PONE-D-22-35675Determinants of Breastfeeding Attitudes of Mothers in Jordan: A Cross-sectional StudyPLOS ONE

Dear Dr. Alkhaldi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Kind regards,

Ghada Abdrabo Abdellatif Elshaarawy, M.D

Academic Editor

PLOS ONE

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Additional Editor Comments (if provided):

1) ABSTRACT:

� No need for details of methodology in the abstract. Only main points. It should not include the type of statistical analysis.

� Methodology has to mention the elements included as measuring parameter but without details.

2) INTRODUCTION:

� Newest Global/ Regional/ Jordan prevalence of mothers’ attitude toward breastfeeding should be stated.

� The current situation of other developed and developing countries should also be added.

� The benefits of conducting the study to the community should be explained.

3) METHODS:

� The characteristics of the study participants should be mentioned as inclusion criteria and exclusion criteria (if any).

� How long did it take to complete each questionnaire?

� What types of data (quantitative and/or qualitative) were used?

� Definitions as postnatal period, Infant, exclusive breastfeeding, ……. etc. should be mentioned.

� How did the authors get the study subjects? They have to clearly address their sampling technique?

� Authors should include a reference for using the stated formula in calculating the sample size. Furthermore, the basis of sample size calculation should be mentioned to know the confidence level and the margin of error. Please give a justification for the sample size. How did you determine the sample size?

4) RESULTS:

� In table 3, the sentence: “Overall mean attitude toward infant feeding was 3.95 ± 1.04 (out of 5)” need to be explained.

5) DISCUSSION:

� Discuss by using the scientific reasoning the mothers’ attitude toward breastfeeding and the determinants of this attitude in other developing and developed countries with similar context. The manuscript could be greatly strengthened if the authors could compare the findings of the study with other findings and state the reasons for the strengths and weaknesses in each section.

6) CONCLUSION:

� It should be specific and based on the findings of the study.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Partly

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Response to reviewers

The authors have submitted a manuscript titled “Determinants of breastfeeding attitudes of mothers in Jordan” This study is very useful and adds a significant value in the maternal and child health system of Ethiopia regarding the perception and attitudes of breastfeeding. However, I will recommend some of the minor suggestions to make this manuscript better.

1)In addition, exclusive breast feeding for six months, continued for two years and beyond with the provision of safe and appropriate complementary foods are the most important strategies for promoting child survival and health [4]. However, the benefits of breastfeeding are underestimated, and the proportion of mothers who breastfeed their new-borns is way below the recommended levels globally and Jordan is not an exception [5, 6].

In this statement Although importance of breastfeeding has been explained quite evidently, addition of relevant information in context of exclusive breastfeeding globally as well as regionally should be explained

2) These factors include mothers’ age, income, education, mode of delivery and availability of breastfeeding counselling before, during and after delivery, and past breastfeeding experience [7-13].

How the mentioned socio-demographic factors are crucial for breastfeeding experience should be elaborated. For ex- how education is important for prevalence of exclusive breastfeeding.

3) In addition, health professionals’ attitudes, type of health care facility where delivery occurred, and admission of the infant in neonatal intensive care unit (NICU) influence the process of breastfeeding by women [9, 14-17

Justification of how healthcare professionals’ attitude or type of care received is important for perception of breastfeeding

4) The target population for the current study was postnatal women in the maternity ward. The sample size calculated using a confidence interval of 95% and a margin of error of 5%. A sample size of atleast 290 was found to be adequate

How did the authors have selected the samples and how they were found to be adequate have they taken any reference from similar studies of same population or whether they have done any sample size calculation.

5) Friendly, prepared with a suitable place for breastfeeding. Policies and laws on marketing formula milk and breastmilk substitutes, paid maternity leave, availability of day care facilities, breastfeeding breaks for employed mothers, should all be enforced

In above statement Information regarding milk bank for those mothers who are unable to breastfeed the child due to less milk production.

6) Special counselling provided to mothers who had caesarean delivery and who have new-borns in the NICU is essential. Policies and laws on marketing formula milk and breastmilk substitutes, paid maternity leave, availability of day care facilities.

Importance of propagation of importance of breastfeeding through mhealth.,

Reviewer #2: This is interesting research. The authors need a little help in improving the writing and need to get a statistician on-board to help with the statistical test and appropriate interpretation. After making some improvements, the manuscript can get to a point where it is publishable in this journal.

Abstract

The first two statements in the abstract are not objective. They are also not presented in a scientific manner, but rather as a more casual and social statement. For the analysis, the authors use a multiple linear regression model to assess the association between attitude scores from the IIFAS questionnaire, and various maternal sociodemographic and pregnancy related characteristics. However, they report odds ratios, which is not the metric that results from a linear regression model. The authors need to get a statistician on their team.

Introduction:

End of paragraph 2:

Non-scientific expression, and no references – “The proportion of mothers who breastfeed their newborns ‘is way below’ the recommended levels globally, and Jordan ‘is not an’ exception”. (correct usage: Jordan is no exception).

End of paragraph 3:

Incomplete sentence – “Furthermore, several studies have demonstrated that mothers’ attitudes toward breastfeeding is a significant predictor of their intention, initiation, and continuation of.”

Paragraph 4 and 5 needs to be tighter and better worded for a scientific journal. For example, ‘What determines women’s attitude towards breastfeeding?’ can be stated as ‘We sought to assess factors that determine women’s attitude towards breastfeeding’. Also, the authors do not build interest on the need for their research in an effective manner.

Methods:

Study Design and setting

COVID lockdown and responsive adjustments at the study setting looks like an unnecessary sub-heading. These details can just be incorporated into the paragraph on setting.

Population and Sample

Sample size calculation: The Section on Population and Sample is too concise and needs further detail with respect to power and sample size calculations. Insufficient details are given, and the sentence ‘A sample size of at least 290 was found to be adequate’ is lacking. The authors need to explain what a sample size of 290 is adequate for. This section is a good place to discuss sample size and power calculations. What is the minimal difference that can be detected with a sample size of 290?

Study Instrument

This section is not presented with proper English grammar, punctuation, and sentence structure. It needs to be presented better. Some sentences in this section appear like bullet points instead of complete sentences. For example, “Iowa Infant Feeding Attitude Scale, a validated tool used to measure attitudes of mothers toward infant feeding.”. Other sentences are too long and need to be broken down. For example, “Eight statements indicate positive attitude toward breastfeeding and nine statements indicate positive attitude towards formula feeding, the latter were reverse-scored before calculating the total scores of all items”. Other statements that are grammatically incorrect include “The researcher used a validated Arabic version of the IIFAS was used after permission from the author”.

The second paragraph in this section includes a sentence that starts with “The fourth aspect”. This is confusing, and the authors did not explicitly indicate what the first three aspects were. Also, the same sentence continues on to read ‘abased’ instead of ‘based’.

Data collection procedure

The first sentence has incorrect punctuation, lacks proper structure, and grammar.

Correct grammar would imply using ‘completing’ instead of ‘completed’ in the statement: “The response rate was 95%, with 301 mothers ‘completing’… questions”.

Analysis

This section mentions, “To determine the specific factors that influence breastfeeding attitude among participating mothers in the current study, independent t-test and one-way ANOVA statistical tests were performed”. However, the results as presented in Table 4 can be more appropriately stated as follows: “Independent t-test and one-way ANOVA tests were performed to assess if the total attitude score towards breastfeeding different significantly across each of the measured patient characteristics”.

The section mentions the use of ‘multiple linear regression models’ but talks about expressing results as adjusted odds ratios with 95% CI. Logistic regression models produce odds ratios, and the statement used in this section is not congruent with the results produced in the subsequent section.

Results

It is more appropriate to use the term ‘presents’ than ‘demonstrates’ when talking about the tables. For example, ‘Table 1 presents sociodemographic characteristics…. information”.

The sentence is not correctly constructed: “The most common pregnancy complication among mothers was gestational diabetes (16%), and 26% had preterm deliveries constitutes 26% of infants”.

The title for table 1 does not make sense.

The authors need to be consistent in the tables and in the text with regards to decimal places on percentages (e.g., use one decimal place throughout the manuscript for %s) and make sure the percentages reported in the table and the manuscript text match exactly.

The title for table 2 needs to be improved.

The sentence right above Table 2 reads ‘firth’ instead of ‘birth’.

The IIFAS statement with the second highest mean score as mentioned in the text in the paragraph above table 3 does not match with what is presented in Table 3.

The statement “This indicates a neutral postnatal attitude to breastfeeding” is unsubstantiated based on a mean total summed attitude score of 65 and a standard deviation of 7.15. There needs to be a statistical test that proves this statement.

In the paragraph that starts with the statement ‘Table 4 displays’, the second sentence mentions ‘attitude towards breastfeeding was significantly higher’, but a higher attitude is not a valid statement. Perhaps a ‘higher score’ or a ‘more positive attitude’ would be a more suitable word.

In the next paragraph right after Table 4, the authors list 6 independent variables, but the sentence reads, “Of the five independent variables”.

The results as presented in Table 5 need to be presented better and the title for Table 5 needs to be more concise. It appears that the authors used a multiple linear regression model, with the participant’s ‘Total attitude score’ as the dependent variable, and age, education, income, intention to breastfeed, gestational age, and neonatal ICU admission as the independent variables. However, at least four of the independent variables would be categorical variables. The author needs to state which category was used as the reference, particularly for categories with more than two response options, example, Education. Furthermore, the authors do not interpret these coefficients in the results section, either by their unstandardized estimates, or standardized estimates. It must be pointed out that manuscripts don’t typically report standardized coefficients from a multiple linear regression model since they are not directly interpretable. Unstandardized coefficients use the natural unit of measure for the specific variable and can be easily interpreted, and are therefore, the only reported coefficients in scientific manuscripts. For example, based on the results in Table 5, a unit increase in income results in a 1.61-point increase in the attitude score. However, this interpretation would only apply if income was measured as a continuous variable. However, the authors did not state if income is a continuous variable in their model, and in case it was categorical, the reference category is not mentioned. This makes interpreting the coefficients difficult. Assuming that the model is specified correctly, the p-values would suggest the variables/maternal factors that are significantly associated with the total scores on the IIFAS questionnaire. Finally, it appears that the authors are interpreting the standardized coefficients as odds ratios based on their statement in the abstract. This is incorrect, and a statistician would be a good addition to the team in improving this paper.

Reviewer #3: Determinants of Breastfeeding Attitudes of Mothers in Jordan: A Cross-sectional Study

Revision of the study “Determinants of Breastfeeding Attitudes of Mothers in Jordan: A Cross-sectional Study”.

This study aims to investigate the Breastfeeding Attitudes of Mothers in Jordan; during the study period January 2020 to May 2021.

Evidence suggests that the breastfeeding attitudes are higher in low-income mothers and general people.

Limitations of the study are noted and discussed.

I think the paper covers an import area of research.

I have listed some specific comments below that the authors should take into account before this

work could be published.

Abstract:

“The mean attitude score for participants was 65.0 ±7.15, indicating a neutral attitude. Factors associated with positive breastfeeding attitude were high income (p=0.048), pregnancy complications (p= 0.049), delivery complications (p= 0.008), prematurity (p= 0.042), intention to breastfeed (p= 0.002) and willingness to breastfeed (p= 0.005). Multiple linear regression results indicated higher income and intention to breastfeed as predictors of positive breastfeeding attitude (AOR 0.019; 95% CI 0.30-2.91 and AOR 1.52; 95%CI 0.05-10.20 respectively).”

I believe focusing on these risk factors should be the main aim of the study. What do you

mean when you say: “positive breastfeeding attitude”? Please specify if these were protective or risk factors.

Introduction:

1. Could you please add 2 or 3 references about the global scenario regarding Breastfeeding Attitudes of Mothers?

Method:

1. Which sampling technique authors were used?

Result:

The tables and figures are well described.

Discussion:

Overall discussion was well written. Just add 2 or 3 references which is related to your significant results.

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6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Dr Ritik Agrawal

Reviewer #2: No

Reviewer #3: Yes: Sadia Afrin

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PONE-D-22-35675R1Determinants of Breastfeeding Attitudes of Mothers in Jordan: A Cross-sectional StudyPLOS ONE

Dear Dr. Alkhaldi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by April 10, 2023, 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ghada Abdrabo Abdellatif Elshaarawy, M.D

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments (if provided):

Reviewer #2 comment which was not corrected:

The authors need to be consistent in the tables and in the text with regards to decimal places on percentages (e.g., use one decimal place throughout the manuscript for %s) and make sure the percentages reported in the table and the manuscript text match exactly.

Make sure you thoroughly address the reviewers' comments and concerns and ensure the manuscript is free of any editorial or grammatical errors.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: All comments have been addressed

Reviewer #5: (No Response)

Reviewer #6: (No Response)

Reviewer #7: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Partly

Reviewer #7: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: I Don't Know

Reviewer #7: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #4: No

Reviewer #5: Yes

Reviewer #6: (No Response)

Reviewer #7: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #4: Yes

Reviewer #5: No

Reviewer #6: No

Reviewer #7: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #4: The study involves analyzing data of breastfeeding attitudes of mothers in Jordan that gathered from one teaching hospital in Amman to examine the attitudes of mothers toward breastfeeding. The methods used a questionnaire according to Iowa Infant Feeding Attitude Scale to measure attitudes of mothers toward infant feeding. The results showed that the mean attitude score for participants was 65.0 ±7.15, indicating a neutral attitude. Factors associated with positive breastfeeding attitude were high income (p=0.048), pregnancy complications (p= 0.049), delivery complications (p= 0.008), prematurity (p= 0.042), intention to breastfeed (p= 0.002) and willingness to breastfeed (p= 0.005).

Comments and inquiries below are mostly minor: Please see the attached document:

1. Could you include how the participants were recruited? Did they receive hard copy, or they answered orally? Explain the method.

2. Was there a complete lockdown in the delivery section? If yes, mention the period.

3. Could you state the inclusion or exclusion criteria for selecting the participants?

4. Was there an informed consent or not?

5. Did you use any sampling method? Like random or systemic sampling technique for selecting the participants.

6. It looks like interview. Is that right? If yes, did all the patients answered verbally? How long was it take? If mixed, written or interview, what was the percentage of each. Did you record the interview?

7. In the data collection procedure section: line 9: Medical students entered the answers electronically. Do you mean for analyzing the data? Clarify.

8. Did you take the permissions from the patients before collecting these data? Explain

9. In the analysis section: In addition, the mean and standard deviation for individual items of IIFAS, and total score for the attitude toward breastfeeding for each respondent were calculated. How? Which test did you use?

10. In table 4: undetermined: Why, what was the reason? explain that in the footnote under the table.

11. Why are mothers more likely to use formula than breastfeed?

12. In the end of page 14: healthcare provider: Did they use ads for breastfeeding? What kind of encourage did they provide?

Reviewer #5: Comment” The characteristics of the study participants should be mentioned as inclusion criteria and exclusion. The authors responded “There were no inclusion or exclusion criteria” . It cannot be, there must be inclusion and exclusion criteria for every study and yours of no exception .

Other comments by reviewers were endorsed adequately by the authors.

Further Comments:

Under Introduction: the statement “Yet, About 44% of infants 0–6 months old are exclusively breastfed over the period of 2015-2020 [4]. Where? I cannot access the link for reference 4.

Under Introduction: the statement “The decision about infant feeding seems to be made before childbirth” the authors quoted reference [21], however this conclusion was not mentioned in that article. Please revise.

The objective of the study should be stated clearly at the end of the introduction.

What was the validity and reliability of IIFAS questionnaire

Item 17 of IIFAS questionnaire is about drinking alcohol for breastfeeding women. I find it difficult to ask Muslim Jordanian women this question. Please address my concern.

The authors stated that “ The researcher used a validated Arabic version of the IIFAS was used after permission from the author” and they quoted reference 29 for this statement. Indeed, the authors under reference 29 used a semi structured questionnaire survey and they did not use IIFAS questionnaire, please revise.

Under data collection procedure: the authors sated that “response rate was 95% with 301 mothers completing the questionnaires” What was the dominator for 301 mothers?

The authors stated that “monthly family income of 450 Jordan Dinar or less” please convert this to US$ as readers are unfamiliar with Jordan Dinar.

Reviewer #6: General comment:

Based on other studies on the determinants of breastfeeding, some of which are included in the manuscript bibliography, my question to the authors is: why was “knowledge of breastfeeding” not included in the study question? The Iowa Infant Feeding Attitude Survey (IIFAS) questionnaire used for data collection has items that can be better classified as “knowledge” rather than as “attitude”. The IIFAS tool developers could be asked as to whether they intentionally classified all survey items as assessment of “attitude” when in fact they appear to be testing “knowledge”.

Parturient mothers may be less intimidated to answer questions on their “attitude” and may be more apt to accept participation in the study, as opposed to thinking that they would be tested and evaluated with a survey of their correct or incorrect “knowledge,” whereas attitudes are neither right or wrong. However, the research needs to determine if the items are truly measuring “attitude” or “knowledge.” The manuscript would be clearer to readers if the authors could discuss the issue of “knowledge” versus “attitude” in relation to intent and practice of breastfeeding, and why they have excluded the assessment of knowledge. There may be studies available in the literature that address that issue.

A related issue is the possible presence of myths and cultural beliefs related to breastfeeding practice, and how those affect breastfeeding attitudes. These do not seem to have been addressed in the manuscript, though these myths and beliefs are highly prevalent in many societies. The authors should discuss the possible presence or not of breastfeeding myths and cultural beliefs in their study population of Jordan.

Specific comments:

Abstract.

Second sentence has a misspelling of “determine.”

Methodology

Medical students were used to interview mothers for this study. What percentage of these were female? There are two intersecting issues. One is that same-sex (female) interviewers may be more likely to obtain truthful answers from female interviewees. The second is that the interviewees may be also intimidated by perceived better-educated and perceived higher-status medical students, and may provide answers that mothers perceive as the “correct answers” rather than their true attitudes or knowledge.

Results

Table 3 should indicate that the items were taken from the IIFAS questionnaire with reference cited.

At the bottom of Table 3, the label should read “Overall mean score on attitudes toward infant feeding = 3.95 + 1.04”.

Readers may likely wonder why an attitude score of 3.95 + 1.04 is considered by the authors as a “neutral” attitude. This designation should be reconsidered.

Recommendations

Recommendations are primarily to do more studies on “attitudes.” My question again is related to the issue of breastfeeding “knowledge.” Are more studies needed on breastfeeding knowledge as well as on cultural beliefs and myths related to breastfeeding?

Reviewer #7: The paper is generally well written and structured. Overall, this is a clear, concise, and well-written manuscript. The introduction is relevant. Sufficient information about the previous study findings is presented for readers.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #4: No

Reviewer #5: No

Reviewer #6: Yes: Laura Altobelli

Reviewer #7: Yes: Dr. Mahmoud Al-Masaeed

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PONE-D-22-35675R2Determinants of Breastfeeding Attitudes of Mothers in Jordan: A Cross-sectional StudyPLOS ONE

Dear Dr. Alkhaldi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 18 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Ghada Abdrabo Abdellatif Elshaarawy, M.D

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

Reviewer #4 comment: In table 4, What was the reason for undetermined? explain that in the footnote under the table.

Make sure you thoroughly address the reviewer’s #6 comments and concerns.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #4: All comments have been addressed

Reviewer #5: All comments have been addressed

Reviewer #6: (No Response)

Reviewer #7: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: No

Reviewer #7: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: No

Reviewer #7: Yes

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Reviewer #4: No

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: (No Response)

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Reviewer #4: Yes

Reviewer #5: Yes

Reviewer #6: Yes

Reviewer #7: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #4: (No Response)

Reviewer #5: Thank you very much for addressing my comments . The required corrections have been made and the manuscript has been improved scientifically. The authors responded to my comment and provided valuable information which are important for the readers. l

Reviewer #6: Page 2. This paper reports on a study conducted on recently-delivered mothers in a Jordan tertiary-level hospital among whom 75% had university or higher education. The authors should provide data on the average educational level of Jordanian women to provide a better understanding of the generalizability of this study. If the authors intended to help explain the low rate of exclusive breastfeeding in Jordan in order to make policy recommendations, a representative selection of study mothers would have been a better choice. The generalizability of findings needs to be prominently discussed at the end of the paper.

In the introduction, the authors cite literature that higher education is associated with a good or positive attitude toward breastfeeding. The authors should try to explain why the study had measured only an average score of “neutral attitude” toward breastfeeding even though such a high proportion of their study mothers had a high level of education. They should explain in the discussion section that this study has dissimilar results to findings of other studies on the issue of higher education mothers, as they found no association of education with the breastfeeding attitude score.

Authors should also note that although highest income mothers had a significantly better attitude score as compared to the lowest income mothers, medium low-level income mothers were also significantly different from lowest income. Discuss the implications of this finding.

The average score of 65 + 7 out of 85 on the IIFAS survey questionnaire was very close to the upper limit of the neutral range 49-69, and could be stated that the tendency was towards a positive attitude.

The authors cite a study by Khasawneb (2020) that found 72% of mothers with a positive attitude toward breastfeeding. The authors should discuss why their findings are so different with only 24% with a positive attitude.

Page 3. After discussing the importance of exclusive breastfeeding, the authors state that the ‘breastfeeding’ rate in Jordan is 25% and compares this to similar rates reported in other countries. The authors should specify if they are referring to exclusive breastfeeding rates as 25%, or to “any breastfeeding” in children 0-5 months of age.

Page 4. In the Introduction, the authors cite two studies conducted in Jordan (2006 and 2018) which reported that positive maternal attitudes toward breastfeeding were associated with exclusive breastfeeding. The authors should provide more details on the socio-demographic-economic characteristics of those two study populations, and also what instruments had been used to measure positive maternal attitude. This would allow the authors to provide a more complete justification of the need for their current study, for their choice of study population, and for their choice of the IIFAS as the attitude measurement instrument.

In order for readers to better understand the current research, the paper would benefit from a discussion of the concept of “attitudes”: what exactly is an attitude, types of attitudes, and whether attitudes are predictive of behavior. The same suggestion is made for the concept of “ intentions”, since 95% of the study population had the intention to breastfeed (see Table 2). This discussion should include an explanation of the differences between “attitudes” and “intentions,” as well as the differences between “intentions” and “behaviors”.

The data on Table 2 should be included in the sections on results, discussion, conclusions, and recommendations. Based on data reported on Table 2, it appears that the hospital is not carrying out a strong role in promoting positive breastfeeding behaviors. Only 43% of study mothers had breastfed in the first day after birth. Also, only 40% of mothers had received breastfeeding counseling (20% prenatal and 20% postnatal) and 60% had received no counseling. This was in spite of the authors’ statement that the study location hospital was an “accredited Baby Friendly Hospital” since 2018.

In regard to the 43% of breastfeeding on Day 1, the correct WHO definition of early initiation of breastfeeding (EIBF) is “provision of mothers' breast milk to infants within the first hour of birth.” EIBF is the breastfeeding indicator that is most predictive of successful breastfeeding and reduced neonatal and infant morbidity and mortality. If the study questionnaire had included the question on initiation of breastfeeding in the first hour of life, this should be reported in Table 2. Breastfeeding on the first day is not an accepted breastfeeding indicator.

Table 4 shows the average score of “attitude toward breastfeeding” (based on the IIFAS) for each category of all the study variables. It is notable that the mean attitude is nearly the same for all categories of all variables. Even for variables such as Working Status of the mother which is mentioned earlier in the paper as a significant factor associated with breastfeeding intentions and practices, the average IIFAS score is exactly the same for both employed and unemployed mothers. The authors should explain why the attitude scores are so very similar for nearly all categories of all variables. One could wonder if the IIFAS is able to detect a difference in attitudes in this study population. If not, the IIFAS could be not really a valid test for this population. On the other hand, if the IIFAS is accurately measuring attitudes toward breastfeeding, then one could conclude that all Jordanian mothers in this population have very similar attitudes toward breastfeeding and in which case, therefore, attitudes are unlikely to be associated with breastfeeding practice. Contrary to findings in this study, in many country studies that could be cited, lower income women are more likely to breastfeed and to exclusively breastfeed for a longer period. That contradiction should be explained.

Statistics

Table 5 with logistic regression results should refer to factors that are “associated” with the attitude score. A cross-sectional observational study cannot infer causality as suggested by the term “predictors.” This issue could extend to the title of the study that uses the term “Determinants.” Table 5 should include a list of control variables beneath the table, if a step-wise regression was used. Alternatively, the table should include OR and CI results of the entire regression model with all variables included that had had <.10 p value in the bivariate analyses. And next to that, the best-fitting model. Each with r and r2 values reported.

Regarding the data presented on Table 5, there do not seem to be clear results on the variables of “monthly family income” and “willingness to breastfeed exclusively.”

On Table 5, the variable on “monthly family income” has 4 levels from low (1) to high (4). Levels 2 and 4 are significant. Level 3 is not significant. These findings cannot be interpreted as only the highest income mothers having significantly better attitudes toward breastfeeding. Rather, the level 2 of income is also significantly different from level 1. (OR 4.72, CI 1.12 – 26.86). The p-level is less important than the CI in regressions.

On Table 5, the variable “willingness to breastfeed exclusively” has confusing confidence intervals. It seems the confidence intervals are inverted for the categories “yes” and “undetermined” and should be reviewed and corrected if necessary.

Conclusions

Conclusions are not supported by data. The discussion refers to the positive associations of “pregnancy complications,” “delivery complications,” and “intention to breastfeed” with the outcome of attitude score. However, the former variables (pregnancy and delivery complications) have non-significant associations in the logistic regression. The latter variable (intention to breastfeed) is not reported in the logistic regression on Table 5.

Conclusions should be modest and not attempt to go beyond the findings of the study. The study does not show that the attitudes measured are predictive of breastfeeding practice. You will not be able to make conclusions and recommendations about how to improve breastfeeding practice as your data does not provide information on that issue.

Recommendations

Recommendations should suggest conducting a study that looks at whether the IIFAS is associated with breastfeeding practices in Jordan, controlling for other factors such as hospital breastfeeding routines (early initiation of breastfeeding, rooming-in, etc), newborn characteristics (prematurity, birth weight, birth by cesarean section, etc) and maternal characteristics (educational level, work status, income, etc). This would be a way to test the concept validity of the IIFAS for the Jordanian population of parturient mothers as a predictor of breastfeeding practice. This study would ideally be conducted on a representative population sample with a prospective design so that results can contribute to policy recommendations for the Jordanian population.

Reviewer #7: The paper is generally well written and structured. Overall, this is a clear, concise, and well-written manuscript.

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Reviewer #4: No

Reviewer #5: No

Reviewer #6: Yes: Laura Altobelli

Reviewer #7: Yes: MAHMOUD AL-MASAEED

**********

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PONE-D-22-35675R3Determinants of Breastfeeding Attitudes of Mothers in Jordan: A Cross-sectional StudyPLOS ONE

Dear Dr. Alkhaldi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by May 29 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Ghada Abdrabo Abdellatif Elshaarawy, M.D

Academic Editor

PLOS ONE

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When submitting your revision, we need you to address these additional requirements.

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Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

Additional Editor Comments:

The correct WHO definition of early initiation of breastfeeding (EIBF) is “provision of mothers' breast milk to infants within the first hour of birth.” EIBF is the breastfeeding indicator that is most predictive of successful breastfeeding and reduced neonatal and infant morbidity and mortality.

Since the data on initiation of breastfeeding in the first hour after delivery is not available, so you should add this to the limitations of the study.

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Determinants of Breastfeeding Attitudes of Mothers in Jordan: A Cross-sectional Study

PONE-D-22-35675R4

Dear Dr. Alkhaldi,

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Kind regards,

Ghada Abdrabo Abdellatif Elshaarawy, M.D

Academic Editor

PLOS ONE

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