Dear Dr. Soldati,

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 Jan 01 2026 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.

• 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,

Taiwo Opeyemi Aremu, MD, MPH, PhD

Academic Editor

PLOS ONE

Journal requirements:

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

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Thank you for stating the following financial disclosure:

[This research was funded by ZonMw, grant number 554002007].

Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

If this statement is not correct you must amend it as needed.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

3. In the online submission form, you indicated that [The data that support the findings of this study are available from the corresponding author upon reasonable request.].

All PLOS journals now require all data underlying the findings described in their manuscript to be freely available to other researchers, either 1. In a public repository, 2. Within the manuscript itself, or 3. Uploaded as supplementary information.

This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If your data cannot be made publicly available for ethical or legal reasons (e.g., public availability would compromise patient privacy), please explain your reasons on resubmission and your exemption request will be escalated for approval.

4. Your ethics statement should only appear in the Methods section of your manuscript. If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript.

5. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Additional Editor Comments (if provided):

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

Reviewer #1: Partly

Reviewer #2: Partly

**********

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

Reviewer #1: N/A

Reviewer #2: N/A

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: No

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

Reviewer #1: Abstract

In the results section, rather than describing the themes, I recommend summarizing the key findings or main takeaways to provide a clear overview.

Background

Line 93-97 should be rephrased to improve clarity

The background section would benefit from additional depth, including evidence from previous studies and a more detailed explanation of the challenges faced by women with UPs.

The study objectives (line 103-109) should be stated more clearly

Methods

The manuscript appear to follow the JARS-Qual checklist instead of the COREQ or SRQR checklist, which are required by PLOS ONE. Please ensure compliance with journal guidelines.

Clarify what information was included in the patient files (line146) and how this data was analyzed.

Consider providing the interview guide as a supplementary file

Explain the process for translating the interviews conducted in Dutch into English

Provide details on how demographic data were analyzed.

Results

In the demographics section:

- Include the attrition rate for the second round of interviews

- Add mean age and key participant characteristics in the text.

Line 193-198 – recommend removing this section

Line 262-263 – Recommend removing this section

Theme 1. While the results provide useful context, consider making this section more concise.

Discussion

The “Main Findings” section should be condensed and integrated with “Interpretation of findings”. I suggest removing the subheading and presenting the content under a single “Discussion” heading.

Include practical recommendations to strengthen the discussion.

Move the “Strengths & Limitations” section immediately before the conclusion and make it more concise.

Combine the “Implications for Future Research” with “Strengths & Limitations”, and shorten this combined section.

Reviewer #2: Introduction: The introduction introduces the reader to the state of the literature about unintended pregnancies and provides a global statistic which highlights the significance of the topic. In line 88-90, the adverse effects of psychiatric vulnerability were described, however, the authors do not describe the mechanism by which these psychiatric vulnerabilities contribute to increased risk of UPs and among which populations (if there are existing disparities). In line 94, review language used when attributing UP to women experiencing psychiatric vulnerability. For example, "...UP among women..." would be more appropriate as the term emphasizes the collective. In line 103-104, there appears to be a misalignment between the gap stated in line 102; ongoing pregnancies is a new term that was not discussed elsewhere in the introduction nor was it defined. To strengthen this section, describe the state of the literature on ongoing pregnancies one this term has been defined as you have done with UP. The gap you have identified should reflect that to date, there has not been a study that explores how women with psychiatric vulnerability experience UP and ongoing pregnancy. In line 104, the objectives are unclear. The term "besides" is informal. Please review the manuscript for similar instances. It appears that your objectives are to (1) identify and describe how UP occurs among women with psychiatric vulnerability and (2) factors that influence decisions around maintaining the pregnancy. In line 107-109, you have introduced a new gap in the literature. The first time it is mentioned should be earlier in the background, not as part of the aims. In doing so, justification for the objectives is substantiated. All persons may not be familiar with family planning which was mentioned twice in the introduction. It may beneficial to define it in this context.

Methods:

Research Study Design: In lines 115-117, there are no citations to support the description of prospective qualitative analysis. To avoid unintentional plagiarism, ensure all ideas that are not originally yours are cited. In 118, a narrative approach was used, however, you fail to describe the appropriate of understanding the construction and meaning of the experience. This is different than phenomenological research from which you would extract meaning from shared experiences among these women to understand the essence of UP. Justification on the narrative approach for this population is warranted. It is unclear how this approach was used and how phenomenological underpinnings were incorporated in extracting meaning from these stories.

Researcher Description: The researchers have thoroughly described their positions but did not disclose the intersection of other identities that may impact their knowledge of the phenomenon, responsiveness, and interpretation of the results. Positionality was alluded to but there is no reference to power dynamics that may have existed based on these identities, both with the study participants and amongst the researchers. There is no description about reflexivity and methods used to address psychological and emotional responses to the data, bracketing, consultation, or other means for example to reduce bias. Failing to provide this information significantly impacts rigor and transparency. The researcher is also an instrument in qualitative inquiry.

Participant Selection and Recruitment: In line 139-140, the type of recruitment (e.g., snowball, convenience, purposive, etc.) needs to be specified. Review this segment as there are some missing punctuations and issues with grammar. For example, in line 147, the sentence should read, "Participants were asked..." instead of "was asked." In line 147-149, clarity is needed on criteria for inviting persons to interviews and partners participating in interviews. Asking participants if their partners wished to participate is called snowball sampling which means you have used both purposive for your primary participants and snowball sampling for recruiting their partners. There is no description about parters receiving informed consent separate from their partner.

Data Collection: In line 159-160, describe your approach to maintaining confidentiality for persons interviewing at the hospital. For in-person interviews, what software or device was used to record the interviews?

Data Analysis: In line 164, specify if a third-party transcribed the interviews OR if the researchers transcribed the interviews independently. Did researchers review the transcriptions and reconcile discrepancies? This information is crucial in ensuring the participants experiences were captured.

Results: In line 187, there are noticeable differences in when follow-up interviews were conducted. In reviewing your methods section, the follow-up time for the second interview was not specified. State the intend follow-up time for the second interview (e.g., estimated 8-weeks postpartum) and if this was not accomplished, factors that influenced follow-ups. The remainder of the results were comprehensive, with select quotes accurately reflecting themes and sub-themes that emerged in the data. Quotes captured the essence of patients' experiences. The researchers did not attempt to interpret these findings and maintained a neutral position by articulating what participants' stated.

Discussion: In lines in 659-681, the discussion section is not designed to restate what is in the results. This information should be interwoven into the interpretation section.

Strengths & Limitations: In line 701-702, there appears to be a typo. Clarify if you are referring to women of low- to middle-class or SES and how this can influence decisions in family planning. There is no mention of instrument limitations for other methodological limitations. For example, how did modifying the semi-structured interview possibly impact responsiveness to prompts and data that was obtained? Examine the limitations of narrative and phenomenological inquiry and the sensitivity of this topic. Furthermore, there is no description of how the presence or absence of partners and support persons may have influenced responses during the interviews.

General: Ensure the interview guide is available in an appendix.

**********

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: No

Reviewer #2: Yes: Shane´ J. Gill

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Exploring unintended pregnancy journeys among women with psychiatric vulnerability using interpretative phenomenological analysis

PONE-D-25-33332R1

Dear Dr. Soldati,

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.

An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support .

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Taiwo Opeyemi Aremu, MD, MPH, PhD

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

**********

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

Reviewer #2: Yes

**********

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

Reviewer #2: N/A

**********

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

The PLOS Data policy

Reviewer #2: Yes

**********

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

Reviewer #2: Yes

**********

Reviewer #2: The authors have thoroughly addressed the recommendations provided in the initial review. In the introduction, the authors introduced substantive literature which was sufficiently synthesized, to provide a comparison of factors that influence psychiatric outcomes among women that experience unintended outcomes. Due diligence was taken to identify differences that may exist within this population, with unique vulnerabilities that may vary by the type of psychiatric diagnosis. In doing so, the authors indirectly address health equity which is central to the literature and manuscript. The aims of the study were described and are consistent with the gap in the literature that the authors identified.

Positionality and reflexivity were added to the manuscript with a robust description of each researchers' respective identities, intersectionality, and the meaning-making, all of which increased rigor and transparency. Furthermore, the availability of this information improves opportunities for replication. To this end, clarification of sampling was provided and aligned with the design and method. The researchers inclusion of a statement of anonymity in data analysis also supports rigor and reduction of bias which are essential in qualitative research. The discussion is more robust compared to the first submission, with repetitive information removed and thorough synthesis of earlier research, allowing for comparison. I thoroughly appreciated the fullness of the limitations section which included a framework in explaining how a reduced sample size may with structural and systemic limitations may shape anticipated effects.

**********

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 #2: Yes: Shané Janelle Gill

**********