A total of 200 participants were divided into four groups: hypnobirthing (n=50), music therapy (n=50), a combination group (n=50), and a control group receiving standard antenatal care (n=50). Pain levels were assessed before and after the intervention using the Visual Analog Scale (VAS). Results The study showed a statistically significant reduction in LBP intensity in all the intervention groups compared to that in the control group (p < 0.001), with the combined intervention group demonstrating the greatest improvement. These findings suggest that both hypnobirthing and music therapy are effective in managing pregnancy-related LBP, and their combination may offer enhanced benefits for managing pregnancy-related LBP. Conclusions This study supports the inclusion of non-pharmacological approaches in routine antenatal care to improve maternal comfort and well-being. 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F1000Research 2025, 14 :868 ( https://doi.org/10.12688/f1000research.168854.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] Murbiah . https://orcid.org/0009-0001-1681-9614 1,2 , Santhna Letchmi Panduragan 1 , Kasmahwati Pardi 1 , Hafizah Che hassan 1 , Husin . 3 Murbiah . https://orcid.org/0009-0001-1681-9614 1,2 , Santhna Letchmi Panduragan 1 , [...] Kasmahwati Pardi 1 , Hafizah Che hassan 1 , Husin . 3 PUBLISHED 03 Sep 2025 Author details Author details 1 Lincoln university Collage, Lincoln University College Faculty of Medicine, Petaling Jaya, Selangor, Malaysia 2 universitas muhammdiyah ahamd dahlan, universitas muhammadiyah ahmad dahlan palembang, palembang, sumatera selatan, Indonesia 3 Sekolah tinggi ilmu kesehatan Bina Husada, sekolah tinggi llmu kesehatan Bina Husada, Palembang, Sumatera selatan, Indonesia Murbiah . Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Santhna Letchmi Panduragan Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Visualization Kasmahwati Pardi Roles: Conceptualization, Formal Analysis, Supervision Hafizah Che hassan Roles: Supervision, Validation Husin . Roles: Data Curation, Investigation, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Global Public Health gateway. Abstract Background Low back pain (LBP) is a common complaint experienced by pregnant women, especially in the third trimester, which can interfere with daily activities, sleep quality, and readiness for labor. Nonpharmacological approaches such as music therapy and hypnobirthing are developing as alternatives that are considered safe, inexpensive, and minimal in side effects, but the effectiveness of the combination of the two methods has not been widely studied in the context of pregnancy in Indonesia Methods This quasi-experimental study aimed to examine the effectiveness of hypnobirthing, music therapy, and their combination in alleviating LBP among third-trimester pregnant women. A total of 200 participants were divided into four groups: hypnobirthing (n=50), music therapy (n=50), a combination group (n=50), and a control group receiving standard antenatal care (n=50). Pain levels were assessed before and after the intervention using the Visual Analog Scale (VAS). Results The study showed a statistically significant reduction in LBP intensity in all the intervention groups compared to that in the control group (p < 0.001), with the combined intervention group demonstrating the greatest improvement. These findings suggest that both hypnobirthing and music therapy are effective in managing pregnancy-related LBP, and their combination may offer enhanced benefits for managing pregnancy-related LBP. Conclusions This study supports the inclusion of non-pharmacological approaches in routine antenatal care to improve maternal comfort and well-being. READ ALL READ LESS Keywords Pregnancy, Low back pain, Hypnobirthing, Music therapy, Third trimester Corresponding Author(s) Murbiah . ( [email protected] ) Close Corresponding author: Murbiah . Competing interests: No competing interests were disclosed. Grant information: This research was supported and financed by Muhammadiyah Ahmad Dahlan University Palembang through campus grants based on work agreement letter number 0280/II/3/AU/F/2022. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 . M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: . M, Panduragan SL, Pardi K et al. Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.12688/f1000research.168854.1 ) First published: 03 Sep 2025, 14 :868 ( https://doi.org/10.12688/f1000research.168854.1 ) Latest published: 13 Jan 2026, 14 :868 ( https://doi.org/10.12688/f1000research.168854.2 )  There is a newer version of this article available. Suppress this message for one day. Introduction Low back pain during pregnancy is one of the most common musculoskeletal complaints experienced by women worldwide, particularly during the third trimester. Based on a global meta-analysis of 28 studies with a total of 12,908 respondents, the prevalence of lower back pain during pregnancy was 40.5%, with a peak of 47.8% in the third trimester ( Omoke et al., 2021 ). This condition not only causes physical discomfort but also reduces the quality of life of pregnant women, limits their daily activities, and increases the risk of medical intervention during labor. Amidst the development of non-pharmacological approaches in nursing practice, music therapy and hypnobirthing are gaining attention as safe, effective, and evidence-based alternative interventions. However, there is limited integration of these approaches in maternal health care policies globally, which calls for rigorous ( Purnamasari, 2021 ). Pregnant women experience discomfort during the adaptation process due to physical and psychological changes. Physiological changes in pregnant women throughout pregnancy can have harmful effects. Low back pain (LBP) during pregnancy is a significant global health issue, ranking as the highest cause of disability worldwide over the past three decades. According to the 2021 Global Burden of Disease study, over 628 million people worldwide experience LBP, with the highest prevalence occurring in women of reproductive age, especially during pregnancy (Li et al., 2024). Although the global prevalence rate has decreased in relative terms, the absolute number of sufferers has increased significantly because of population growth and increased life expectancy. The World Health Organization (WHO) and several international studies have shown that more than 50% of pregnant women experience LBP, especially in the third trimester, which interferes with daily activities and potentially worsens psychological conditions during pregnancy ( Chen et al., 2021 ). Back pain during pregnancy can be caused by weight gain, changing posture, hormone fluctuations, shifting the center of gravity, muscle separation, the natural elasticity of ligaments to prepare for labor, and stress. Lower back discomfort in pregnant women is frequently caused by mechanical instability of the lumbar spine and pelvis. The lumbar joints, ligaments, and muscles are overstressed as a result of compensatory lumber lordosis ( Atis & Rathfisch, 2018 ). Pregnancy hormone changes cause the ligaments connecting the pelvic bones to the spine to relax and the joints to become less rigid. This results in pain when bending, lifting, walking, standing, and sitting for extended periods of time ( Amayri et al., 2023 ). This phenomenon not only limits the physical activities of pregnant women but also affects their quality of life and psychological state to a large extent. There is an increasing need for safe, sustainable, and non-pharmacological approaches to pain management ( Manyozo et al., 2019 ). This condition impacts individuals and adds to the burden of the global health system, given the importance of supporting healthy pregnancies as an essential component of human development. In the academic realm, various non-pharmacological intervention approaches, including music therapy and hypnobirthing, have been developed as part of the integration of health technology, culture-based interventions, and psychological approaches to pain mitigation during pregnancy. This development calls for more profound research to empirically and contextually assess the effectiveness of these approaches ( Salamah, 2019 ). National data from the Indonesian Ministry of Health and other regional studies indicate a substantial prevalence of lower back pain (LBP) among pregnant women in Indonesia, particularly the third trimester. A regional survey indicated that over 60% of pregnant women in South Sumatra experienced back discomfort that impacted their daily activities and sleep quality ( Ismawati, 2022 ). Research in several government hospitals shows that most pain complaints are not managed through evidence-based intervention methods, and pharmacological interventions are often avoided due to risks to the fetus. Despite policies on maternal and child health, interventions for low back pain during pregnancy have not been prioritized in the primary healthcare system. This gap highlights the need for in-depth studies on alternative therapies that are highly effective, safe, and widely applicable. In addition, community-based approaches and health system support need to be designed based on robust and contextualized research results, making this research important not only for theory development but also for the reformulation of maternal care policies at the national level ( Bloom & Reenen, 2021 ). In the third trimester, nursing care for pregnant women with back pain complaints and acute pain problems can be provided through non-pharmacological pain management interventions with distraction and diversion through classical music therapy and hypnobirthing relaxation techniques. Non-pharmacological pain management methods, such as deep breathing exercises, are frequently employed in hospitals ( Hu et al., 2020 ). Typically, doctors use medications to relieve pain. Although much research has been conducted on the influence of music on physical and emotional well-being, there is still a lack of research specifically exploring the effects of traditional Indonesian music. Hypnobirthing and music therapy have emerged as promising complementary therapies for managing pain and anxiety during pregnancy and labor. However, empirical evidence comparing their effectiveness, both individually and in combination, in reducing LBP during late pregnancy remains limited (Thakare et al., 2022). The urgency of this research is highlighted by two main aspects: its contribution to the development of maternity nursing science and its potential implementation in primary health care systems. From an academic perspective, this study enables the renewal of intervention models in nursing based on cultural integration and relaxation psychology. From a practical point of view, the findings of this study can help create standard procedures for music therapy and hypnobirthing that can be used in health centers, especially in cities such as Palembang ( Sr et al., 2021 ). In addition, this study contributes to national efforts to reduce the use of pharmacological interventions during pregnancy, which, in the long run, impacts maternal and fetal safety and health system efficiency. This study aimed to evaluate the effectiveness of hypnobirthing, music therapy, and their combination in reducing lower back pain among third-trimester pregnant women. Methods Study area This study will be conducted in four primary health care centers (PUSKESMAS) spread across the administrative area of Palembang City, South Sumatra Province, Indonesia. Palembang City was chosen as the study location because it has a large population of pregnant women and socio-cultural variations that reflect the diversity of urban community contexts in Indonesia. The selection of Puskesmas as the main research site was based on the role of this institution as a first-level healthcare facility that serves as the starting point for pregnancy and childbirth services for the community. In addition, the presence of midwives and health workers at Puskesmas allows the implementation of therapeutic music and hypnobirthing interventions in a standardized manner, in accordance with applicable medical procedures (Sari et al., 2023). The study is scheduled to last for five months, from October 2024 to February 2025 and consists of the following stages: October 2024 Instrument development and validation, November 2024: submission and approval of ethical clearance by the institutional ethics committee, and acquisition of official research permits from the Indonesian Department of Health and PUSKESMAS. December 2024: Participant recruitment and eligibility screening based on predetermined inclusion and exclusion criteria. January 2025 Intervention phase, involving the administration of music therapy and hypnobirthing sessions for four weeks under the supervision of certified health personnel. February 2025 post-intervention data collection, statistical data processing, and preliminary interpretation of findings. Study design A quasi-experimental design with randomized group allocation was used to assess the effectiveness of non-pharmacological interventions for reducing lower back pain in third-trimester pregnant women. This study involved four parallel groups that received different interventions (Polit & Beck, 2014; Yulius, 2023 ). Inclusion and exclusion criteria of participants The inclusion criteria were as follows: third-trimester pregnant women, experiencing moderate to severe lower back pain, residing in Palembang City, Willing to participate in the full intervention and evaluation process. Exclusion criteria: Experiencing pregnancy complications requiring special care unwilling to participate in the full intervention, having hearing or psychiatric disorders that could influence intervention outcomes Recruitment Sampling is based on the selection of random units from a population. Sampling was carried out using a simple random sampling method, which emphasizes that each member of the population has the same chance/probability of being selected as a research sample ( Yulius, 2023 ). The sample selection process is carried out through initial screening using a low back pain identification questionnaire based on the Visual analog scale (VAS). Respondents who meet the threshold of moderate to severe pain will be given an explanation of the purpose of the study and intervention procedures, then asked to sign an informed consent. A total of 200 third-trimester pregnant women were recruited from the participating health centers using random selection. Participants were then randomly assigned to four groups (n = 50 per group): hypnobirthing in music therapy intervention group, the combined hypnobirthing and music therapy group, and the control group, which received routine antenatal care only leaflet. The sample was determined using a random technique (probability sampling method). Sample size The sample size in this study was determined and calculated using G*Power ( Erdfelder, 2007 ) based on Cohen’s formula ( Brydges, 2019 ) at a significance level of 0.05 and a desired power of 0.90. The estimated effect size was 0,80, derived from a previous study using one-way analysis of variance (ANOVA). The sample size for each group was 41, with a 20% dropout rate, resulting in a total sample size of 50 for each group. Thus, the total number of participants was approximately 200. The sample was proportionally divided into four groups: a music therapy group, a hypnobirthing group, a combination group of hypnobirthing intervention with music therapy, and a control group. The choice of this technique strengthens the statistical power of the data analysis and ensures that the sample size is large enough to detect statistically significant differences between groups. Outcome The primary outcome of the study was the reduction in lower back pain intensity before and after a four-week intervention period. Pain intensity was measured using a Visual Analog Scale (VAS). Tools for collecting information This study used various instruments to measure and intervene in low back pain in pregnant women in their third trimester. Each instrument was designed to ensure the validity and effectiveness of the results in accordance with the quasi-experimental pre- and post-test approach. The instruments used were as follows: Questionnaire The VAS questionnaire was used to measure the level of lower back pain experienced by third-trimester pregnant women before and after the intervention. The VAS was chosen because it is one of the most widely used pain measurement instruments in clinical research and maternity nursing. This scale allows respondents to provide a subjective assessment of pain intensity on a numerical scale from 0 to 10, where 0 indicates no pain and 10 indicates severe pain. The instrument has been shown to have high construct validity in various clinical and nursing contexts and is compatible with quasi-experimental designs that require a systematic comparison of pre- and post-intervention scores ( Bryndal et al., 2020 ). The VAS has been shown to have high construct validity and reliability in a variety of clinical contexts, including maternity nursing (Andreyani & Bhakti, 2023). Hypnobirthing intervention Hypnobirthing intervention is carried out in accordance with standard procedures included guided breathing, visualization, and deep relaxation techniques conducted by a certified practitioner twice weekly for four weeks (Saad & Jariyah, 2022). The music therapy intervention The music therapy intervention was conducted according to the standard procedure of 30 min of daily listening to relaxing instrumental music for 4 weeks. (Saad & Jariyah, 2022), the music used is the traditional “Gending Sriwijaya” composition. This piece, created by Nungcik AR in 1943 and accompanied by Palembang-style gamelan music arranged by A. Dahlan Rachim and R.C. Hardjosubroto is a cultural symbol of South Sumatra. The traditional music of Gending Sriwijaya used in this research is part of the traditional cultural heritage of the people of Palembang, South Sumatra, Indonesia, which is protected by Law Number 28 of 2014 concerning Copyright, specifically related to traditional cultural expressions. the instrumental version of Gending Sriwijaya was published by Sangsaka sound system on June 23, 2019 through the youtube https://www.youtube.com/watch?v=V8lp3F0LoS0&list=RDV8lp3F0LoS0&start_radio=1 . The version does not violate any party’s copyright or license, and its use is intended purely for non-commercial research purposes. The use of Gending Sriwijaya in this research aims to be a form of music therapy intervention that promotes and respects local culture as part of a local wisdom-based approach in maternal health services. The music will not be used outside of academic and scientific interests, will not be used for commercial purposes, and will not change the lyrics or original meaning of the song in a way that could degrade cultural values. Combination group: received a joint intervention combining hypnobirthing techniques and therapeutic music under the same schedule and procedures. Zenodo. Questionnaire and research tools. https://doi.org/10.5281/zenodo.16881327 ( Murbiah, 2025a ). The leaflet The leaflet was given once at the beginning of the intervention (week 1) and briefly discussed by the staff as a form of educational control to control group. Zenodo. Questionnaire and research tools. https://doi.org/10.5281/zenodo.16881327 ( Murbiah, 2025a ). Statistical analysis This study employed a quantitative approach that utilized a pre-test and post-test quasi-experimental design, which included a control group. Therefore, the data analysis techniques used included descriptive and inferential statistical analyses. Descriptive statistics were used to describe the characteristics of the respondents, such as maternal age in years, gestational age in weeks, education, occupation, parity, and pre- and post-intervention pain scores. The data are presented as mean, standard deviation, minimum, maximum, and frequency distribution. Inferential statistics were used to test the effectiveness of the intervention, using a paired sample t-test to compare pain scores before and after the intervention in the same group and an independent sample t-test or ANOVA to determine differences between treatment groups, namely music therapy, hypnobirthing, and a combination of both ( Yulius, 2023 ). Results The research phase began with the approval of the ethics committee and research permit in July 2024. Researchers began to identify respondents based on the following inclusion criteria: pregnant women in the third trimester, experiencing mild to severe lower back pain, and primigravida. After the respondents were collected, lower back pain was measured using a visual analogue scale (VAS) questionnaire on 200 respondents of pregnant women in the third trimester in the working areas of the Pembina Health Center, Nagaswidak Health center, Taman Bacaan Health Center and Pembina Health Center. Data analysis was performed as follows: Based on Table 1 , a total of 200 respondents were involved in this study. The majority of respondents were in the age range of 21-25 years (56%), indicating that most mothers were at the optimal reproductive age. The highest gestational age was in the range of 28-31 weeks (70.5%), indicating that the respondents were in the third trimester phase, which generally experiences an increase in the number of pregnancies. Table 1. Sociodemographic characteristics of participants at baseline. Baseline characteristics Music therapy group Hypnobirthing group Combination group Control group Full sample N % N % N %/ N % N % Age (years) 15-20 1 0.5 0 0 3 1.5 1 0.5 5 2.5 21-25 30 15 31 15.5 28 14 23 11.5 112 56 26-30 13 6.5 16 8 10 5 16 8 55 27.5 31-35 6 3 3 1.5 9 4.5 9 4.5 27 13.5 36-40 0 0 0 0 0 0 0 0 0 0 41-45 0 0 0 0 0 0 1 0.5 1 0.5 Pregnancy Age (Weeks) 24-27 1 0.5 0 0 0 0 0 0 1 0.5 28-31 36 18 35 17.5 35 17.5 35 17.5 141 70.5 32-35 13 6.5 15 7.5 15 7.5 15 7.5 58 29 Education Middle School 7 14 10 20 10 20 12 24 39 19.5 High School 33 66 32 64 33 66 30 60 128 64 University 10 20 8 16 7 14 8 16 33 16.6 Work Wife House 41 82 42 84 40 80 38 76 161 80.5 Working 9 18 8 16 10 20 12 24 39 19.5 Marital Status Single 0 0 0 0 0 0 0 0 0 0 Married 50 100 50 100 50 100 50 100 200 100 Based on Table 2 , the average pain level before music therapy was 5,96 (SD = 1,958), and the average pain level after music therapy was 4,48 (SD =1,644). The average pain level before Hypnobirthing was 6,50 (SD = 1,619, the average pain level after music therapy was 4,50 (SD =1,619), and the average pain level before Hypnobirthing with music therapy was 5,50 (SD = 1,669. The average pain level after music therapy was 3,52 (SD =1,644), and the average pain level in the control group was 5,22 (SD = 1,075. The average pain level after control group was 4,56 (SD =1,280). Table 2. Distribution of low back pain score pre and post intervention. Intervention N Pre intervention Post intervention Mean SD Min-Max Mean SD Min-Max Hypnoburthing group 50 5.96 1,958 3-9 4.48 1,644 2-7 Music therapy group 50 6.50 1,619 4-9 4.50 1,619 2-7 Combination group 50 5.50 1,669 3-8 3.52 1,644 1-6 Control group 50 5.22 1,075 4-7 4.56 1,280 2-7 Based on Table 3 , the average pain score before the combined therapy (hypnobirthing and music therapy) was 5,50 (SD = 1,669), indicating moderate to severe pain levels. After the combined intervention, the average pain score decreased to 3,52 (SD = 1,644), showing a significant reduction to mild pain levels. The mean difference in pain scores (pre-vs. post-test) was 1,803 (SD = 2,157), demonstrating a substantial reduction in pain following the combined therapy. The paired t-test statistic (t(49) = 22,496) was highly significant (p 0.000). This confirms that the observed reduction in pain scores was not due to chance but was likely caused by the combined effect of hypnobirthing and music therapy. Table 3. Paired Sample t-Test for low back pain score before and after intervention (per Group). Variable N Low back pain (Pre) Low back pain (Post) T df P value Cohen’s d M SD M SD Music Therapy 50 5.96 1,958 4.48 1,644 10,984 49 0.000 1.553 Hypnobirthing 50 6.50 1,619 4.50 1,619 14,289 49 0.000 2.503 Combination 50 5.50 1,669 3.52 1,644 22,496 49 0.000 3.865 Control 50 5.22 1,075 4.56 1,280 5,505 49 0.000 1.092 Based on Table 4 , the ANOVA test revealed a statistically significant difference in the effectiveness of the interventions (F = 20.521, p: 0,000) This indicating that at least one group differed significantly in terms of pain reduction. Table 4. One Way ANOVA summary for pain reduction between intervention group and control group. Variable SS Df Mean Square F P Between groups 73.600 3 24.533 20.521 0.000 Within groups 234.320 196 1.196 Total 307.929 199 Based on Table 5 , the average pain score before the combined therapy (hypnobirthing and music therapy) was 5,50 (SD = 1,669), indicating moderate to severe pain levels. After the combined intervention, the average pain score decreased to 3,52 (SD = 1,644), showing a significant reduction to mild pain levels. The mean difference in pain scores (pre-test vs. post-test) was 1,803 (SD = 2,157), demonstrating a substantial reduction in pain following the combined therapy. The paired t-test statistic (t(49) = 22,496) was highly significant with p: 0.000. This confirms that the observed reduction in pain scores was not due to chance but was likely caused by the combined effect of hypnobirthing and music therapy. Table 5. Post hoc comparisons using Tukey HSD test for mean pain scores between the groups. Group 1 Group 2 Mean Difference 95%CI P Significant Music Therapy Hypnobirthing -0.080 (-0.65 – 0.49) 0.980 No Music Therapy Combination 0.160 (-0.41 – 0.73) 0.884 No Music Therapy Control -1.360 (-1.93 – -0.79) 0.000 Yes Hypnobirthing Music Therapy 0.080 (-0.49 – 0.65) 0.983 No Hypnobirthing Combination 0.240 (-0.33 – 0.81) 0.691 No Hypnobirthing Control -1.280 (-1.85 – -0.71) 0.000 Yes Combination Music Therapy -0.160 (-0.73 – 0.41) 0.884 No Combination Hypnobirthing -0.240 (-0.81 – 0.33) 0.691 No Combination Control -1.520 (-2.09 – -0.95) 0.000 Yes Control Music Therapy 1.360 (0.79 – 1.93) 0.000 Yes Control Hypnobirthing 1.280 (0.71 – 1.85) 0.000 Yes Control Combination 1.520 (0.95 – 2.09) 0.000 Yes Discussion The findings demonstrate that both hypnobirthing and music therapy are effective in reducing LBP during the third trimester of pregnancy. The superior effectiveness of the combined intervention suggests potential synergistic benefits when these approaches are used concurrently. These results align with previous studies, highlighting the efficacy of relaxation-based therapies in managing prenatal discomfort. Integrating these non-invasive, low-cost interventions into antenatal care protocols may enhance maternal comfort, reduce dependence on pharmacological pain relief, and support holistic prenatal care. Saad and Jariyah (2022) found that hypnobirthing works through the cognitive-emotional pathway by reducing anxiety and activating positive suggestion mechanisms. Therefore, when these two approaches are combined, the result is not simply a summation of effects but a synergy that strengthens the body’s adaptive response to pain. This aligns with the biopsychosocial approach to pain management, which emphasizes the importance of integrating biological, psychological, and sociocultural interventions ( Maidawilis et al., 2023 ). Comparison between the three intervention groups showed that the combination of hypnobirthing and music therapy provided the best results in reducing lower back pain, followed by single hypnobirthing and single music therapy. This finding indicates that integrating non-pharmacological methods with different but complementary approaches can strengthen the effect of interventions on pain. This combination of methods addresses pain perception from two directions: cognitive-affective through hypnobirthing and sensory-emotional through music ( Asmara et al., 2017 ). In terms of implementation, these results show that combined interventions have enormous potential for application in midwifery practice in Indonesia, especially in non-invasive antenatal care. The application of a multimodal approach that combines cultural and psychological aspects provides a more holistic therapeutic response and empowers patients. This effectiveness is the basis for developing an integrated intervention model in the management of musculoskeletal pain in pregnancy ( Hall et al., 2016 ). Nursing care for pregnant women with back pain and acute pain issues may include non-pharmacological pain management therapies, such as distraction and diversion through classical music therapy and hypnobirthing relaxation techniques. Non-pharmacological pain management techniques, such as deep breathing exercises, are commonly used in hospitals. Medications are generally employed exclusively for pain relief ( Cheung et al., 2023 ). Despite extensive research on the impact of music on physical and emotional health, there remains a deficiency of studies explicitly examining the effects of traditional Indonesian music, such as Gending Sriwijaya, on lower back pain in pregnant women ( Santiváñez-Acosta et al., 2020 ). This synergy amplifies the release of endorphins and oxytocin, inhibits cortisol production, and decreases the perception of the threat often associated with pregnancy pain. These combined effects create optimal physical and psychological conditions for a sustained reduction in pain. In other words, the combination of interventions provides a layered stimulus that supports the mother’s self-regulation capacity for pain ( Sr et al., 2021 ). Furthermore, the combined intervention of hypnobirthing and therapeutic music works through physiological pathways and creates profound psychospiritual effects on pregnant women. In hypnobirthing, pregnant women are directed to enter a deeper state of relaxed awareness through positive affirmation and visualization techniques ( Sr et al., 2021 ). This process maximizes the emotional and cognitive resonance effects when paired with traditional music, such as Gending Sriwijaya. Traditional music has a stable and harmonious rhythmic and melodic structure, which is known to facilitate light trance states that are ideal for the reception of positive suggestions during hypnobirthing sessions. Conclusion Hypnobirthing and music therapy significantly reduced pregnancy-related lower back pain, with their combination yielding the most pronounced benefits. These non-pharmacological interventions should be considered for routine use in third-trimester prenatal care to improve maternal wellbeing. All interventions were effective, and a combined approach may offer better benefits or be a promising holistic approach. Ethical considerations This study was approved by head of ethics review committee Dr. Suzanna, S.Kep., Ns., M. Kep on 25 November 2024 by Health Research Ethics Committee of IKesT Muhammadiyah Palembang have granted ethical approval No: 002009/KEP IKesT Muhammadiyah Palembang/2024). The approval is based on 7 (seven) WHO 2011 Standard and guidance part III ( WHO, 2011 ), Namely Ethical basis for decision-making will reference to the fulfilment of 2016 CIOMS guideline ( CIOMS, 2016 ). The respondents were third-trimester pregnant women who experienced mild to severe lower back pain. Prior to participation, all eligible pregnant women were informed about the study objectives, procedures, potential risks, and benefits. Written informed consent was obtained from all participants before data collection began. The consent process emphasized voluntary participation, the right to withdraw at any stage without any consequences, and assurance of confidentiality. No parental or guardian consent was required since all participants were adults above the age of 18 years. All collected data were anonymized to ensure participant privacy and confidentiality, and after being explained, the respondents are asked to sign the availability of being a respondent on the consent sheet provided. Zenodo. Questionnaire and research tools. https://doi.org/10.5281/zenodo.16881327 ( Murbiah, 2025a ). Data availability Zenodo. Research data (DataSet). https://doi.org/10.5281/zenodo.16758814 ( Murbiah, 2025b ). Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). This Project contains the following underlying data: Research Dataset (DataSet) This file includes raw and cleaned numerical data on low back pain scores (VAS), demographic characteristics, and intervention groups (music therapy, hypnobirthing, combined intervention, and control) from 200 third-trimester pregnant women participants. Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgments We would like to express our deepest gratitude to the University of Muhammadiyah Palembang (UMAD) and the Faculty of Nursing, Lincoln University College (LUC), Malaysia for their academic support and facilities throughout this research. We also extend our sincere appreciation to the Head of the Community Health Center and all health workers in the field for their cooperation, dedication, and active contribution to implementing the intervention and collecting data. All assistance and support from these various parties were integral to the success of this study. References Amayri A, Khalayli N, Haj Ali D, et al. : Low back pain in a sample of Syrian pregnant women: A cross-sectional study. Health Sci. Rep. 2023; 6 (7): e1389. 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Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 03 Sep 2025 ADD YOUR COMMENT Comment Author details Author details 1 Lincoln university Collage, Lincoln University College Faculty of Medicine, Petaling Jaya, Selangor, Malaysia 2 universitas muhammdiyah ahamd dahlan, universitas muhammadiyah ahmad dahlan palembang, palembang, sumatera selatan, Indonesia 3 Sekolah tinggi ilmu kesehatan Bina Husada, sekolah tinggi llmu kesehatan Bina Husada, Palembang, Sumatera selatan, Indonesia Murbiah . Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Santhna Letchmi Panduragan Roles: Conceptualization, Formal Analysis, Methodology, Supervision, Visualization Kasmahwati Pardi Roles: Conceptualization, Formal Analysis, Supervision Hafizah Che hassan Roles: Supervision, Validation Husin . Roles: Data Curation, Investigation, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This research was supported and financed by Muhammadiyah Ahmad Dahlan University Palembang through campus grants based on work agreement letter number 0280/II/3/AU/F/2022. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 13 Jan 2026, 14:868 https://doi.org/10.12688/f1000research.168854.2 version 1 Published: 03 Sep 2025, 14:868 https://doi.org/10.12688/f1000research.168854.1 Copyright © 2025 . M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 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Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 03 Sep 2025 Views 0 Cite How to cite this report: Pramesona BA. Reviewer Report For: Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.5256/f1000research.186071.r412885 ) The direct URL for this report is: https://f1000research.com/articles/14-868/v1#referee-response-412885 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 23 Oct 2025 Bayu Anggileo Pramesona , Department of Public Health, Faculty of Medicine, Lampung University (Universitas Lampung), Bandar Lampung, Indonesia Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.186071.r412885 Abstract: Methods: Where was the study setting and when the study was conducted? What the statistical analysis used in this study? Conclusion: It should be more specific and refers ... Continue reading READ ALL Abstract: Methods: Where was the study setting and when the study was conducted? What the statistical analysis used in this study? Conclusion: It should be more specific and refers to your study objective. Introduction. What is the urgency to do this study in the primary health care setting? Methods: “This study will be conducted in four primary health care centers (PUSKESMAS) spread across the administrative area of Palembang City, South Sumatra Province, Indonesia”. This study has been conducted or will be conducted??? The authors stated the Palembang City was chosen as the study location because it has a large population of pregnant women and socio-cultural variations that reflect the diversity of urban community contexts in Indonesia. Please add the specific number or rank compared to other cities or provinces in Indonesia with reference Is there any specific reasons for choosing those public health centers as your study site? Please add the ethical clearance number and the institution issued the letter The authors stated developed and validated the instrument in Oct 2024, which instrument which developed and validated? And what kind of validity and reliability test that you conducted? “In the intervention phase, the authors involving the administration of music therapy and hypnobirthing sessions for four weeks under the supervision of certified health personnel ”, who were they?? The authors used randomization for a quasi-experimental study design?? How did you know the respondents had psychiatric disorders so you excluded them? The inclusion criteria were as follows: third-trimester pregnant women, experiencing moderate to severe lower back pain. Why you chose the pregnant women who had severe LBP? Did they take the medication to relieve the pain? It should be clear in the inclusion criteria because it could recall the bias of your outcome. For the hypnobirthing intervention, please elaborate the intervention, how the technical steps of that intervention. When the respondents practice this intervention? At home? Alone? Assisted by whom? How you know the respondents did it correctly? I did not see any explanation about the combined intervention part. It should be clearly stated with detail steps. Results: Don’t repeat this sentence “The research phase began with the approval of the ethics committee and research permit in July 2024. Researchers began to identify respondents based on the following inclusion criteria: pregnant women in the third trimester, experiencing mild to severe lower back pain, and primigravida. After the respondents were collected, lower back pain was measured using a visual analogue scale (VAS) questionnaire on 200 respondents of pregnant women in the third trimester in the working areas of the Pembina Health Center, Nagaswidak Health center, Taman Bacaan Health Center and Pembina Health Center”. It has been stated in the methods part Please add the baseline data analysis for those 4 groups, is there any differences between groups? P=0.000 should be written as p<0.001 Discussion All interventions have a significant reduction in pain. However, the combined intervention had a higher reduction score compared to other groups. How you discuss it?? Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Health policy, public health nursing, healthcare management I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Pramesona BA. Reviewer Report For: Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.5256/f1000research.186071.r412885 ) The direct URL for this report is: https://f1000research.com/articles/14-868/v1#referee-response-412885 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 13 Jan 2026 Murbiah murbiah , Lincoln university Collage, Lincoln University College Faculty of Medicine, Petaling Jaya, Malaysia 13 Jan 2026 Author Response Dear Reviewer We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention ... Continue reading Dear Reviewer We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study.” Below we provide a detailed response to each point raised: 1. Abstract a. We have added information about the location and time of the study to the Abstract and Methods sections, namely: “ The study was conducted at four Community Health Centers (Puskesmas) in Palembang City, South Sumatra Province, Indonesia. 2. The statistical analyses used included the Paired Sample t-test, One-Way ANOVA, and Post hoc comparisons using Tukey HSD test for mean pain scores between the groups. This information has been added to the abstract section of the Methods section b. The conclusion section has been clarified to align with the research objectives. It now reads: “Music therapy and hypnobirthing have been proven effective in reducing lower back pain intensity in pregnant women in their third trimester, with the combination of both therapies providing the most significant effect.” 2. Introduction We have added an explanation in the Introduction section that this research is important to be conducted in primary health care facilities because most pregnant women in Indonesia receive antenatal care at community health centers. The implementation of non-pharmacological therapies such as music and hypnobirthing at the primary level can strengthen promotive-preventive services and reduce dependence on analgesics during pregnancy. 3.Methods a. We have revised the sentence to the past tense: “This study was conducted in four primary health care centers (PUSKESMAS) spread across the administrative area of Palembang City, South Sumatra Province, Indonesia. Palembang b. We have added data from the South Sumatra Health Profile for the city of Palembang in 2024, which shows that Palembang has approximately 27,775 pregnant women, ranking first in South Sumatra Province. This information was included with official references from the Health Office. c. The four health centers were selected purposively because they had high numbers of antenatal visits, represented urban and suburban areas, and had health workers certified in hypnobirthing and music therapy. This explanation has been included in the Methods section. d. This study was approved by head of ethics review committee Dr. Suzanna, S.Kep., Ns., M. Kep on 25 November 2024 by Health Research Ethics Committee of IKesT Muhammadiyah Palembang have granted ethical approval No: 002009/KEP IKesT Muhammadiyah Palembang/2024). e. The instruments developed were the Music and Hypnobirthing Side Effect Checklist (MHSEC). Content validity was tested using the Content Validity Index (CVI = 0.92) with three experts, while reliability was tested using Cronbach’s Alpha (α = 0.84). This information has been clarified in the Methods section f. Interventions are carried out under the supervision of a certified hypnobirthing midwife who has received official training from an accredited institution g. The process of allocating participants into four groups was carried out using a computer-based random number generator prepared by an independent researcher. Participant identification numbers were entered into a list and randomized automatically using the Research Randomizer application (https://www.randomizer.org/). The randomization results were sealed in sequential sealed envelopes to maintain the confidentiality of the allocation h. Respondents with moderate to severe pain were selected because clinically this condition requires non-pharmacological intervention to avoid the use of analgesics. We confirmed that all respondents did not take analgesic medication during the study period, as stated in the exclusion criteria i. Hypnobirthing intervention is carried out in accordance with standard procedures included guided breathing, visualization, and deep relaxation techniques conducted by a certified practitioner Each hypnobirthing session lasts 30 minutes twice weekly for four week. j. Combination group: received a joint intervention combining hypnobirthing techniques and therapeutic music under the same schedule and procedures. The combined intervention included hypnobirthing sessions accompanied by relaxing instrumental music played at a slow tempo of 50–70 bpm under the supervision of certified health professionals. 4.Result Duplicate sentences have been removed from the Results section to avoid redundancy. The statistical notation has been corrected throughout the manuscript to p < 0.001. 5. Discussion The Discussion section has been expanded with an explanation that the synergistic effects of music therapy and hypnobirthing enhance the parasympathetic relaxation response and lower cortisol levels, thereby optimizing pain perception reduction We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team Dear Reviewer We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study.” Below we provide a detailed response to each point raised: 1. Abstract a. We have added information about the location and time of the study to the Abstract and Methods sections, namely: “ The study was conducted at four Community Health Centers (Puskesmas) in Palembang City, South Sumatra Province, Indonesia. 2. The statistical analyses used included the Paired Sample t-test, One-Way ANOVA, and Post hoc comparisons using Tukey HSD test for mean pain scores between the groups. This information has been added to the abstract section of the Methods section b. The conclusion section has been clarified to align with the research objectives. It now reads: “Music therapy and hypnobirthing have been proven effective in reducing lower back pain intensity in pregnant women in their third trimester, with the combination of both therapies providing the most significant effect.” 2. Introduction We have added an explanation in the Introduction section that this research is important to be conducted in primary health care facilities because most pregnant women in Indonesia receive antenatal care at community health centers. The implementation of non-pharmacological therapies such as music and hypnobirthing at the primary level can strengthen promotive-preventive services and reduce dependence on analgesics during pregnancy. 3.Methods a. We have revised the sentence to the past tense: “This study was conducted in four primary health care centers (PUSKESMAS) spread across the administrative area of Palembang City, South Sumatra Province, Indonesia. Palembang b. We have added data from the South Sumatra Health Profile for the city of Palembang in 2024, which shows that Palembang has approximately 27,775 pregnant women, ranking first in South Sumatra Province. This information was included with official references from the Health Office. c. The four health centers were selected purposively because they had high numbers of antenatal visits, represented urban and suburban areas, and had health workers certified in hypnobirthing and music therapy. This explanation has been included in the Methods section. d. This study was approved by head of ethics review committee Dr. Suzanna, S.Kep., Ns., M. Kep on 25 November 2024 by Health Research Ethics Committee of IKesT Muhammadiyah Palembang have granted ethical approval No: 002009/KEP IKesT Muhammadiyah Palembang/2024). e. The instruments developed were the Music and Hypnobirthing Side Effect Checklist (MHSEC). Content validity was tested using the Content Validity Index (CVI = 0.92) with three experts, while reliability was tested using Cronbach’s Alpha (α = 0.84). This information has been clarified in the Methods section f. Interventions are carried out under the supervision of a certified hypnobirthing midwife who has received official training from an accredited institution g. The process of allocating participants into four groups was carried out using a computer-based random number generator prepared by an independent researcher. Participant identification numbers were entered into a list and randomized automatically using the Research Randomizer application (https://www.randomizer.org/). The randomization results were sealed in sequential sealed envelopes to maintain the confidentiality of the allocation h. Respondents with moderate to severe pain were selected because clinically this condition requires non-pharmacological intervention to avoid the use of analgesics. We confirmed that all respondents did not take analgesic medication during the study period, as stated in the exclusion criteria i. Hypnobirthing intervention is carried out in accordance with standard procedures included guided breathing, visualization, and deep relaxation techniques conducted by a certified practitioner Each hypnobirthing session lasts 30 minutes twice weekly for four week. j. Combination group: received a joint intervention combining hypnobirthing techniques and therapeutic music under the same schedule and procedures. The combined intervention included hypnobirthing sessions accompanied by relaxing instrumental music played at a slow tempo of 50–70 bpm under the supervision of certified health professionals. 4.Result Duplicate sentences have been removed from the Results section to avoid redundancy. The statistical notation has been corrected throughout the manuscript to p < 0.001. 5. Discussion The Discussion section has been expanded with an explanation that the synergistic effects of music therapy and hypnobirthing enhance the parasympathetic relaxation response and lower cortisol levels, thereby optimizing pain perception reduction We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team Competing Interests: No competing interests Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 13 Jan 2026 Murbiah murbiah , Lincoln university Collage, Lincoln University College Faculty of Medicine, Petaling Jaya, Malaysia 13 Jan 2026 Author Response Dear Reviewer We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention ... Continue reading Dear Reviewer We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study.” Below we provide a detailed response to each point raised: 1. Abstract a. We have added information about the location and time of the study to the Abstract and Methods sections, namely: “ The study was conducted at four Community Health Centers (Puskesmas) in Palembang City, South Sumatra Province, Indonesia. 2. The statistical analyses used included the Paired Sample t-test, One-Way ANOVA, and Post hoc comparisons using Tukey HSD test for mean pain scores between the groups. This information has been added to the abstract section of the Methods section b. The conclusion section has been clarified to align with the research objectives. It now reads: “Music therapy and hypnobirthing have been proven effective in reducing lower back pain intensity in pregnant women in their third trimester, with the combination of both therapies providing the most significant effect.” 2. Introduction We have added an explanation in the Introduction section that this research is important to be conducted in primary health care facilities because most pregnant women in Indonesia receive antenatal care at community health centers. The implementation of non-pharmacological therapies such as music and hypnobirthing at the primary level can strengthen promotive-preventive services and reduce dependence on analgesics during pregnancy. 3.Methods a. We have revised the sentence to the past tense: “This study was conducted in four primary health care centers (PUSKESMAS) spread across the administrative area of Palembang City, South Sumatra Province, Indonesia. Palembang b. We have added data from the South Sumatra Health Profile for the city of Palembang in 2024, which shows that Palembang has approximately 27,775 pregnant women, ranking first in South Sumatra Province. This information was included with official references from the Health Office. c. The four health centers were selected purposively because they had high numbers of antenatal visits, represented urban and suburban areas, and had health workers certified in hypnobirthing and music therapy. This explanation has been included in the Methods section. d. This study was approved by head of ethics review committee Dr. Suzanna, S.Kep., Ns., M. Kep on 25 November 2024 by Health Research Ethics Committee of IKesT Muhammadiyah Palembang have granted ethical approval No: 002009/KEP IKesT Muhammadiyah Palembang/2024). e. The instruments developed were the Music and Hypnobirthing Side Effect Checklist (MHSEC). Content validity was tested using the Content Validity Index (CVI = 0.92) with three experts, while reliability was tested using Cronbach’s Alpha (α = 0.84). This information has been clarified in the Methods section f. Interventions are carried out under the supervision of a certified hypnobirthing midwife who has received official training from an accredited institution g. The process of allocating participants into four groups was carried out using a computer-based random number generator prepared by an independent researcher. Participant identification numbers were entered into a list and randomized automatically using the Research Randomizer application (https://www.randomizer.org/). The randomization results were sealed in sequential sealed envelopes to maintain the confidentiality of the allocation h. Respondents with moderate to severe pain were selected because clinically this condition requires non-pharmacological intervention to avoid the use of analgesics. We confirmed that all respondents did not take analgesic medication during the study period, as stated in the exclusion criteria i. Hypnobirthing intervention is carried out in accordance with standard procedures included guided breathing, visualization, and deep relaxation techniques conducted by a certified practitioner Each hypnobirthing session lasts 30 minutes twice weekly for four week. j. Combination group: received a joint intervention combining hypnobirthing techniques and therapeutic music under the same schedule and procedures. The combined intervention included hypnobirthing sessions accompanied by relaxing instrumental music played at a slow tempo of 50–70 bpm under the supervision of certified health professionals. 4.Result Duplicate sentences have been removed from the Results section to avoid redundancy. The statistical notation has been corrected throughout the manuscript to p < 0.001. 5. Discussion The Discussion section has been expanded with an explanation that the synergistic effects of music therapy and hypnobirthing enhance the parasympathetic relaxation response and lower cortisol levels, thereby optimizing pain perception reduction We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team Dear Reviewer We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study.” Below we provide a detailed response to each point raised: 1. Abstract a. We have added information about the location and time of the study to the Abstract and Methods sections, namely: “ The study was conducted at four Community Health Centers (Puskesmas) in Palembang City, South Sumatra Province, Indonesia. 2. The statistical analyses used included the Paired Sample t-test, One-Way ANOVA, and Post hoc comparisons using Tukey HSD test for mean pain scores between the groups. This information has been added to the abstract section of the Methods section b. The conclusion section has been clarified to align with the research objectives. It now reads: “Music therapy and hypnobirthing have been proven effective in reducing lower back pain intensity in pregnant women in their third trimester, with the combination of both therapies providing the most significant effect.” 2. Introduction We have added an explanation in the Introduction section that this research is important to be conducted in primary health care facilities because most pregnant women in Indonesia receive antenatal care at community health centers. The implementation of non-pharmacological therapies such as music and hypnobirthing at the primary level can strengthen promotive-preventive services and reduce dependence on analgesics during pregnancy. 3.Methods a. We have revised the sentence to the past tense: “This study was conducted in four primary health care centers (PUSKESMAS) spread across the administrative area of Palembang City, South Sumatra Province, Indonesia. Palembang b. We have added data from the South Sumatra Health Profile for the city of Palembang in 2024, which shows that Palembang has approximately 27,775 pregnant women, ranking first in South Sumatra Province. This information was included with official references from the Health Office. c. The four health centers were selected purposively because they had high numbers of antenatal visits, represented urban and suburban areas, and had health workers certified in hypnobirthing and music therapy. This explanation has been included in the Methods section. d. This study was approved by head of ethics review committee Dr. Suzanna, S.Kep., Ns., M. Kep on 25 November 2024 by Health Research Ethics Committee of IKesT Muhammadiyah Palembang have granted ethical approval No: 002009/KEP IKesT Muhammadiyah Palembang/2024). e. The instruments developed were the Music and Hypnobirthing Side Effect Checklist (MHSEC). Content validity was tested using the Content Validity Index (CVI = 0.92) with three experts, while reliability was tested using Cronbach’s Alpha (α = 0.84). This information has been clarified in the Methods section f. Interventions are carried out under the supervision of a certified hypnobirthing midwife who has received official training from an accredited institution g. The process of allocating participants into four groups was carried out using a computer-based random number generator prepared by an independent researcher. Participant identification numbers were entered into a list and randomized automatically using the Research Randomizer application (https://www.randomizer.org/). The randomization results were sealed in sequential sealed envelopes to maintain the confidentiality of the allocation h. Respondents with moderate to severe pain were selected because clinically this condition requires non-pharmacological intervention to avoid the use of analgesics. We confirmed that all respondents did not take analgesic medication during the study period, as stated in the exclusion criteria i. Hypnobirthing intervention is carried out in accordance with standard procedures included guided breathing, visualization, and deep relaxation techniques conducted by a certified practitioner Each hypnobirthing session lasts 30 minutes twice weekly for four week. j. Combination group: received a joint intervention combining hypnobirthing techniques and therapeutic music under the same schedule and procedures. The combined intervention included hypnobirthing sessions accompanied by relaxing instrumental music played at a slow tempo of 50–70 bpm under the supervision of certified health professionals. 4.Result Duplicate sentences have been removed from the Results section to avoid redundancy. The statistical notation has been corrected throughout the manuscript to p < 0.001. 5. Discussion The Discussion section has been expanded with an explanation that the synergistic effects of music therapy and hypnobirthing enhance the parasympathetic relaxation response and lower cortisol levels, thereby optimizing pain perception reduction We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team Competing Interests: No competing interests Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Srinivasan AR. Reviewer Report For: Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.5256/f1000research.186071.r412884 ) The direct URL for this report is: https://f1000research.com/articles/14-868/v1#referee-response-412884 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 06 Oct 2025 Abu R. Srinivasan , Sri Balaji Vidyapeeth (Deemed to be University), Pillayarkuppam, Puducherry, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.186071.r412884 Did the authors measure the adverse effects of music therapy at all??? If so, did they prepare self-report questionnaires and rating scales (duly validated) to assess psychological and physiological data,prior to and following treatment??. The authors must please note ... Continue reading READ ALL Did the authors measure the adverse effects of music therapy at all??? If so, did they prepare self-report questionnaires and rating scales (duly validated) to assess psychological and physiological data,prior to and following treatment??. The authors must please note that clinical observation and client interviews are also regarded crucial for documenting symptoms such as irritability, boredom, or even the exacerbation of the existing condition. Likewise, did the authors collect data through participant self-reports for assessing symptoms such as dizziness or anxiety and any other pertinent clinical observations.As an extension of the endeavour, then data analysis could be completed by computing the rate of adverse events, with particular reference to serious vs. non-serious effects as well as hypnosis-related vs. other possible causes. Outcome The primary outcome of the study was the reduction in lower back pain intensity before and after a four-week intervention period........Can this sentence be written without any ambiguity??? Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Biochemistry related to metabolism and metabolic disorders, Endocrine Biochemistry, Music as an adjuvant therapeutic modality, Diagnostic enzymology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Srinivasan AR. Reviewer Report For: Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.5256/f1000research.186071.r412884 ) The direct URL for this report is: https://f1000research.com/articles/14-868/v1#referee-response-412884 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 13 Jan 2026 Murbiah murbiah , Lincoln university Collage, Lincoln University College Faculty of Medicine, Petaling Jaya, Malaysia 13 Jan 2026 Author Response Dear Reviewer, We sincerely thank the Reviewer for this valuable input and for emphasizing the importance of monitoring potential side effects associated with the intervention. Below we provide a detailed ... Continue reading Dear Reviewer, We sincerely thank the Reviewer for this valuable input and for emphasizing the importance of monitoring potential side effects associated with the intervention. Below we provide a detailed response to each point raised: 1. Measurement of Side Effects Thank you for your valuable comments. In this study, the side effects of the intervention were observed using the Music and Hypnobirthing Side Effect Checklist (MHSEC). Music and hypnobirthing Side Effect Checklist (MHSEC) developed and validated by researchers (I-CVI = 1.00; Cronbach's Alpha = 0.926). This instrument assesses physical and psychological symptoms that may arise during the intervention, including dizziness, nausea, headache, restlessness, palpitations, drowsiness, distraction, back pain, abnormal fetal movement, and mood. Observations were made before and after each therapy session by trained observers to ensure the safety of the intervention. We have added an explanation that adverse event data collection was conducted through participant self-reports and observations. Adverse event severity analysis has also been added to the results section, with classifications of “mild,” “moderate,” and “severe.” No severe adverse events were found in any of the intervention groups. 2. Data interpretation Thank you for your suggestion.The sentence has been revised to be clearer and more specific about the main results and the intervention period. The main results of the study showed a significant reduction in lower back pain intensity after four weeks of intervention in all treatment groups, with the greatest reduction in the combination group of hypnobirthing and music therapy compared to the control group (p < 0.001). 3. literature. Thank you for the reviewer's attention to the literature aspect. We have updated and expanded the bibliography by including the latest literature published between 2018 and 2023, covering experimental research results, meta-analyses, and systematic reviews relevant to the topics of hypnobirthing and music therapy. We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team Dear Reviewer, We sincerely thank the Reviewer for this valuable input and for emphasizing the importance of monitoring potential side effects associated with the intervention. Below we provide a detailed response to each point raised: 1. Measurement of Side Effects Thank you for your valuable comments. In this study, the side effects of the intervention were observed using the Music and Hypnobirthing Side Effect Checklist (MHSEC). Music and hypnobirthing Side Effect Checklist (MHSEC) developed and validated by researchers (I-CVI = 1.00; Cronbach's Alpha = 0.926). This instrument assesses physical and psychological symptoms that may arise during the intervention, including dizziness, nausea, headache, restlessness, palpitations, drowsiness, distraction, back pain, abnormal fetal movement, and mood. Observations were made before and after each therapy session by trained observers to ensure the safety of the intervention. We have added an explanation that adverse event data collection was conducted through participant self-reports and observations. Adverse event severity analysis has also been added to the results section, with classifications of “mild,” “moderate,” and “severe.” No severe adverse events were found in any of the intervention groups. 2. Data interpretation Thank you for your suggestion.The sentence has been revised to be clearer and more specific about the main results and the intervention period. The main results of the study showed a significant reduction in lower back pain intensity after four weeks of intervention in all treatment groups, with the greatest reduction in the combination group of hypnobirthing and music therapy compared to the control group (p < 0.001). 3. literature. Thank you for the reviewer's attention to the literature aspect. We have updated and expanded the bibliography by including the latest literature published between 2018 and 2023, covering experimental research results, meta-analyses, and systematic reviews relevant to the topics of hypnobirthing and music therapy. We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team Competing Interests: No competing interests Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 13 Jan 2026 Murbiah murbiah , Lincoln university Collage, Lincoln University College Faculty of Medicine, Petaling Jaya, Malaysia 13 Jan 2026 Author Response Dear Reviewer, We sincerely thank the Reviewer for this valuable input and for emphasizing the importance of monitoring potential side effects associated with the intervention. Below we provide a detailed ... Continue reading Dear Reviewer, We sincerely thank the Reviewer for this valuable input and for emphasizing the importance of monitoring potential side effects associated with the intervention. Below we provide a detailed response to each point raised: 1. Measurement of Side Effects Thank you for your valuable comments. In this study, the side effects of the intervention were observed using the Music and Hypnobirthing Side Effect Checklist (MHSEC). Music and hypnobirthing Side Effect Checklist (MHSEC) developed and validated by researchers (I-CVI = 1.00; Cronbach's Alpha = 0.926). This instrument assesses physical and psychological symptoms that may arise during the intervention, including dizziness, nausea, headache, restlessness, palpitations, drowsiness, distraction, back pain, abnormal fetal movement, and mood. Observations were made before and after each therapy session by trained observers to ensure the safety of the intervention. We have added an explanation that adverse event data collection was conducted through participant self-reports and observations. Adverse event severity analysis has also been added to the results section, with classifications of “mild,” “moderate,” and “severe.” No severe adverse events were found in any of the intervention groups. 2. Data interpretation Thank you for your suggestion.The sentence has been revised to be clearer and more specific about the main results and the intervention period. The main results of the study showed a significant reduction in lower back pain intensity after four weeks of intervention in all treatment groups, with the greatest reduction in the combination group of hypnobirthing and music therapy compared to the control group (p < 0.001). 3. literature. Thank you for the reviewer's attention to the literature aspect. We have updated and expanded the bibliography by including the latest literature published between 2018 and 2023, covering experimental research results, meta-analyses, and systematic reviews relevant to the topics of hypnobirthing and music therapy. We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team Dear Reviewer, We sincerely thank the Reviewer for this valuable input and for emphasizing the importance of monitoring potential side effects associated with the intervention. Below we provide a detailed response to each point raised: 1. Measurement of Side Effects Thank you for your valuable comments. In this study, the side effects of the intervention were observed using the Music and Hypnobirthing Side Effect Checklist (MHSEC). Music and hypnobirthing Side Effect Checklist (MHSEC) developed and validated by researchers (I-CVI = 1.00; Cronbach's Alpha = 0.926). This instrument assesses physical and psychological symptoms that may arise during the intervention, including dizziness, nausea, headache, restlessness, palpitations, drowsiness, distraction, back pain, abnormal fetal movement, and mood. Observations were made before and after each therapy session by trained observers to ensure the safety of the intervention. We have added an explanation that adverse event data collection was conducted through participant self-reports and observations. Adverse event severity analysis has also been added to the results section, with classifications of “mild,” “moderate,” and “severe.” No severe adverse events were found in any of the intervention groups. 2. Data interpretation Thank you for your suggestion.The sentence has been revised to be clearer and more specific about the main results and the intervention period. The main results of the study showed a significant reduction in lower back pain intensity after four weeks of intervention in all treatment groups, with the greatest reduction in the combination group of hypnobirthing and music therapy compared to the control group (p < 0.001). 3. literature. Thank you for the reviewer's attention to the literature aspect. We have updated and expanded the bibliography by including the latest literature published between 2018 and 2023, covering experimental research results, meta-analyses, and systematic reviews relevant to the topics of hypnobirthing and music therapy. We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team Competing Interests: No competing interests Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Sharma DC, Sharma J and Zehra S. Reviewer Report For: Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.5256/f1000research.186071.r412881 ) The direct URL for this report is: https://f1000research.com/articles/14-868/v1#referee-response-412881 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 16 Sep 2025 Dinesh C. Sharma , Bio musicology or Music Therapy, Km. Mayawati Government Girls P.G. College, Badalpur, Uttar Pradesh, India Jyoti Sharma , Research Associate (DST-CURIE) Dept of Bio musicology, Km. Mayawati Government Girls P.G. College, Badlapur, Uttar Pradesh, India Sumbul Zehra , Indian Association of Music Therapy, Delhi, Delhi, India Approved VIEWS 0 https://doi.org/10.5256/f1000research.186071.r412881 Summary of the Article The manuscript titled " Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study " presents a quasi-experimental investigation involving 200 third-trimester pregnant women recruited from four ... Continue reading READ ALL Summary of the Article The manuscript titled " Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study " presents a quasi-experimental investigation involving 200 third-trimester pregnant women recruited from four primary health care centers in Palembang, Indonesia. Participants were randomly allocated into four groups: hypnobirthing, music therapy, combined therapy, and control (n=50 each). Pain intensity was assessed using the Visual Analog Scale (VAS) before and after a four-week intervention. The results indicate a statistically significant reduction in pain intensity across all intervention groups compared to the control (p < 0.001), with the combined intervention group showing the greatest improvement. The authors conclude that both hypnobirthing and music therapy are effective, and their combination provides synergistic benefits, supporting the use of these interventions as part of routine antenatal care. Strengths • The study addresses a significant clinical problem , pregnancy-related low back pain, which affects quality of life and labor outcomes. • Use of a quasi-experimental design with four groups provides good comparative power. • Incorporation of traditional Indonesian music is an important contribution to culturally contextualized maternal care research. • The study reports proper ethical approval, informed consent, and anonymization of data. Points for Improvement • While the paper mentions "random group allocation," it does not describe how randomization was implemented (lottery method, random number generator, sealed envelopes?). • Details on standardization of hypnobirthing sessions (duration, script used, practitioner training) and music therapy sessions (volume, environment control) are insufficient. Authors should specify steps taken to ensure intervention fidelity and reproducibility. • The control group received "standard antenatal care with a leaflet." Please clarify whether attention control was ensured to reduce placebo effects (e.g., similar time spent with staff as intervention groups). • Future research directions could include multi-center RCTs, cost-effectiveness studies, and assessment of psychological well-being outcomes. Overall Recommendation The study addresses a relevant problem and presents promising findings with potential implications for maternal health practice. However, minor revisions are required before the article can be considered scientifically sound and can be indexed. Decision: Minor Revision Required Summary of Required Revisions: • Clarify randomization method, intervention fidelity, and control group comparability. • Include confidence intervals and more detailed statistical reporting. • Expand discussion of study limitations and suggest future research directions. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Bio-musicology, Music Therapy, Complimentary and Alternative Medicine, Breast Cancer We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Sharma DC, Sharma J and Zehra S. Reviewer Report For: Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.5256/f1000research.186071.r412881 ) The direct URL for this report is: https://f1000research.com/articles/14-868/v1#referee-response-412881 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 13 Jan 2026 Murbiah murbiah , Lincoln university Collage, Lincoln University College Faculty of Medicine, Petaling Jaya, Malaysia 13 Jan 2026 Author Response We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low ... Continue reading We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study.” We appreciate the reviewer’s positive assessment of our study’s clinical relevance, methodological design, and cultural contribution. Below we provide a detailed response to each point raised: 1. Clarification of Randomization Method Thank you for your very constructive feedback. We have clarified the randomization procedure in the Research Methods section. The allocation process was conducted using a computer-based random number generator via the Research Randomizer application. The randomization results were placed in sealed envelopes in sequential order to maintain the confidentiality of the allocation. (see the sample size section). 2. Intervention Fidelity and Standardization We agree with this comment. In the Intervention Procedures section, we have added the following information: Hypnobirthing interventions are conducted according to standard procedures that include guided breathing techniques, visualization, and deep relaxation performed by certified practitioners. Each Hypnobirthing session lasts 30 minutes, twice a week for four weeks Music therapy sessions use music Music therapy interventions are carried out in accordance with standard procedures, namely listening to soothing instrumental music for 30 minutes every day for four weeks, with a slow tempo of 50–70 beats per minute, moderate music volume, and a quiet environment. This aims to maintain the consistency of participants' sensory experiences. (Saad & Jariyah, 2022), the music used is the traditional composition “Gending Sriwijaya”. This work, created by Nungcik AR in 1943 and accompanied by Palembang-style gamelan music arranged by A. Dahlan Rachim and R.C. Hardjosubroto, is a symbol of South Sumatran culture. The traditional Gending Sriwijaya music used in this study is part of the traditional cultural heritage of the Palembang community in South Sumatra, Indonesia. 3. Control Group and Attention Control Thank you for your valuable suggestion. We have added a note that the leaflet was given once at the beginning of the intervention (week 1) and briefly discussed by the staff as a form of educational control to control group. The control group received 30-minute light education sessions conducted by health workers, so that the duration and attention received were comparable to the intervention group. The educational material consisted of information in the form of leaflets about hypnobirthing and music therapy. 4. Statistical Reporting and Confidence Intervals We have revised the Results section by adding a 95% confidence interval (CI) and effect size to Table 5. 5. Study Limitations and Future Directions We have followed up on this input by adding a new paragraph in the Discussion section. We highlight the limitations of this study include the quasi-experimental design, which did not fully control for selection bias, and limitations in the subjective measurement of pain using the VAS. Further research is recommended in the form of a multi-center randomized controlled trial (RCT) and a cost-effectiveness analysis to assess the economic benefits of this intervention in routine antenatal care. We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study.” We appreciate the reviewer’s positive assessment of our study’s clinical relevance, methodological design, and cultural contribution. Below we provide a detailed response to each point raised: 1. Clarification of Randomization Method Thank you for your very constructive feedback. We have clarified the randomization procedure in the Research Methods section. The allocation process was conducted using a computer-based random number generator via the Research Randomizer application. The randomization results were placed in sealed envelopes in sequential order to maintain the confidentiality of the allocation. (see the sample size section). 2. Intervention Fidelity and Standardization We agree with this comment. In the Intervention Procedures section, we have added the following information: Hypnobirthing interventions are conducted according to standard procedures that include guided breathing techniques, visualization, and deep relaxation performed by certified practitioners. Each Hypnobirthing session lasts 30 minutes, twice a week for four weeks Music therapy sessions use music Music therapy interventions are carried out in accordance with standard procedures, namely listening to soothing instrumental music for 30 minutes every day for four weeks, with a slow tempo of 50–70 beats per minute, moderate music volume, and a quiet environment. This aims to maintain the consistency of participants' sensory experiences. (Saad & Jariyah, 2022), the music used is the traditional composition “Gending Sriwijaya”. This work, created by Nungcik AR in 1943 and accompanied by Palembang-style gamelan music arranged by A. Dahlan Rachim and R.C. Hardjosubroto, is a symbol of South Sumatran culture. The traditional Gending Sriwijaya music used in this study is part of the traditional cultural heritage of the Palembang community in South Sumatra, Indonesia. 3. Control Group and Attention Control Thank you for your valuable suggestion. We have added a note that the leaflet was given once at the beginning of the intervention (week 1) and briefly discussed by the staff as a form of educational control to control group. The control group received 30-minute light education sessions conducted by health workers, so that the duration and attention received were comparable to the intervention group. The educational material consisted of information in the form of leaflets about hypnobirthing and music therapy. 4. Statistical Reporting and Confidence Intervals We have revised the Results section by adding a 95% confidence interval (CI) and effect size to Table 5. 5. Study Limitations and Future Directions We have followed up on this input by adding a new paragraph in the Discussion section. We highlight the limitations of this study include the quasi-experimental design, which did not fully control for selection bias, and limitations in the subjective measurement of pain using the VAS. Further research is recommended in the form of a multi-center randomized controlled trial (RCT) and a cost-effectiveness analysis to assess the economic benefits of this intervention in routine antenatal care. We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team Competing Interests: No competing interests Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 13 Jan 2026 Murbiah murbiah , Lincoln university Collage, Lincoln University College Faculty of Medicine, Petaling Jaya, Malaysia 13 Jan 2026 Author Response We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low ... Continue reading We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study.” We appreciate the reviewer’s positive assessment of our study’s clinical relevance, methodological design, and cultural contribution. Below we provide a detailed response to each point raised: 1. Clarification of Randomization Method Thank you for your very constructive feedback. We have clarified the randomization procedure in the Research Methods section. The allocation process was conducted using a computer-based random number generator via the Research Randomizer application. The randomization results were placed in sealed envelopes in sequential order to maintain the confidentiality of the allocation. (see the sample size section). 2. Intervention Fidelity and Standardization We agree with this comment. In the Intervention Procedures section, we have added the following information: Hypnobirthing interventions are conducted according to standard procedures that include guided breathing techniques, visualization, and deep relaxation performed by certified practitioners. Each Hypnobirthing session lasts 30 minutes, twice a week for four weeks Music therapy sessions use music Music therapy interventions are carried out in accordance with standard procedures, namely listening to soothing instrumental music for 30 minutes every day for four weeks, with a slow tempo of 50–70 beats per minute, moderate music volume, and a quiet environment. This aims to maintain the consistency of participants' sensory experiences. (Saad & Jariyah, 2022), the music used is the traditional composition “Gending Sriwijaya”. This work, created by Nungcik AR in 1943 and accompanied by Palembang-style gamelan music arranged by A. Dahlan Rachim and R.C. Hardjosubroto, is a symbol of South Sumatran culture. The traditional Gending Sriwijaya music used in this study is part of the traditional cultural heritage of the Palembang community in South Sumatra, Indonesia. 3. Control Group and Attention Control Thank you for your valuable suggestion. We have added a note that the leaflet was given once at the beginning of the intervention (week 1) and briefly discussed by the staff as a form of educational control to control group. The control group received 30-minute light education sessions conducted by health workers, so that the duration and attention received were comparable to the intervention group. The educational material consisted of information in the form of leaflets about hypnobirthing and music therapy. 4. Statistical Reporting and Confidence Intervals We have revised the Results section by adding a 95% confidence interval (CI) and effect size to Table 5. 5. Study Limitations and Future Directions We have followed up on this input by adding a new paragraph in the Discussion section. We highlight the limitations of this study include the quasi-experimental design, which did not fully control for selection bias, and limitations in the subjective measurement of pain using the VAS. Further research is recommended in the form of a multi-center randomized controlled trial (RCT) and a cost-effectiveness analysis to assess the economic benefits of this intervention in routine antenatal care. We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study.” We appreciate the reviewer’s positive assessment of our study’s clinical relevance, methodological design, and cultural contribution. Below we provide a detailed response to each point raised: 1. Clarification of Randomization Method Thank you for your very constructive feedback. We have clarified the randomization procedure in the Research Methods section. The allocation process was conducted using a computer-based random number generator via the Research Randomizer application. The randomization results were placed in sealed envelopes in sequential order to maintain the confidentiality of the allocation. (see the sample size section). 2. Intervention Fidelity and Standardization We agree with this comment. In the Intervention Procedures section, we have added the following information: Hypnobirthing interventions are conducted according to standard procedures that include guided breathing techniques, visualization, and deep relaxation performed by certified practitioners. Each Hypnobirthing session lasts 30 minutes, twice a week for four weeks Music therapy sessions use music Music therapy interventions are carried out in accordance with standard procedures, namely listening to soothing instrumental music for 30 minutes every day for four weeks, with a slow tempo of 50–70 beats per minute, moderate music volume, and a quiet environment. This aims to maintain the consistency of participants' sensory experiences. (Saad & Jariyah, 2022), the music used is the traditional composition “Gending Sriwijaya”. This work, created by Nungcik AR in 1943 and accompanied by Palembang-style gamelan music arranged by A. Dahlan Rachim and R.C. Hardjosubroto, is a symbol of South Sumatran culture. The traditional Gending Sriwijaya music used in this study is part of the traditional cultural heritage of the Palembang community in South Sumatra, Indonesia. 3. Control Group and Attention Control Thank you for your valuable suggestion. We have added a note that the leaflet was given once at the beginning of the intervention (week 1) and briefly discussed by the staff as a form of educational control to control group. The control group received 30-minute light education sessions conducted by health workers, so that the duration and attention received were comparable to the intervention group. The educational material consisted of information in the form of leaflets about hypnobirthing and music therapy. 4. Statistical Reporting and Confidence Intervals We have revised the Results section by adding a 95% confidence interval (CI) and effect size to Table 5. 5. Study Limitations and Future Directions We have followed up on this input by adding a new paragraph in the Discussion section. We highlight the limitations of this study include the quasi-experimental design, which did not fully control for selection bias, and limitations in the subjective measurement of pain using the VAS. Further research is recommended in the form of a multi-center randomized controlled trial (RCT) and a cost-effectiveness analysis to assess the economic benefits of this intervention in routine antenatal care. We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team Competing Interests: No competing interests Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 03 Sep 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 2 (revision) 13 Jan 26 read read Version 1 03 Sep 25 read read read Dinesh C. Sharma , Km. Mayawati Government Girls P.G. College, Badalpur, India Jyoti Sharma , Km. Mayawati Government Girls P.G. College, Badlapur, India Sumbul Zehra , Indian Association of Music Therapy, Delhi, India Abu R. Srinivasan , Sri Balaji Vidyapeeth (Deemed to be University), Pillayarkuppam, India Bayu Anggileo Pramesona , Lampung University (Universitas Lampung), Bandar Lampung, Indonesia Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Pramesona B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 06 Feb 2026 | for Version 2 Bayu Anggileo Pramesona , Department of Public Health, Faculty of Medicine, Lampung University (Universitas Lampung), Bandar Lampung, Indonesia 0 Views copyright © 2026 Pramesona B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for your great effort to revise the manuscript. I think all my comments have been addressed properly by the authors, and I have no further comments. Thank you. Competing Interests No competing interests were disclosed. Reviewer Expertise Health policy, public health nursing, healthcare management I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Pramesona BA. Peer Review Report For: Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.5256/f1000research.194657.r450032) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-868/v2#referee-response-450032 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Srinivasan A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 23 Jan 2026 | for Version 2 Abu R. Srinivasan , Sri Balaji Vidyapeeth (Deemed to be University), Pillayarkuppam, Puducherry, India 0 Views copyright © 2026 Srinivasan A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors had taken due cognizance of the comments/suggestions/pertinent points made by this Reviewer and have since amended the initial version of the manuscript suitably and appropriately, to the best possible and optimal extent, in keeping with the objectivity and reliability of the study. Furthermore, the manuscript in the present form appears quite robust which would also pave way for further studies in research, related to evidence based medicine. The study affords immense potentials in the promulgation of integrated and tailored interventions that would go a long way. In addition, studies related to comparisons, in future, utilizing different genres of music would generate novel findings. Also, the present study has opened newer vistas for carrying out further comprehensive studies using mixed methods and qualitative research centering around fetal and neonatal outcomes. Competing Interests No competing interests were disclosed. Reviewer Expertise Biochemistry related to metabolism and metabolic disorders, Endocrine Biochemistry, Music as an adjuvant therapeutic modality, Diagnostic enzymology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Srinivasan AR. Peer Review Report For: Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.5256/f1000research.194657.r450031) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-868/v2#referee-response-450031 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Pramesona B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 23 Oct 2025 | for Version 1 Bayu Anggileo Pramesona , Department of Public Health, Faculty of Medicine, Lampung University (Universitas Lampung), Bandar Lampung, Indonesia 0 Views copyright © 2025 Pramesona B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Abstract: Methods: Where was the study setting and when the study was conducted? What the statistical analysis used in this study? Conclusion: It should be more specific and refers to your study objective. Introduction. What is the urgency to do this study in the primary health care setting? Methods: “This study will be conducted in four primary health care centers (PUSKESMAS) spread across the administrative area of Palembang City, South Sumatra Province, Indonesia”. This study has been conducted or will be conducted??? The authors stated the Palembang City was chosen as the study location because it has a large population of pregnant women and socio-cultural variations that reflect the diversity of urban community contexts in Indonesia. Please add the specific number or rank compared to other cities or provinces in Indonesia with reference Is there any specific reasons for choosing those public health centers as your study site? Please add the ethical clearance number and the institution issued the letter The authors stated developed and validated the instrument in Oct 2024, which instrument which developed and validated? And what kind of validity and reliability test that you conducted? “In the intervention phase, the authors involving the administration of music therapy and hypnobirthing sessions for four weeks under the supervision of certified health personnel ”, who were they?? The authors used randomization for a quasi-experimental study design?? How did you know the respondents had psychiatric disorders so you excluded them? The inclusion criteria were as follows: third-trimester pregnant women, experiencing moderate to severe lower back pain. Why you chose the pregnant women who had severe LBP? Did they take the medication to relieve the pain? It should be clear in the inclusion criteria because it could recall the bias of your outcome. For the hypnobirthing intervention, please elaborate the intervention, how the technical steps of that intervention. When the respondents practice this intervention? At home? Alone? Assisted by whom? How you know the respondents did it correctly? I did not see any explanation about the combined intervention part. It should be clearly stated with detail steps. Results: Don’t repeat this sentence “The research phase began with the approval of the ethics committee and research permit in July 2024. Researchers began to identify respondents based on the following inclusion criteria: pregnant women in the third trimester, experiencing mild to severe lower back pain, and primigravida. After the respondents were collected, lower back pain was measured using a visual analogue scale (VAS) questionnaire on 200 respondents of pregnant women in the third trimester in the working areas of the Pembina Health Center, Nagaswidak Health center, Taman Bacaan Health Center and Pembina Health Center”. It has been stated in the methods part Please add the baseline data analysis for those 4 groups, is there any differences between groups? P=0.000 should be written as p<0.001 Discussion All interventions have a significant reduction in pain. However, the combined intervention had a higher reduction score compared to other groups. How you discuss it?? Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Health policy, public health nursing, healthcare management I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 13 Jan 2026 Murbiah murbiah, Lincoln university Collage, Lincoln University College Faculty of Medicine, Petaling Jaya, Malaysia Dear Reviewer We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study.” Below we provide a detailed response to each point raised: 1. Abstract a. We have added information about the location and time of the study to the Abstract and Methods sections, namely: “ The study was conducted at four Community Health Centers (Puskesmas) in Palembang City, South Sumatra Province, Indonesia. 2. The statistical analyses used included the Paired Sample t-test, One-Way ANOVA, and Post hoc comparisons using Tukey HSD test for mean pain scores between the groups. This information has been added to the abstract section of the Methods section b. The conclusion section has been clarified to align with the research objectives. It now reads: “Music therapy and hypnobirthing have been proven effective in reducing lower back pain intensity in pregnant women in their third trimester, with the combination of both therapies providing the most significant effect.” 2. Introduction We have added an explanation in the Introduction section that this research is important to be conducted in primary health care facilities because most pregnant women in Indonesia receive antenatal care at community health centers. The implementation of non-pharmacological therapies such as music and hypnobirthing at the primary level can strengthen promotive-preventive services and reduce dependence on analgesics during pregnancy. 3.Methods a. We have revised the sentence to the past tense: “This study was conducted in four primary health care centers (PUSKESMAS) spread across the administrative area of Palembang City, South Sumatra Province, Indonesia. Palembang b. We have added data from the South Sumatra Health Profile for the city of Palembang in 2024, which shows that Palembang has approximately 27,775 pregnant women, ranking first in South Sumatra Province. This information was included with official references from the Health Office. c. The four health centers were selected purposively because they had high numbers of antenatal visits, represented urban and suburban areas, and had health workers certified in hypnobirthing and music therapy. This explanation has been included in the Methods section. d. This study was approved by head of ethics review committee Dr. Suzanna, S.Kep., Ns., M. Kep on 25 November 2024 by Health Research Ethics Committee of IKesT Muhammadiyah Palembang have granted ethical approval No: 002009/KEP IKesT Muhammadiyah Palembang/2024). e. The instruments developed were the Music and Hypnobirthing Side Effect Checklist (MHSEC). Content validity was tested using the Content Validity Index (CVI = 0.92) with three experts, while reliability was tested using Cronbach’s Alpha (α = 0.84). This information has been clarified in the Methods section f. Interventions are carried out under the supervision of a certified hypnobirthing midwife who has received official training from an accredited institution g. The process of allocating participants into four groups was carried out using a computer-based random number generator prepared by an independent researcher. Participant identification numbers were entered into a list and randomized automatically using the Research Randomizer application (https://www.randomizer.org/). The randomization results were sealed in sequential sealed envelopes to maintain the confidentiality of the allocation h. Respondents with moderate to severe pain were selected because clinically this condition requires non-pharmacological intervention to avoid the use of analgesics. We confirmed that all respondents did not take analgesic medication during the study period, as stated in the exclusion criteria i. Hypnobirthing intervention is carried out in accordance with standard procedures included guided breathing, visualization, and deep relaxation techniques conducted by a certified practitioner Each hypnobirthing session lasts 30 minutes twice weekly for four week. j. Combination group: received a joint intervention combining hypnobirthing techniques and therapeutic music under the same schedule and procedures. The combined intervention included hypnobirthing sessions accompanied by relaxing instrumental music played at a slow tempo of 50–70 bpm under the supervision of certified health professionals. 4.Result Duplicate sentences have been removed from the Results section to avoid redundancy. The statistical notation has been corrected throughout the manuscript to p < 0.001. 5. Discussion The Discussion section has been expanded with an explanation that the synergistic effects of music therapy and hypnobirthing enhance the parasympathetic relaxation response and lower cortisol levels, thereby optimizing pain perception reduction We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team View more View less Competing Interests No competing interests reply Respond Report a concern Pramesona BA. Peer Review Report For: Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.5256/f1000research.186071.r412885) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-868/v1#referee-response-412885 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Srinivasan A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 06 Oct 2025 | for Version 1 Abu R. Srinivasan , Sri Balaji Vidyapeeth (Deemed to be University), Pillayarkuppam, Puducherry, India 0 Views copyright © 2025 Srinivasan A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Did the authors measure the adverse effects of music therapy at all??? If so, did they prepare self-report questionnaires and rating scales (duly validated) to assess psychological and physiological data,prior to and following treatment??. The authors must please note that clinical observation and client interviews are also regarded crucial for documenting symptoms such as irritability, boredom, or even the exacerbation of the existing condition. Likewise, did the authors collect data through participant self-reports for assessing symptoms such as dizziness or anxiety and any other pertinent clinical observations.As an extension of the endeavour, then data analysis could be completed by computing the rate of adverse events, with particular reference to serious vs. non-serious effects as well as hypnosis-related vs. other possible causes. Outcome The primary outcome of the study was the reduction in lower back pain intensity before and after a four-week intervention period........Can this sentence be written without any ambiguity??? Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Biochemistry related to metabolism and metabolic disorders, Endocrine Biochemistry, Music as an adjuvant therapeutic modality, Diagnostic enzymology I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 13 Jan 2026 Murbiah murbiah, Lincoln university Collage, Lincoln University College Faculty of Medicine, Petaling Jaya, Malaysia Dear Reviewer, We sincerely thank the Reviewer for this valuable input and for emphasizing the importance of monitoring potential side effects associated with the intervention. Below we provide a detailed response to each point raised: 1. Measurement of Side Effects Thank you for your valuable comments. In this study, the side effects of the intervention were observed using the Music and Hypnobirthing Side Effect Checklist (MHSEC). Music and hypnobirthing Side Effect Checklist (MHSEC) developed and validated by researchers (I-CVI = 1.00; Cronbach's Alpha = 0.926). This instrument assesses physical and psychological symptoms that may arise during the intervention, including dizziness, nausea, headache, restlessness, palpitations, drowsiness, distraction, back pain, abnormal fetal movement, and mood. Observations were made before and after each therapy session by trained observers to ensure the safety of the intervention. We have added an explanation that adverse event data collection was conducted through participant self-reports and observations. Adverse event severity analysis has also been added to the results section, with classifications of “mild,” “moderate,” and “severe.” No severe adverse events were found in any of the intervention groups. 2. Data interpretation Thank you for your suggestion.The sentence has been revised to be clearer and more specific about the main results and the intervention period. The main results of the study showed a significant reduction in lower back pain intensity after four weeks of intervention in all treatment groups, with the greatest reduction in the combination group of hypnobirthing and music therapy compared to the control group (p < 0.001). 3. literature. Thank you for the reviewer's attention to the literature aspect. We have updated and expanded the bibliography by including the latest literature published between 2018 and 2023, covering experimental research results, meta-analyses, and systematic reviews relevant to the topics of hypnobirthing and music therapy. We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team View more View less Competing Interests No competing interests reply Respond Report a concern Srinivasan AR. Peer Review Report For: Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.5256/f1000research.186071.r412884) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-868/v1#referee-response-412884 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Sharma D et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 16 Sep 2025 | for Version 1 Dinesh C. Sharma , Bio musicology or Music Therapy, Km. Mayawati Government Girls P.G. College, Badalpur, Uttar Pradesh, India Jyoti Sharma , Research Associate (DST-CURIE) Dept of Bio musicology, Km. Mayawati Government Girls P.G. College, Badlapur, Uttar Pradesh, India Sumbul Zehra , Indian Association of Music Therapy, Delhi, Delhi, India 0 Views copyright © 2025 Sharma D et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Summary of the Article The manuscript titled " Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study " presents a quasi-experimental investigation involving 200 third-trimester pregnant women recruited from four primary health care centers in Palembang, Indonesia. Participants were randomly allocated into four groups: hypnobirthing, music therapy, combined therapy, and control (n=50 each). Pain intensity was assessed using the Visual Analog Scale (VAS) before and after a four-week intervention. The results indicate a statistically significant reduction in pain intensity across all intervention groups compared to the control (p < 0.001), with the combined intervention group showing the greatest improvement. The authors conclude that both hypnobirthing and music therapy are effective, and their combination provides synergistic benefits, supporting the use of these interventions as part of routine antenatal care. Strengths • The study addresses a significant clinical problem , pregnancy-related low back pain, which affects quality of life and labor outcomes. • Use of a quasi-experimental design with four groups provides good comparative power. • Incorporation of traditional Indonesian music is an important contribution to culturally contextualized maternal care research. • The study reports proper ethical approval, informed consent, and anonymization of data. Points for Improvement • While the paper mentions "random group allocation," it does not describe how randomization was implemented (lottery method, random number generator, sealed envelopes?). • Details on standardization of hypnobirthing sessions (duration, script used, practitioner training) and music therapy sessions (volume, environment control) are insufficient. Authors should specify steps taken to ensure intervention fidelity and reproducibility. • The control group received "standard antenatal care with a leaflet." Please clarify whether attention control was ensured to reduce placebo effects (e.g., similar time spent with staff as intervention groups). • Future research directions could include multi-center RCTs, cost-effectiveness studies, and assessment of psychological well-being outcomes. Overall Recommendation The study addresses a relevant problem and presents promising findings with potential implications for maternal health practice. However, minor revisions are required before the article can be considered scientifically sound and can be indexed. Decision: Minor Revision Required Summary of Required Revisions: • Clarify randomization method, intervention fidelity, and control group comparability. • Include confidence intervals and more detailed statistical reporting. • Expand discussion of study limitations and suggest future research directions. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? I cannot comment. A qualified statistician is required. Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Bio-musicology, Music Therapy, Complimentary and Alternative Medicine, Breast Cancer We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 13 Jan 2026 Murbiah murbiah, Lincoln university Collage, Lincoln University College Faculty of Medicine, Petaling Jaya, Malaysia We would like to sincerely thank the reviewer for the thoughtful and constructive feedback provided on our manuscript entitled “Effectiveness of Hypnobirthing, Music Therapy, and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study.” We appreciate the reviewer’s positive assessment of our study’s clinical relevance, methodological design, and cultural contribution. Below we provide a detailed response to each point raised: 1. Clarification of Randomization Method Thank you for your very constructive feedback. We have clarified the randomization procedure in the Research Methods section. The allocation process was conducted using a computer-based random number generator via the Research Randomizer application. The randomization results were placed in sealed envelopes in sequential order to maintain the confidentiality of the allocation. (see the sample size section). 2. Intervention Fidelity and Standardization We agree with this comment. In the Intervention Procedures section, we have added the following information: Hypnobirthing interventions are conducted according to standard procedures that include guided breathing techniques, visualization, and deep relaxation performed by certified practitioners. Each Hypnobirthing session lasts 30 minutes, twice a week for four weeks Music therapy sessions use music Music therapy interventions are carried out in accordance with standard procedures, namely listening to soothing instrumental music for 30 minutes every day for four weeks, with a slow tempo of 50–70 beats per minute, moderate music volume, and a quiet environment. This aims to maintain the consistency of participants' sensory experiences. (Saad & Jariyah, 2022), the music used is the traditional composition “Gending Sriwijaya”. This work, created by Nungcik AR in 1943 and accompanied by Palembang-style gamelan music arranged by A. Dahlan Rachim and R.C. Hardjosubroto, is a symbol of South Sumatran culture. The traditional Gending Sriwijaya music used in this study is part of the traditional cultural heritage of the Palembang community in South Sumatra, Indonesia. 3. Control Group and Attention Control Thank you for your valuable suggestion. We have added a note that the leaflet was given once at the beginning of the intervention (week 1) and briefly discussed by the staff as a form of educational control to control group. The control group received 30-minute light education sessions conducted by health workers, so that the duration and attention received were comparable to the intervention group. The educational material consisted of information in the form of leaflets about hypnobirthing and music therapy. 4. Statistical Reporting and Confidence Intervals We have revised the Results section by adding a 95% confidence interval (CI) and effect size to Table 5. 5. Study Limitations and Future Directions We have followed up on this input by adding a new paragraph in the Discussion section. We highlight the limitations of this study include the quasi-experimental design, which did not fully control for selection bias, and limitations in the subjective measurement of pain using the VAS. Further research is recommended in the form of a multi-center randomized controlled trial (RCT) and a cost-effectiveness analysis to assess the economic benefits of this intervention in routine antenatal care. We are deeply grateful for the reviewer’s constructive feedback, which has substantially improved the rigor and clarity of our manuscript. We have revised the paper accordingly and believe these changes address all concerns raised. Thank you for your valuable time and insightful review. warm regard murbiah and team View more View less Competing Interests No competing interests reply Respond Report a concern Sharma DC, Sharma J and Zehra S. Peer Review Report For: Effectiveness of Hypnobirthing, Music therapy and Combined Intervention in Reducing Low Back Pain Among Third-Trimester Pregnant Women: A Quasi-Experimental Study [version 1; peer review: 1 approved, 2 approved with reservations] . F1000Research 2025, 14 :868 ( https://doi.org/10.5256/f1000research.186071.r412881) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-868/v1#referee-response-412881 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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