PONE-D-23-04748A Qualitative Analysis of Women’s Postnatal Experiences of Breastfeeding Supports During the Perinatal Period in IrelandPLOS ONE

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3. We noted in your submission details that a portion of your manuscript may have been presented or published elsewhere. [A report outlining the initial findings of this study has been published online by Bainne Beatha (Bainne Beatha and O’Sullivan, 2022). This report predominantly focuses on the quantitative findings, but includes a summary of the results in the present paper.] Please clarify whether this [conference proceeding or publication] was peer-reviewed and formally published. If this work was previously peer-reviewed and published, in the cover letter please provide the reason that this work does not constitute dual publication and should be included in the current manuscript.

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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: Yes

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

Reviewer #1: N/A

Reviewer #2: N/A

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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: No

Reviewer #2: No

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

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Reviewer #1: Yes

Reviewer #2: 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: Manuscript Number: PONE-D-23-04748

Thank you for the opportunity to review this article, I appreciate the time and effort the research team has placed in the conduction of this study, writing of this manuscript, and preparing it for submission. This study provides insight on the experiences of breastfeeding supports during the perinatal period in Ireland, it can potentially inform future interventions and programs for the improvement of breastfeeding support in maternity care. Below are specific recommendations for the manuscript text:

Introduction:

Since the study period was conducted before and during the covid19 pandemic (and the impact is mentioned in the findings and discussion) it would be useful to have information on this section on how the pandemic disrupted maternity care services.

Please discuss in the introduction recent relevant evidence on the overall experience of breastfeeding in Ireland, it would be then useful to then compare this study findings to said evidence in the discussion section, examples of recent evidence:

Murphy et al, 2022 - Women's experiences of initiating feeding shortly after birth in Ireland: A secondary analysis of quantitative and qualitative data from the National Maternity Experience Survey. Midwifery,Volume 107,2022,103263,ISSN 0266-6138,https://doi.org/10.1016/j.midw.2022.103263.

Quinn et al, 2019-A qualitative exploration of breastfeeding support groups in Ireland from the women's perspectives ,Midwifery,Volume 78,2019,Pages 71-77,ISSN 0266-6138,https://doi.org/10.1016/j.midw.2019.08.001.

Methods:

Please provide a section on ethical considerations beyond the informed consent, how was confidentiality and privacy addressed, how was data managed? Who had access to the data?

Data collection

Line 126: please reference survey monkey and provide a description of what it is such as “web-based survey platform.”

Line 128: it is not clear why the authors considered the sample to be a convenience sample instead of a purposeful one just because recruitment was done online, if applicable please change to purposeful sample, if not, please clarify.

Data analysis

Line 137 and 138: since quantitative findings are not included in this study, how quant analysis was conducted is irrelevant, it would be more appropriate to mention that quantitative findings have been disseminated elsewhere and include a reference.

It is best practice in qualitative research to have a social theory (e.g, critical race theory, feminism, etc) guiding the analysis and interpretation of findings, was any social theory considered? If so, please specify it in this section.

Line:140-141: reference needed for interpretivist paradigm

Line 151-156: thank you for the positionality statement, do authors have any reflections on any assumptions or structures on power that might have influenced the analysis? If so, how were they addressed? For the sake of reflexivity and best qualitative research practice it would be useful to add a sentence expanding on the above if applicable.

Results

Sample characteristics

There is a repetitive use of the words over half in this whole section, it is ok to use the percentages, please report accordingly.

Thematic analysis

Very interesting and important findings in this section!

Please consider changing the order of theme 1 and theme 2 to improve the logical narrative of the findings, it could be clearer to discuss “breastfeeding support in theory but not in practice” first, and then discuss how that support was not given because “ support was either inaccessible, inadequate and/or inappropriate”.

I suggest selecting the most relevant, representative or impactful quotes and removing others to avoid repetition, and then using the remaining wordcount to provide more commentary on the analysis of the selected quotes.

In the quotes throughout this section please considering using the word participant or a pseudonym instead of subject to avoid dehumanization of women.

For clarity, I suggest re-numbering the subthemes in theme 1 as 1.1, 1.2 and 1.3 and the subthemes in theme 2 as 2.1, 2.2 and 2.3.

Line 246: please edit this quote to clarify the participant is referring to breastfeeding when saying bf’ing and bf as it might not be obvious to all readers

In sub theme 3 inappropriate support, sub theme 1 Breastfeeding problems were given breastfeeding solutions and sub theme 2 emphasis and formula in maternity wards, there seems to be an ongoing theme of mistreatment of women, such as violent disregard for body autonomy of women ( grabbing their breasts, being manhandled), their emotional well-being (referring to their nipples as “ unsuitable”) and personal feeding choices (“giving formula without the participants consent”). This is an important finding from a health equity and women’s reproductive rights perspective, I suggest regrouping the relevant quotes under inappropriate support sub-theme, and or a another subtheme , as it can be argued that mistreatment of women is not really support.

Discussion:

Great discussion! Please take into consideration suggestions about this section on the introduction feedback regarding other relevant evidence in the Irish context.

Line 594-596: Please provide reference that support the claim that the ten steps to successful breastfeeding could allowed for more positive breastfeeding experiences.

Strengths and limitations:

Line 608: as a note, qualitative findings are not meant to be generalizable therefore a representative sample of the population is not needed.

Conclusions:

Line 619: because qualitative findings are not generalizable and the sample was not representative, the assertion in line 619 and 620 cannot be made from the findings of this study alone (and that’s ok! The findings are valid and important), please edit this sentence to explicitly center the experiences of women in this study and not of the country as a whole.

Reviewer #2: Thank you for the opportunity to review this paper which reports qualitative responses to a survey question regarding support during breastfeeding experiences. The survey received many responses which speaks to the demand and interest regarding breastfeeding in the Irish context. The authors have broadly navigated well the challenges of analysing qualitative data collected through a principally quantitative lens (survey). The following feedback is offered to further strengthen this paper.

Study Context/Setting

The introduction provides sufficient information about breastfeeding in the Irish context and the role of the BFHI, thank you. For an international audience, more context is needed on maternity care in Ireland as it is relevant to this study. If the authors could please address the following points:

1. Explain the scope of the midwife in Ireland with respect to breastfeeding and breastfeeding education

a. What training do midwives receive on breastfeeding and supporting women to breastfeed, as this is part of their scope of practice?

b. What involvement do midwives have in the provision antenatal breastfeeding education?

2. Explain routine postnatal care in Ireland

a. How long do women typically stay in hospital postpartum?

b. Is there a postnatal visiting midwifery service that provides further support in the postnatal period following discharge?

For readers unfamiliar with the topic, it would also be of value to compare breastfeeding rates in Ireland with those in similar countries.

Study Design

The stated aim of this study is to describe women’s personal experiences of supports for breastfeeding within the Irish healthcare system during their time in the maternity unit, or during their home birth in Ireland to provide evidence for how support can be improved. To meet this aim, a single open-ended question at the end of a cross-sectional survey was used, “if you have any other comments about the breastfeeding support you received in the maternity unit or during your homebirth, please add them here”. Both the wording of this question and the choice of a survey tool to collect the data limit the richness and depth of experiences that may be captured and the ability of the research team to meet this aim. Please reflect on this as a limitation of the study design.

Similarly, we would encourage the authors to consider if the choice of thematic analysis is appropriate considering the depth of responses to the questions. The inclusion of a few sentences or a paragraph to justify why this approach was chosen is recommended.

We note that the thematic analysis was conducted by one author, overseen by a senior researcher. This is not standard practice in thematic analysis. Please address this as a limitation and consider how it may influence the study findings.

The research findings would be strengthened by explanation of how the confirmability of the research findings was addressed. This may clarify how the findings reflect the participants’ experiences as opposed to the researchers’ potential biases. A paragraph articulating how reflexivity has been considered, including if any of the research team are midwives or women with lived experience, or presenting the findings to women or key stakeholders for feedback/member checking may be of value here.

The description of themes provides a moving snapshot of women’s experiences of breastfeeding supports in Ireland, well done. Please place a participant ID number after all quotes and please do not repeat the same quote multiple times (subject 1041). We would also encourage the authors to reconsider the term, “subject”, and to review the quotes to ensure that they support the description of the themes. Please also review the description of themes and subthemes and consider more clearly delineating them from each other. For example, the subthemes, “Inaccessible support”, “Inadequate support” and “Inappropriate support” are repetitive and not clearly differentiated from one another.

The authors have acknowledged that they moved from a convenience sampling approach to purposive sampling to capture more nationally representative data, as a limitation of this study.

Discussion and Conclusion

Given the low breastfeeding rates in Ireland, breastfeeding support is clearly an important area of research. The findings articulated in this paper show that further research is urgently needed on how healthcare providers can be better supported to, in turn, support women to breastfeed. This is an important contribution to the literature. However, there is a strong emphasis in the framing of this study (introduction and discussion) on the role of IBCLCs. While these IBCLCs are clearly important stakeholders and valued by the women, the provision of breastfeeding support is well within the scope of midwives as indicated in International Confederation of Midwives Essential Competencies. We encourage the authors to consider how midwifery staffing shortages, training needs and systems issues may have contributed to the lack of breastfeeding support reported by the women in this study in their discussion. The authors are also encouraged to consider how these findings may inform future research to address factors influencing poor breastfeeding support.

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Reviewer #1: No

Reviewer #2: No

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A Qualitative Analysis of Women’s Postnatal Experiences of Breastfeeding Supports During the Perinatal Period in Ireland

PONE-D-23-04748R1

Dear Dr. O'Sullivan,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Kyaw Lwin Show, MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #1: 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 #1: Yes

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

Reviewer #1: N/A

**********

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 #1: No

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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 #1: Yes

**********

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 #1: (No Response)

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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: No

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