PONE-D-25-09271Validating and Prioritizing Prenatal Breastfeeding Education Recommendations: A Nominal Group Technique Study with Postnatal Mothers and Healthcare Professionals.PLOS ONE

Dear Dr. Grealish,

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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PLOS ONE

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Additional Editor Comments:

Dear authors, please consider the comments of the reviewers, including my own:

1. The objective of the study is to identify and prioritize recommendations for breastfeeding education. The results should therefore be clearer on what were the recommendations that were identified and how they were prioritized. Now, the results showed emergent themes, which in my opinion, does not answer your objectives.

2. PLOS does not require blinding of previously conducting research and operates via open peer review. There is no need to redact the previous study and might be better if you cite them here so we can assess anything that needs to be assessed.

3. Recommendations should not be bulleted and should still be presented narratively.

4. Please shorten your paper as it is too long as it stands.

5. Add a limitations section to your 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: Partly

Reviewer #2: Partly

Reviewer #3: Partly

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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: Yes

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: No

Reviewer #2: No

Reviewer #3: No

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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: 1. The sample size of this study is small, and the age, region, economic income, and occupation representativeness of the pregnant woman sample need to be considered. It is advisable to add a description of the rationale for the selection of the sample size, or to clarify the limitations of the small sample size in the discussion.

2. Using Ritchie framework analysis and Nvivo coding, in line with qualitative research specifications, the consensus formation process needs to be supplemented with details, how to solve the parallel ranking.

3. Refine data availability claims (e.g., repository name or access link)

4. Optimize language expressions, correct grammatical errors, and improve readability (e.g. whether "Addin' in a bit about the challenges" should be "Adding a bit about the challenges")

5. If no clear ethical approval document is seen, whether the time of this study meets the ethical approval requirements.

Reviewer #2: This study aims to validate and refine the proposed recommendations from a previous qualitative study to enhance prenatal breastfeeding education classes in Ireland.

Major comments:

1. Interview sample size, selection, and characteristics

The authors report that they selectively recruited participants who had participated in the prior qualitative study. What was the inclusion criteria in the previous study? How many participants were invited of which only 6 postnatal mothers agreed to participate? I’m concerned about the sample size, selection process, as well as the sample characteristics. The authors mention that the low breastfeeding rates underscore a pronounced cultural inclination towards formula feeding within Irish society. Ethnicity may play a strong role in this case and 2 out of 6 postnatal mothers were Asian Indians. Also, in the text they mention Black Irish but in the table Irish and Black are separate categories. I’m wondering about the external validity of the study.

2. Intro: “Irish-based studies on breastfeeding education have primarily focused on the relationship between breastfeeding education and outcomes such as initiation rates, duration, attitudes, and behaviours [16-19].”

What did these studies find? Briefly describe whether education had any significant (positive or negative) on these outcomes.

3. World Health Organization’s 10 Steps to Successful Breastfeeding is integral to the paper and I recommend presenting these steps in a table instead of supplementary file so that readers can relate to the discussion in the paper.

4. Methods section on scoring and ranking is confusing. Postnatal mothers assigned scores but did not rank the recommendations to my understanding. The scores ranged from 1-5 but number of options for each domain ranged from 2-4. There’s a considerable variation in how respondents scored i.e. in S3 table Question 2, participant 1 gave scores (2,1,4,4) whereas participant 2 gave scores (3,2,5,5). Authors need to give more details and clarify this difference in system of scoring.

See scoring vs ranking on page 19 as well: “In the session with postnatal mothers, participants ranked the recommendations using a descending scoring system, assigning 5 points to their highest priority and 1 point to their lowest.”

5. The authors identified 7 recommendations as emerging from the initial list. Table S4 lists these. Why does the summary in S5 have only 6 of these recommendations?

6. The paper needs formatting. The section and sub section headings are not clear. Please number them or clearly use different text size or style to indicate the difference. The numbering of themes in the emergent themes section is inconsistent (1, 1.1, 2, 2.2, 3, 4, 5). Why not number them 1-7?

Themes 1 and 1.1 were part of the same recommendation in the questionnaire as well as tables S4 and S5. Why were they split in the text?

The breakout room theme (part of question 3) is missing from this list altogether whereas this was identified as a priority by mothers.

7. Section 2.1 is “Group Educational Sessions Featuring Real-Life Stories and Shared Experiences” but divergence and discordance discussion is around breakout rooms?

8. Section 3 on Ensuring Consistent and Accurate Breastfeeding Guidance (Pg 26) says “While mothers particularly valued standardized guidelines and a handbook to eliminate conflicting information, healthcare professionals emphasised training and mentorship equally. The healthcare professionals felt that hands-on training and ongoing mentorship would ensure that all staff members effectively interpret and apply the guidelines.”

From table S3, handbook was ranked 3 out of 4 by mothers, why would you say that mothers particularly valued it when they didn’t?

9. On page 27 “The divergence in emphasis reflects a difference in

perspective on the mechanisms for achieving consistency—mothers prioritized a unified resource. At the same time, the healthcare professionals focused on a broader approach, including training

and mentorship.”

Mother did not prioritize a unified source as per table S3. Rather training was ranked second by them and unified source was ranked third after it. Mothers first priority was to establish standardized guidelines and clear consistent communication practices.

On page 30, addressing breastfeeding in public seems more discordant than divergence because the healthcare professions do not believe it fits into the current 10-step guidelines framework whereas the rest of the themes were fitting into the framework but just prioritized differently.

Minor comments:

1. Pg 5: “Participants included healthcare professionals (n=4) and postnatal mothers (n=4)”

Postnatal mothers n=6?

2. Pg 6: “Moreover, community-level interventions promoting partner engagement and shifting societal perceptions were highlighted as essential components of a comprehensive strategy to improve breastfeeding outcomes”

Add period at the end of the sentence.

3. Pg 11: “Data were collected on online on two separate days via MS Teams, approximately 3 weeks apart, with each online session lasting between 3.5 hours”

Please check grammar

4. Pg 16: “Table 1 provides demographic details of all 6 postnatal mothers and 4 healthcare professionals (lactation consultants/ midwives) who participated in the study from three tertiary hospitals (n=10).

Please remove n=10 as it is misleading and redundant.

5. Pg 16, Table 1: Age (mean) should be Age mean (sd)?

6. Pg 18:

“The educational attainment of the healthcare professionals ranged from a Master’s degree (n=3;75%) and a Bachelor’s degree (n=1; 25%).”

“Most of the postnatal mothers were co-habiting (n 4; 66.67%), married (n=2; 33.33%) and identified as Irish (n=3; 50%), Black (Irish, African) (n=1; 16.67%) and Asian (Indian) (n=2; 33.33%).”

“Three of the postnatal mothers identified as in full-time employment (n=3; 50%), unemployed (n=2; 33.33%), and one mother (n=1; 16.67%) did not disclose her employment status.”

Please check grammar for all the sentences listed.

7. Pg 19: “This approach entailed carefully triangulating the mothers’ consensus priorities with the healthcare professional’s feasibility evaluations, particularly noting alignment with the WHO’s ten steps to successful breastfeeding.”

Consider numeric 10 steps instead of ten steps as in the rest of the paper.

Reviewer #3: Overall: this paper is important and although focuses on Ireland's context, I think has global appeal in its findings and the type of analysis. The conclusions from your data are well supported and logical and the recommendations that follow are appropriate given your findings.

Abstract:

If permissible by the journal, in the background of your abstract include the PMID when referencing your earlier study.

Introduction:

- does 40% at three months mean exclusively breastfed or does it include combo feeding? make that clear throughout if you mean exclusive (as in no introduction to formula)

- what is the highest breastfeeding initiation rate in Europe for comparison?

- Checked your numbers from the 2020 report and the stat for 2020 actually says 62.3% not 60%. Please double check your numbers for the other statistics as I don't have access to the journal for the other statistics

-Your intro mentions a need for personalization with breastfeeding education, are these programs you're referring to talking about one on one lactation consultant education, prenatal education from your hospital, education immediately postpartum, group education? Please specify

Recruitment:

- Although rapport and familiarity is nice, I don't know given the nature of your study necessitated it

- how did you determine that 10 participants was enough to collect this type of information? Did you feel like you reached saturation with your data collection?

- also curious the breastfeeding histories of the moms that participated. I imagine there would be differences in opinion for the woman who did extended breastfeeding vs. the woman who didn't continue after leaving hospital

data collection:

- between what and 3.5? was the second session shorter or longer 3.5?

- if participants were going to silently rank and review, why choose a group format and not just a survey with follow up individual interviews (if needed)? What benefit was there to using a focus group vs another method for this type of data collection?

data analysis:

- did you use verbatim transcription for NVIVO?

Table 1:

- In the United States (my location), Black is considered a "race" not an "ethnicity". Does "Irish" mean white here? White would be considered a race. Did your Black participant not come from Ireland? What does any other "white" background mean, like from another European country? Consider a restructure of this variable and break into two variables with 1 for ethnicity if any participants were citizens from another country than Ireland and the other variable to be Race (White, Black, Asian, Another race). Not necessary to note your Asian participant was Indian unless she's from India.

- Marital status- nobody was living solo?

- I can see the benefit of having all the demographics in one table, however I would consider reorganizing the variable order by adding row headers for the mothers and the staff and placing variables under their respective headers

Ideas generated:

-read again to make sure you're not repeating your methods section, omit any repetition

Results:

- i think there is value in including just a very high level summary table of the WHO 10 steps (just what each step is would be sufficient) for reference so someone doesn't have to google it to understand what you are specifically referencing throughout

- It sounds like your healthcare providers are not particularly enthusiastic around public breastfeeding and would only discuss if they needed to based on the quotation selected. Does that feel like an accurate interpretation?

Discussion:

- breastfeeding Peer learning isn't mentioned until the recommendations section but is an evidence based approach to breastfeeding education. Consider expanding on that a little more in the discussion when talking about the importance of storytelling.

Fig 1:

- Your used a step-wise program but this branching figure doesn't apply time particularly well given the arrows are going east/west rather than down. Please restructure for clarity.

Fig 2:

- Does not seem as necessary to me considering it is clearly outlined within the paper itself.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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PONE-D-25-09271R1Validating and Prioritizing Prenatal Breastfeeding Education Recommendations: A Nominal Group Technique Study with Postnatal Mothers and Healthcare Professionals.PLOS ONE

Dear Dr. Grealish,

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 Aug 10 2025 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:

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• 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,

Veincent Christian Pepito

Academic Editor

PLOS ONE

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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.

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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 #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: 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 #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: No

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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 #1: 1.Sample Representativeness:While the use of a purposive sample is justified for qualitative NGT studies, the authors should further acknowledge the limited generalizability of the findings and discuss this as a study limitation.

2.Language and Structure:The manuscript is written in generally clear English, but some segments—especially those with extensive participant quotations—could benefit from slight condensation or thematic grouping for better clarity and flow.

3.Figures and Tables (Optional):Consider including a visual summary (e.g., a flowchart of the NGT process or a radar chart summarizing consensus priorities) to enhance readability and support international readers’ comprehension.

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Reviewer #1: No

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Validating and Prioritizing Prenatal Breastfeeding Education Recommendations: A Nominal Group Technique Study with Postnatal Mothers and Healthcare Professionals.

PONE-D-25-09271R2

Dear Dr. Grealish,

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,

Veincent Christian Pepito

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: