Cessation of breastfeeding in mothers of preterm infants-A mixed method study.

INTRODUCTION: Many women cease breastfeeding earlier than desired. This study examined the cessation of breastfeeding among mothers of preterm infants. Thus, the aim was to describe the cessation of breastfeeding in mothers of preterm infants up to 12 months after birth.
METHOD: This mixed methods study used a convergent design with both qualitative data, consisting of written comments, and quantitative data, on breastfeeding status and breastfeeding satisfaction. The data were collected from questionnaires sent to the mothers at three points during the first year after birth. In total, 270 mothers of preterm infants who breastfed at the time of discharge from the neonatal unit provided data for the study. The quantitative and qualitative data were analysed separately with statistical tests and hermeneutical analysis, respectively and then together according to the convergent mixed methods design.
RESULTS: Four themes of the meanings of the cessation of breastfeeding were identified in the qualitative analysis: "Desire to regain the mother's and the infant's well-being", "The mothers interpretation that the infants actively ceased breastfeeding", "The mother's body and/or the infants' signals showing the way" and "The mother's own will and perceived external obstacles". Mothers who did not breastfeed as long as they wanted were more likely to report less satisfaction with breastfeeding, a shorter breastfeeding period, and less activity when ceasing breastfeeding. In comparison, mothers who breastfed as long as they wanted were more satisfied with breastfeeding, breastfed for a longer period of time and were more active in decision making in breastfeeding cessation.
CONCLUSION: Maternal passivity or activity influenced the cessation of breastfeeding in mothers of preterm infants who breastfed at the time of discharge from the neonatal unit. Passive behaviour related to breastfeeding may result in early cessation of breastfeeding, and low breastfeeding satisfaction while active behaviour may increase breastfeeding length and satisfaction.

Introduction

In Sweden, almost all mothers initiate breastfeeding at birth, but during the first week, 20% cease breastfeeding, and by two months, almost 35% have ceased [1]. In Sweden, there was a decline in exclusive breastfeeding of preterm infants from 2004–2013 [2], and the decline continued from 2013–1017 [3]. Approximately 60% of mothers ceased breastfeeding earlier than they desired. Difficulties with lactation, infant nutrition and weight gain, illness, medication and difficulties with expressing breast milk have been reported to be associated with the earlier cessation of breastfeeding [4].

Mothers of preterm infants are in a vulnerable and fragile situation in which breastfeeding may be considered a key aspect of becoming a mother; in addition, motherhood and breastfeeding often begin in a medical and unfamiliar setting [5]. The initial period of breastfeeding is important since early breastfeeding experiences cause mothers to question their suitability for motherhood [6].Mothers of preterm infants experience breastfeeding in the first 12 months after birth as a journey to finding their own way in breastfeeding, which means that every mother has her own experiences of being in this situation and copes with these experiences according to her own unique situation [7].However, mothers of preterm infants may struggle with breastfeeding for example, with breastfeeding sleepy or immature infants, infant latching, disorganized feeding behaviour or insufficient milk supply, which may continue over a long time [8, 9]. If breastfeeding difficulties occur, a mother may feel threatened and be consumed by concerns about her own body and/or her infant due to pain, discomfort or questions about the amount of milk she is or should be producing. In addition, women’s own expectations and/or experiences of objectifying care within the health care system can lead to feelings of loneliness and anxiety [10]. For a mother to have the possibility of breastfeeding as long as she wants, breastfeeding support is crucial [11]. However, mothers of preterm infants have little control over breastfeeding support they receive and inadequate support diminishes breastfeeding [12]. Previous research has found that lower breastfeeding satisfaction, lower self-efficacy, partial breastfeeding at discharge, a low maternal educational level, the use of soothing methods, negative maternal experiences and longer stays in the neonatal unit increased the risk of breastfeeding cessation in mothers of preterm infants [13-15]. In summary, our literature review shows that few studies have examined the cessation of breastfeeding during the first year after birth in mothers of preterm infants; to be able to support breastfeeding, further research in this area is important. The aim of the study is to describe the cessation of breastfeeding in mothers of preterm infants up to 12 months after birth.

Materials and methods

Design

The present study adopted a mixed method design with a convergent approach [16]. This design was used to define the relationships between breastfeeding cessation, maternal explanations for breastfeeding cessation, breastfeeding satisfaction and breastfeeding status throughout the first year of life.

Inclusion and exclusion criteria and setting

During a randomized controlled trial (RCT) conducted after discharge from six neonatal units in Sweden, breastfeeding mothers of preterm infants (gestational age <37 weeks) provided data about breastfeeding cessation during the first 12 months after birth. The results from the RCT are presented elsewhere [17, 18]. The inclusion criteria in the RCT were mothers of preterm infants who breastfed (any breastfeeding) at discharge and had been hospitalized for at least 48 hours in the neonatal unit. Exclusion criteria were mothers who had severe physical or mental illness, language difficulties that could not be resolved, or who had an infant who was transferred to another ward or hospital or where the infant was terminally ill. Eligible mothers were invited to participate in the study approximately one week before discharge. Additional inclusion criteria were providing left written comments on the questionnaire, answering the questions on breastfeeding satisfaction and/or whether the mother breastfeed as long as she wanted. A flowchart over the enrolment is presented in Fig 1. The six neonatal units were level IIIa or IIIb units according to American Academy of Pediatrics Committee on Fetus and Newborn [19]. None of the units were certified as baby friendly. The study received ethical approval from the regional ethical review board in Uppsala, No. 2012/292 and 2012/292/2. After receiving oral and written information about the study, all participating mothers signed a written consent form.

Fig 1

Flowchart.

A flowchart over the enrolment in the study.

Author JE is a paediatric nurse, and author LP is a midwife by profession with long-term experiences in neonatal and midwifery care. Our preunderstanding and experiences from our professions give us openness to new experiences and insights within the cessation of breastfeeding in mothers of preterm infants. We questioning and continuously reflect over our preunderstanding in relation to analyzing and interpret the data.

Data collection

Quantitative and qualitative data were collected simultaneously via questionnaires sent to the mothers 8 weeks after discharge from the neonatal unit and 6 and 12 months after the birth of their infants as part of the RCT. The data were collected between March 2013 and December 2015.

Health care professionals collected quantitative demographic data and breastfeeding (exclusive or partial) data at the time of the infant’s discharge from the neonatal unit. Breastfeeding (exclusive, partial or no) and breastfeeding satisfaction were measured with self-report questions in the questionnaires at all follow-ups. The World Health Organization’s definition of breastfeeding and a 24 hours recall period were used. Exclusive breastfeeding was defined as follows: feeding with breast milk only, regardless of the feeding method, as well as any medications, fortification and vitamins. Partial breastfeeding was defined as follows: feeding with breast milk in combination with formula and/or solid food. No breastfeeding was defined as follows: fully feeding with formula and/or solid food [20]. The questions to both health care professionals and mothers about breastfeeding included the definitions of exclusive, partial and no breastfeeding.

Measures

Breastfeeding satisfaction was measured with the following question at all follow-ups: “Are you satisfied with your breastfeeding experience?” A 10-centimetre visual analogue scale ranging from very dissatisfied to very satisfied was used for responses. Data regarding whether the mother breastfed as long as she wanted were collected in the 12-month questionnaire with the following question: “If you have ceased breastfeeding, did you breastfeed as long as you wanted?” The response options were yes or no.

The qualitative data consisted of written comments from the mothers. The comments were collected with one open-ended question (asked at the follow-ups) and one question with a free text option (asked in the 12 month questionnaire). Only the data describing the cessation of breastfeeding were used. In the questionnaires, the following open-ended question was asked at all follow-ups: “If you want, feel free to write about what you have experienced while breastfeeding/bottle-feeding your baby”. Furthermore, in the 12-month questionnaire, the mothers had the option to provide a free-text response to the following question: “If you have ceased breastfeeding, did you breastfeed as long as you wanted?”

Analysis

The quantitative and qualitative data were analysed separately with statistical tests and hermeneutical analysis, respectively, and then together according to a convergent design, as described by Creswell (2017). In some analyses, the data were divided based on whether the mother breastfed as long as she wanted.

The quantitative data were analysed using IBM SPSS Statistics for Windows, version 25.0 (Armonk, NY: IBM Corp.). The statistical significance level was set to p <0.05. Descriptive statistics were presented as the numbers, percentages, and means and standard deviations (SDs) for normally distributed variables and as the medians and interquartile ranges (IQRs) for non-normally distributed variables. The Mann-Whitney U-test was used to analyse the potential differences between breastfeeding satisfaction and whether the mothers breastfed as long as they wanted. Breastfeeding satisfaction was unevenly distributed. A chi2 test was used to analyse the potential associations between the dichotomous variables i.e., demographic data and whether the mothers breastfed as long as they wanted.

The qualitative data were analysed through hermeneutic analysis based on a reflective lifeworld approach inspired by hermeneutical and phenomenological philosophy [21, 22]; this analysis aimed to explore the mothers’ experiences of breastfeeding cessation. We chose the approach and method in order to provide rigorous scientific foundation for the analysis. The intention of the hermeneutical part of the analysis was to gain understanding of the meanings in the data. The lowest level of the hermeneutical spiral includes the identification of themes related to the meanings in the data, and the most abstract form of explanation is the overall theme. A hermeneutical explanation is not a cause-effect explanation but rather an intentional explanation of the variation in the meanings in the data and why this variation occurs [22].

The mother’s written comments were transcribed from the questionnaires to a Microsoft Word document by JE. First, the written comments from the two open-ended questions were read as a whole. Then, the Word document was printed on paper, and all comments regarding the cessation of breastfeeding were cut into separate pieces of paper. These comments were sorted into groups with similar meanings, which ultimately resulted in the identification of four themes of the meaning of breastfeeding cessation. Second, all comments corresponding to each of the four themes were then sorted by whether the mother breastfed as long as she wanted and were marked with each mother’s breastfeeding status at each follow-up, resulting in the emergence of a pattern of meaning of breastfeeding cessation. Each comment was marked with the mothers’ code, and the same code was used in the quantitative data set. Hence, we were able to connect the written comments with answers to the question about whether the mother breastfed as long as she wanted and breastfeeding outcome. Quotes from the mothers are presented in the results with each mother’s randomized code, for example, SU10. Each mother’s breastfeeding status at each follow-up, for example, exclusive (e), partial (p) or no (n), is also presented in chronological order as follows: (discharge), (8 w after discharge), (6 months after birth), (12 months after birth). Finally, the total number of months spent breastfeeding is presented, for example, ceased breastfeeding at 8 months (m). Some mothers (n = 16) left written comments in one or more of the follow-up questionnaires but did not answer the question about whether they breastfed as long as they wanted. Their comments did not differ from the other comments; hence, all comments were analysed together.

Finally, an overall theme was interpreted through the linking of the themes of the meaning of the cessation of breastfeeding from the qualitative data and the quantitative data to form an overall theme, i.e., a new whole. To determine the overall theme, an analysis of the mothers’ approaches, concepts, words or ways of reasoning, breastfeeding data and breastfeeding satisfaction as well as mothers’ descriptions of breastfeeding cessation and its meanings was conducted. We jointly carried out the analysis between the two authors by grouping and discussing the data, individual themes of the meaning of breastfeeding cessation and overall theme until we reached consensus. An illustration of the analysis and the coding process is presented in Table 1.

Table 1

Illustration of the analysis and the coding process of the qualitative data.

Code	Written comment	Theme of the meaning of the cessation of breastfeeding	The mother breastfed as long as she wanted
SU40	I probably would have needed help to cease earlier. I tried for a month and then felt really bad.	Design to regain the mother’s and the infant’s well-being	No
F87	My daughter started biting me, so I quit. I would have liked to breastfeed for 1 year.		No
F28	I ceased breastfeeding because of my son's allergy. It was both milk protein and eggs. I was milk-free even when I was breastfeeding.		Yes
Ö54	My child decided that he wanted to quit:) he was more interested in solid food.	The mother's interpretation that the infants actively ceased breastfeeding	No
SU9	I could breastfeed longer, but my child became uninterested and it became a natural ending		No
T12	The child did not want to breastfeed anymore, he became uninterested, which made me lose interest too.		Yes
SU11	In the end, it was only nighttime, and my daughter probably realized that she didn't need it.		Yes
K89	The breast milk disappeared.	The mother’s body and/or the infants’ signals showing the way	No
T7	It was lovely to breastfeed; however, my daughter was difficult to feed. She couldn't really breastfeed. In the end, my milk drained and we had to give formula and bottle, which went very well.		No
F64	My baby was no longer interested in breastfeeding.		Yes
Ö65	I breastfeed as long as my baby wanted to breastfeed. After about five months, he had tired; there was not enough milk.		Yes
T20	I chose to start working after 7 months. I had to stop when the [infant's] father would be home.	Mother's own will and perceived external obstacles	No
K72	Hindered because of work.		No
SU53	Felt like I wanted to quit, and it went great!		Yes
F67	To make the father-child relationship better and more harmonious, it has made it easier for us to cease breastfeeding.		Yes

Results

The characteristics of the participating mothers are presented in Table 2. In total, 270 mothers contributed data to the study. The open-ended question and the optional free-text response yielded 165 written comments about breastfeeding cessation from 149 mothers. The mothers who breastfed as long as they wanted left 55 comments, and the mothers who did not breastfeed as long as they wanted left 94 comments. Sixteen mothers left written comments but did not answer the question about whether they breastfed as long as they wanted.

Table 2

Characteristics of the participants.

Demographic variables	n (%) median [IQR*]
Maternal variables
Age, years	30 [17]
Maternal educational level
Higher education	150 (56)
Upper secondary school or less	120 (44)
Primipara	153 (57)
Mothers not born in Sweden	16 (6)
Vaginal birth	154 (57)
Multiple birth	22 (8)
Gestational age at birth, weeks	34 [3]
Exclusive breastfeeding
at discharge	222 (82)
8 weeks after discharge	167 (62)
6 months after birth	72 (27)
Partial breastfeeding 12 months after birth	48 (21)#

Characteristics of the participating mothers (n = 270) and infants (n = 292).

*IQR = interquartile range

#Missing data on 42 mothers

Significantly more mothers breastfed as long as they wanted than did not breastfeed as long as they wanted. Mothers who breastfed as long as they wanted reported significantly higher breastfeeding satisfaction at 8 weeks after discharge and 6 and 12 months after birth than mothers who did not breastfeed as long as they wanted (Table 3).

Table 3

Breastfeeding satisfaction, exclusive breastfeeding and demographic factors for mothers who breastfed as long as they wanted and mothers who did not breastfeed as long as they wanted (n = 185).

Presented as the percentage (%) or median [interquartile range, IQR] and p-value.

Breastfed as long as they wanted	Yes	No	p-value
Breastfed as long as they wanted	107 (57)	78 (43)	<0.001
Maternal educational level			0.35
Higher education	63 (59)	49 (63)
Low maternal educational level (upper secondary school or less)	44 (41)	29 (37)
Parity*			0.18
Primipara	59 (56)	49 (64)
Multipara	47 (44)	28 (36)
Country of birth			0.46
Mothers born in Sweden	103 (96.3)	74 (94.9)
Mothers not born in Sweden	4 (3.7)	4 (5.1)
Multiple birth			0.04
Singleton	101 (94.4)	67 (86)
Twins	6 (5.6)	11 (14)
Gestational age at birth			0.10
<32 weeks	10 (9.3)	13 (17)
32–36 weeks	97 (90.7)	65 (83)
Breastfeeding satisfaction
8 weeks after discharge	9.2 [2.2]	7.4 [4.6]	0.002
6 months after birth	9.3 [2.4]	7.7 [5.2]	0.003
12 months after birth	9.0 [2.5]	6.8 [5.9]	<0.001
Breastfeeding at discharge			0,001
Exclusive/partial	9 (8.4)	21 (27)
No	98 (91.6)	57 (73)
Breastfeeding 8 weeks after discharge			0.42
Exclusive/partial	5 (4.7)	10 (13)
No	102 (95.3)	68 (87)
Breastfeeding 6 months after birth			<0,001
Exclusive/partial	18 (17)	38 (49)
No	89 (83)	40 (51)
Breastfeeding 12 months after birth
Partial	5 (4.7)	2 (2.6)	0.37
No	102 (95,3)	76 (97.4)
Breastfeeding length, weeks	35 [17]	25.5 [24]	<0.001

* Missing data on 2 mothers

There was a statistically significant difference in exclusive breastfeeding between mothers who breastfed as long as they wanted and mothers who did not breastfeed as long as they wanted at discharge and 8 weeks after discharge, but there was not a significant difference in exclusive breastfeeding 6 months after birth or in partial breastfeeding 12 months after birth (Table 3). Mothers who breastfed as long as they wanted breastfed (any breastfeeding) an average of ten weeks longer than mothers who did not breastfeed as long as they wanted (p<0.001) (Table 3).

There were no statistically significant differences between mothers who breastfed as long as they wanted and mothers who did not breastfeed as long as they wanted in maternal educational level, parity, gestational week (<32 or >32) or maternal birth country. However, significantly more mothers with twins than mothers with singleton infants did not breastfeed as long as they wanted (Table 3).

The comments from the two open-ended questions resulted in the identification of four themes of the meaning of the cessation of breastfeeding, which are described below.

The mother’s body and/or the infant’s signals showing the way was one of the themes that emerged in mothers’ descriptions of the cessation of breastfeeding. The mothers described their perceptions that they had a low milk supply, that the breast milk vanished or that there was not enough breast milk for the infant to be satisfied when breastfeeding and/or to gain weight. Some mothers also explained that when they started to give the infant formula or solid food, the breast milk dried up, and it was difficult to continue breastfeeding.

Based on the mothers’ descriptions about insufficient milk supply, the drying up of breast milk appeared to happen suddenly, quickly and/or without warning. Negative feedback from the body e.g., insufficient milk supply seemed to reduce the mothers’ belief in their ability to breastfeed. The body "lived" its own life and the body thus became an object that the mother adapted to. The mothers became passive and seemed nonplussed.

The milk started to dry up. Did not have enough milk. SU21, p, p, n, n (ceased breastfeeding at 3 m)

he breastmilk vanished. K89, p, p, n, n (ceased breastfeeding at 3 m)Did not have enough breast milk; in the end, my daughter would rather have the bottle. F107, p, p, n, n (ceased breastfeeding at 4 m)

Regarding this theme, there was a difference between mothers who did and did not breastfeed as long as they wanted; mothers who did not breastfeed as long as they wanted wrote more descriptions (n = 33) and seemed to cease breastfeeding earlier than the mothers who breastfed as long as they wanted (n = 16). More mothers who did not breastfeed as long as they wanted were partially breastfeeding at discharge than mothers who breastfed as long as they wanted. Some of the mothers who did not breastfeed as long as they wanted also described their infants as not having the energy/ability to breastfeed. Among the mothers who breastfed as long as they wanted, the most prominent change in breastfeeding was between nine and 12 months after birth, compared to one to six months after birth for the mothers who did not breastfeed as long as they wanted.

The milk [breast milk] was not enough for the infant to be satisfied, and when the bottle came into the picture, the infant did not suck as well on the breast. T1, e, e, n, n (ceased breastfeeding at 6 m)

Another theme that emerged was the mother’s interpretation that the infants actively ceased breastfeeding. The mothers explained that their infants were no longer interested in breastfeeding or that the infant did not want to breastfeed. Other descriptions noted that the infant chose to cease or was ready to cease breastfeeding. The mother’s interpretation that the infant rejected breastfeeding was a more active action than the mother’s interpretation that her body or her infant was showing the way. Perceived negative feedback from the child further reduced the desire to breastfeed among mothers who breastfed as long as they wanted.

The child did not want to breastfeed; he simply became uninterested, which made me lose my interest. T12, e, p, p, n (ceased breastfeeding at 9 m)

However, mothers who did not breastfeed as long as they wanted expressed a desire to continue breastfeeding.

My son suddenly chose to stop breastfeeding. I had wanted to continue for a few more months. T5, p, p, p, n (ceased breastfeeding at 10 m)

Mothers whose data supported this theme breastfed their infants 6 to 13 months, with most of them breastfeeding approximately 9–12 months; however, more mothers who did not breastfeed as long as they wanted breastfed for a shorter period.

Regarding the theme of the desire to regain the mother’s and infant’s well-being, the mothers stated that they ceased breastfeeding because of pain; for most of them, this pain was a result of the infant’ biting on the breast. Several mothers described their own mental health and medication as reasons for ceasing breastfeeding. In addition, in some cases, the mothers reported that their infants health, such as fussiness and screaming that was associated with an allergy to the protein in cow’s milk or other sicknesses. Therefore, ceasing breastfeeding was something the mother did to improve her own or her infant’s well-being.

I wanted to breastfeed for longer, but decreased mental health made the decision to cease breastfeeding the best for everyone. SK50, e, e, p, n (ceased breastfeeding at 8 m)

A few mothers described that a new pregnancy hindered the continuation of breastfeeding; all of these mothers breastfed as long as they wanted. The mothers described that their breasts were sore, they felt unwell, their milk supply decreased or the infant did not breastfeed because of a new pregnancy. One mother wanted to cease breastfeeding to regain menstruation to become pregnant again.

Most mothers in this theme, including both mothers who breastfed as long as they wanted and mothers who did not breastfeed as long as they wanted, breastfed for 9–12 months. The exceptions were mothers who indicated their own mental health as the reason for breastfeeding cessation; these mothers ceased early (1–3 months).

The mother's own will and perceived external obstacles were additional reasons to cease breastfeeding. An external obstacle was returning to work. Mothers described returning to work either as obstacle or as a choice; work was described as an obstacle only by mothers who did not breastfeed as long as they wanted. One mother wrote that breastfeeding did not work at all, while others wrote that they wanted to breastfeed for longer.

I chose to start working after seven months. I was forced to cease breastfeeding when [infant’s] the father would be home. T20, e, e, e, n (ceased breastfeeding at 7 m)

Several mothers wrote that they wanted to cease breastfeeding or that they felt that they had breastfed enough; however, these feelings were described only by mothers who breastfed for as long as they wanted. Some mothers described that they ceased breastfeeding to get more sleep at night, while other mothers ceased breastfeeding so that they could share the feeding with the father.

I felt that I wanted to cease and it went great. SU 53, e, e, p, n (ceased breastfeeding at 8 m)

The mothers who breastfed as long as they wanted breastfed for eight to >12 months or more, while the mothers who did not breastfeed as long as they wanted breastfed for 2–12 months.

Overall theme: Breastfeeding cessation–an act based on passivity or activity

The triangulation and interpretation of the qualitative and quantitative data revealed that the mothers who breastfed as long as they wanted and the mothers who did not breastfeed as long as they wanted showed some similarities. However, they also differed in terms of the meaning of breastfeeding cessation and how many mothers described the reasons for cessation.

In the analysis, it was observed that the mothers who did not breastfeed as long as they wanted were less active in promoting their breast milk supply and were less active when breastfeeding ceased. These mothers also described less harmonious breastfeeding and used powerless language when discussing the cessation of breastfeeding. They described their experiences of cessation with phrases such as “dried up”, “not enough”, “ran out”, “was not enough”, “unfortunately, [the milk] left”, “never got [the milk]”, “there is nothing” or “nothing comes”. Such expressions were interpreted as indication their passivity and their not taking control over their bodies and milk production, which were related to thoughts of having a biologically predetermined amount of breast milk that could not be influenced by the mother herself, even if the infant was breastfeeding. In other words, these mothers saw their lack of breast milk as something they could not do anything and therefore passively accepted it. They were also generally more dissatisfied with breastfeeding and breastfed for a significantly shorter time than mothers who breastfed as long as they wanted. If the mother took a passive approach to her body’s ability for milk production, there was a risk of her being more passive in breastfeeding and a risk of breastfeeding cessation before she wanted.

On the other hand, mothers who breastfed as long as they wanted seemed to be more active in making decisions and to have power over breastfeeding cessation. These mothers also described responses from their infant that they interpreted to indicate that the infant did not want what was offered. However, these mothers described more harmonious breastfeeding (i.e., breastfeeding went smoothly with no major problems or difficulties) and used more empowered language when discussing the cessation of breastfeeding. For example, when they described their experiences, they used phrases such as “decided”, “chose”, “lost interest”, “feel ready”, “does not want” or “satisfied”. The meanings of such language suggest that the mothers perceived their own body’s ability to be more powerful and influential than did mothers who did not breastfeed as long as they wanted; in addition, they perceived the amount of breast milk to be something that they themselves could control. Therefore, mothers who breastfed as long as they wanted were interpreted as taking an active approach to allow them to take control over the breastfeeding situation and cessation. The mothers who breastfed as long as they wanted were generally more satisfied with their breastfeeding and breastfed significantly longer than the mothers who did not breastfeed as long as they wanted. Being more active in decision making and taking power seemed to facilitate breastfeeding. A schematic figure of the results is shown in Fig 2.

Fig 2

Schematic figure.

A schematic figure of the overall interpretation and the themes of the meaning of breastfeeding cessation in relation to breastfeeding length, breastfeeding satisfaction and breastfeeding cessation.

Discussion

The results of this study showed that for mothers of preterm infants who breastfed at the time of discharge from the neonatal unit, the decision to cease breastfeeding seemed to depend on the mother’s passivity or activity in relation to her body’s ability, her breast milk production, and her own will as well as the infant’s behaviour and signals. Mothers who did not breastfeed as long as they wanted were less satisfied with breastfeeding, breastfed for a shorter period and were less active; they did not take control over breastfeeding and were not reflective when ceasing breastfeeding. In contrast, mothers who breastfed as long as they wanted were more satisfied with breastfeeding, breastfed for a longer period of time and were more active in decision making and in taking command in breastfeeding.

The mothers who did not breastfeed as long as they wanted breastfed an average of 10 weeks less than did the mothers who breastfed as long as they wanted. This shorter breastfeeding duration may reflect that the mothers had breastfeeding problems. In our study, a few mothers described breastfeeding problems such as mastitis, wounds and/or cracked nipples as reasons for breastfeeding cessation, which has been a common finding in other studies [23, 24]. However, in our study, many mothers described issues with their milk supply. This has also been described in other studies, for example, that of Gianni et al. (2018), who found that mothers who were admitted to a neonatal unit and had problems expressing breast milk or provided an inadequate amount of breast milk had a higher risk of breastfeeding cessation prior to discharge [25, 26]. Even in studies with mothers of full-term infants, concern about milk supply was a cause of breastfeeding cessation [27, 28]. Additionally, Collin et al. (2002) showed that the infant’s behaviour and signs of being unsatisfied were interpreted as an indicator of an insufficient milk supply [28]. In our study, the mothers did not seem to take action to address milk supply issues, such as trying to increase milk production or seeking help. This inaction may have been due to a lack of knowledge or trust in their own ability to breastfeed. Avery et al. (2009) suggested that mothers who are confident about breastfeeding and breast milk production during pregnancy develop a “confident commitment”, in which the decision to continue breastfeeding is made [29]. Without such commitment, the cessation of breastfeeding may follow challenges with breastfeeding, which indicates that breastfeeding is a learned skill and not a predetermined skill. This suggestion is interesting in relation to the results of the present study, which indicated that mothers who did not breastfeed as long as they wanted were passive and had a predetermined negative view of their body’s ability to breastfeed and to produce breast milk. Both Dykes (2006) and Martin (2001) highlighted that the Western view and industrialized dualistic manner of thinking about women’s bodies as producers and as objects may have consequences for individual women, who imagines themselves as being alienated from their own bodies [30, 31]. Dykes (2006) suggested that doubt and mistrust towards the body and breast milk production, presented in the present study as passivity and not taking control, can be a consequence of a Western view of women’s bodies, which become dominated into being passive objects. Instead, the breastfeeding body must be considered from a non-dualistic way of thinking, and the breastfeeding experience must be seen as an embodied experience [30]. It seems to be important for health care professionals who support mothers of preterm infants in breastfeeding to be aware that mothers seem to have different views on the ability of their bodies to produce breast milk. Mothers who tend to see their bodies as passive objects and who do not take control in an active way must be strengthened to believe in their bodies ability to breastfeed as long as they want. Genuine support strengthens mothers, as shown by Ericson and Palmer (2018). Genuine support is individually adapted and includes both practical and emotional support. Furthermore, genuine support also includes being listened to and being met with respect, understanding and knowledge [12]. In a caring situation in which support is provided, there must be an openness towards each mother’s unique breastfeeding situation. Such openness was described by Galvin and Todres (2009) as openheartedness [32]. Being openhearted involves presence for the other person, embodiment and practical responsiveness.

Another interesting result was that many mothers, especially those who breastfed as long as they wanted, stated that their infants wanted to cease breastfeeding and/or lost interest in breastfeeding. Most mothers who breastfed as long as they wanted ceased breastfeeding approximately 8–12 months after birth, which is the time when solid foods are introduced according to national recommendations. In Sweden, few mothers breastfeed their infants after one year of age [1]. This can be compared to a study examining breastfeeding length in non-industrial populations, which showed that breastfeeding until two to four years of age was common [33]. A book on cultural perspectives on breastfeeding claimed that both culture and the medicalisation of breastfeeding are responsible for the shortened periods of breastfeeding in the Western world. Observations of the mother-infant relationship in traditional societies has shown that all mothers breastfed their children, often until 3 to 4 years of age, which is also supported by palaeontological evidence [34].

Limitations

The trustworthiness of the study is strengthened by the mixed method design, which strengthens the understanding of breastfeeding cessation through the use of both qualitative and quantitative data [16]. Many mothers provided similar comments on the cessation of breastfeeding; hence, the interpretation of the themes of the meaning of breastfeeding cessation is likely trustworthy. Additionally, the results can probably also be transferred to similar contexts because of the relatively large number of comments and the similarities in the comments on cessation of breastfeeding despite the participants being spread over a large part of Sweden. Although the comments provided by the mothers were relatively short, there were many comments, leading to the identification of a wide variety of meanings in the data instead of an in-depth description of meanings. This wide variety of meanings may be of interest to investigate in more depth in future research [35]. However, to deepen the understanding of breastfeeding cessation, it may be beneficial to perform in-depth interviews with mothers. The authors remained open to the data but also questioned and continuously reflected on the analysis and results, which strengthened the credibility and confirmability of the findings. A further strength of the study was the long follow-up, during which we measured breastfeeding satisfaction repeatedly and assessed the cessation of breastfeeding close to the time of event/experience. It does not appear that the intervention in the RCT study affected the results of this study. The intervention lasted until 14 days after discharge and did not affect breastfeeding [18]. It seems unlikely that the intervention would have affected the cessation of breastfeeding, which usually happened much later, as supported by the analysis.

A limitation is that the questions measuring breastfeeding satisfaction and whether the mother breastfeed as long as she wanted were not validated. However, the breastfeeding satisfaction question had a strong correlation (r = 0.70–0.74) with the validated Maternal Breastfeeding Evaluation Scale [36], which also measures breastfeeding satisfaction. That the mothers answered at all follow-ups.

Conclusion

Passive and active behaviour influence the cessation of breastfeeding in mothers of preterm infants who breastfed at the time of discharge from the neonatal unit. Passive behaviour increases the risk of early breastfeeding cessation and lower breastfeeding satisfaction, while active behaviour increases breastfeeding length and satisfaction. This is important knowledge when supporting breastfeeding and designing interventions to support breastfeeding.

6 Mar 2020

PONE-D-20-00937

Cessation of breastfeeding in mothers of preterm infants – a mixed method study

PLOS ONE

Dear Dr Ericson,

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Partly

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: I Don't Know

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Reviewer #1: No

Reviewer #2: No

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Reviewer #1: No

Reviewer #2: 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: The inclusion criteria for both mothers and preterm infants are not explicitly stated. Measures to ensure validity and reliability of the data collection instrument used in the quantitative study was not indicated.The measures to ensure trustworthiness of the qualitative aspect of the study were also not made explicit in the manuscript. Some of the percentages do not sum up to 100%. Some of the words used and sentences need to be revised for clarity.

Reviewer #2: Review of: Cessation of breastfeeding in preterm infants – a mixed method study.

Introduction:

The decline in breastfeeding of preterm infants are based on data from 2004-2013 from the Swedish National Quality Register. Are there not any newer data that can be drawn from the Register to evaluate current breastfeeding status?

You refer to a study of breastfeeding problems as experienced by mothers of healthy infants with a GA of > 35 weeks. Several studies report preterm infants to be in increased risk of breastfeeding problems, and one might argue that breastfeeding problems of mature and premature infants might differ, for instance in prevalence, e.g. sleepy infant, not enough milk (which you also discuss later in your manuscript under discussion) Therefore you should also refer to studies of breastfeeding problems as experienced by mothers of preterm infants.

Line 72-73: To have the possibility of breastfeeding as long as one wants, breastfeeding support is crucial. Yes!, but please support this by a reference.

Method:

The methods section needs to be revised. You should consider sub-headings in ‘Materials and methods’ to enhance the reading of the manuscript, e.g. sub-heading: Design, setting and participants, and sub-heading: Data collection, and sub-heading: Measures.

Please state how many mothers were eligible for study in the study period and how many were approached about the study? You could also add a figure illustration the inclusion process and response rates during the study period. Did you have any ethical considerations in regard to recruiting participants; e.g. critical ill infant, mother with mental disease or psychological issues? When were mothers approached at the neonatal unit? At discharge? A week before?

Please define exclusively and partial breastfeeding, e.g. did you follow WHO’s definition? And how was the mothers informed, as it seems as they self-reported breastfeeding status after discharge? Therefore, please state clearly when breastfeeding status were reported by healthcare professionals (at discharge?) and self-reported by mothers (after discharge?). Please elaborate on setting, e.g. were any hospitals ‘babyfriendly’ (BFIH)?, and inclusion criteria, e.g. were only singleton infants recruited? In Table 1 multiple births appears but should be mentioned in ‘Methods’. No exclusion criteria are mentioned? Please elaborate if you did or did not have any considerations in this regard, e.g. language?

Line 104-106 and line 111-113 are unclear. Did you include data (free text) from the question mentioned in line 111-113 in your qualitative analysis if it described breastfeeding cessation?

Line 139-140: How did you sort these comments as you described that they were sorted by breastfeeding as long as the mother wanted or not?

Coding 6, 12 months after birth is according to the infants real birth date and not adjusted to gestational age (GA)? Please state shortly in line 96 if questionnaires were distributed according to real birth date.

Argumentation for choice of method for qualitative analysis could be improved. Please state if you used any software to analyze the qualitative data.

Please add a table illustrating your analysis and coding process, as it will enhance the reader’s ability to assess the quality of your analysis.

Results:

Response rates during the study period are missing, see comment under methods.

Can you add a comment in regard to how the amount of qualitative data (total comments) were distributed in regard to who breastfeed as long as they wanted and who did not breastfeed as long as they wanted (line 131 -132) as you in your analysis state that comments were lacking in some themes from mothers not breastfeeding as long as they wanted (line 189-190).

Line 178: drying up? Reflect upon wording as your quotes reflects mothers’ wording and the text your academic language, e.g. consider ‘insufficient milk supply’?

Line 190: left or lack?

Discussion:

Line 305 and line 307: You say studies but only refer to one study? E.g. in breastfeeding problems there are many studies relevant to add as references.

Line 342-343. Did you collect data in regard to solid food introduction in your study population? Or are there studies describing that solid food are introduced in preterm infants by 8-12 months after birth? That number is not adjusted to GA? As introduction of solid foods are earlier, as reported in term infants.

Line 345-348. Please make your argumentation clear in short writing. , e.g. remove redundant text.

Line 348: Are there any studies you could refer to as to support your hypothesis?

Please elaborate further on strengths and limitations of your study as it by now is hardly described; e.g. what steps did you take to enhance the validity of your study?

As your study is secondary analysis of data derived from a larger intervention study (RCT), you have not stated how it might have or have not affected the results of your study, which is an important issue to address, when reporting the validity of your findings.

You should also add a short description about how you dealt with/used/reflected on your preunderstanding throughout your study (under Methods) as your preunderstanding can create bias and reduce validity. You could as well state if your e.g. profession could create potential bias.

General reflections:

The manuscript should be grammar checked as there are several typos and edited in the use of English, as some wordings could be improved. Several places in the manuscript authors’ names of references could be deleted as seems redundant text and will improve the reading of manuscript, e.g. for example, Feenstra et al and for example Gianni et al. Replace with only the reference in Vancouver style.

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: Reviewers report Manuscript Number PONE-D-20-00937.docx

Click here for additional data file.

23 Apr 2020

Dear editor and reviewers

Thank you for the opportunity to revise our manuscript and for the comments that have been given to us. In the revised manuscript we have made track changes to the original version. Withdrawn texts were not retained as crossed-out text. Please find below our replies to the comments.

We have addressed the comments from the editor. We have an objective. We have clarified the description of the sampling strategy, participant inclusion/exclusion criteria and the number of participants recruited. We have clarified the reporting of the data collection and data analysis procedures. We have expanded the discussion of potential sources of bias and the discussion of limitations.

We have used the SRQR checklist to ensure complete reporting of the qualitative part of the study.

Reviewer #1: The inclusion criteria for both mothers and preterm infants are not explicitly stated.

Reply: Thank you; we have added that information in the method section.

Measures to ensure validity and reliability of the data collection instrument used in the quantitative study was not indicated.

Reply: We have added a sentence about the validity of the measures in the discussion.

The measures to ensure trustworthiness of the qualitative aspect of the study were also not made explicit in the manuscript. Some of the percentages do not sum up to 100%. Some of the words used and sentences need to be revised for clarity.

Reply: We have revised through the whole manuscript.

Reviewer #2:

Introduction:

The decline in breastfeeding of preterm infants are based on data from 2004-2013 from the Swedish National Quality Register. Are there not any newer data that can be drawn from the Register to evaluate current breastfeeding status?

Reply: There are no newer published data. However, we added a reference from the Swedish Neonatal Quality register (annual report) that show a continued decline in breastfeeding. Unfortunately, the report is in Swedish, but you may see the figures.

You refer to a study of breastfeeding problems as experienced by mothers of healthy infants with a GA of > 35 weeks. Several studies report preterm infants to be in increased risk of breastfeeding problems, and one might argue that breastfeeding problems of mature and premature infants might differ, for instance in prevalence, e.g. sleepy infant, not enough milk (which you also discuss later in your manuscript under discussion) Therefore you should also refer to studies of breastfeeding problems as experienced by mothers of preterm infants.

Reply: We have added a sentence about mothers of preterm infants.

Line 72-73: To have the possibility of breastfeeding as long as one wants, breastfeeding support is crucial. Yes!, but please support this by a reference.

Reply: Thank you, a reference has been added.

Method:

The methods section needs to be revised. You should consider sub-headings in ‘Materials and methods’ to enhance the reading of the manuscript, e.g. sub-heading: Design, setting and participants, and sub-heading: Data collection, and sub-heading: Measures.

Reply: Thank you for your suggestion, we have added subheadings.

Please state how many mothers were eligible for study in the study period and how many were approached about the study? You could also add a figure illustration the inclusion process and response rates during the study period.

Reply: We have added a flowchart over inclusion and exclusion and response rate, se figure 1.

Did you have any ethical considerations in regard to recruiting participants; e.g. critical ill infant, mother with mental disease or psychological issues? When were mothers approached at the neonatal unit? At discharge? A week before?

Reply: Thank you, we have added that information under the method section.

Please define exclusively and partial breastfeeding, e.g. did you follow WHO’s definition? And how was the mothers informed, as it seems as they self-reported breastfeeding status after discharge? Therefore, please state clearly when breastfeeding status were reported by healthcare professionals (at discharge?) and self-reported by mothers (after discharge?).

Reply: Thank you, we have added a definition of breastfeeding and who provided the data.

Please elaborate on setting, e.g. were any hospitals ‘babyfriendly’ (BFIH)?, and inclusion criteria, e.g. were only singleton infants recruited? In Table 1 multiple births appears but should be mentioned in ‘Methods’. No exclusion criteria are mentioned? Please elaborate if you did or did not have any considerations in this regard, e.g. language?

Reply: We have added information of the inclusion and exclusion criteria and neonatal units under settings. Both singleton and twin mothers were recruited.

Line 104-106 and line 111-113 are unclear. Did you include data (free text) from the question mentioned in line 111-113 in your qualitative analysis if it described breastfeeding cessation?

Reply: We have revised the paragraph.

Line 139-140: How did you sort these comments as you described that they were sorted by breastfeeding as long as the mother wanted or not?

Reply: Each comment were marked with the mothers’ code and the same code was used in the quantitative data set. Hence, we could connect the codes with the answer on the question if the mother breastfed as long as she wanted or not. We have added that information in the analysis section.

Coding 6, 12 months after birth is according to the infants real birth date and not adjusted to gestational age (GA)? Please state shortly in line 96 if questionnaires were distributed according to real birth date.

Reply: It was the real birth date, not corrected age. This, have been clarified.

Argumentation for choice of method for qualitative analysis could be improved. Please state if you used any software to analyze the qualitative data.

Reply: We have added more about the analyze process in the text see analysis section.

Please add a table illustrating your analysis and coding process, as it will enhance the reader’s ability to assess the quality of your analysis.

Reply: We have added a table of the analysis process, see table 1.

Response rates during the study period are missing, see comment under methods.

Reply: We have added a flowchart over included and excluded mothers and response rates, se figure 1.

Can you add a comment in regard to how the amount of qualitative data (total comments) were distributed in regard to who breastfeed as long as they wanted and who did not breastfeed as long as they wanted (line 131 -132) as you in your analysis state that comments were lacking in some themes from mothers not breastfeeding as long as they wanted (line 189-190).

Reply: Mothers who did not breastfeed as long as they wanted provided more comments in this theme. We have changed the sentence to clarify.

Line 178: drying up? Reflect upon wording as your quotes reflects mothers’ wording and the text your academic language, e.g. consider ‘insufficient milk supply’?

Reply: We have changed the wording.

Line 190: left or lack?

Reply: They provided more comments. We have clarified the sentence.

Discussion:

Line 305 and line 307: You say studies but only refer to one study? E.g. in breastfeeding problems there are many studies relevant to add as references.

Reply: Thank you, this have been changed.

Line 342-343. Did you collect data in regard to solid food introduction in your study population? Or are there studies describing that solid food are introduced in preterm infants by 8-12 months after birth? That number is not adjusted to GA? As introduction of solid foods are earlier, as reported in term infants.

Reply: We did not collect data on solid food introduction. However, national guidelines recommend introduction of solid foods at 6 months corrected gestational age. We clarified the sentence in the manuscript.

Line 345-348. Please make your argumentation clear in short writing. , e.g. remove redundant text.

Reply: We have revised the sentence.

Line 348: Are there any studies you could refer to as to support your hypothesis?

Reply: We have revised the paragraph.

Please elaborate further on strengths and limitations of your study as it by now is hardly described; e.g. what steps did you take to enhance the validity of your study?

Reply: We have clarified the limitations and trustworthiness of the study.

As your study is secondary analysis of data derived from a larger intervention study (RCT), you have not stated how it might have or have not affected the results of your study, which is an important issue to address, when reporting the validity of your findings.

Reply: We have added a paragraph about the RCT and our study.

You should also add a short description about how you dealt with/used/reflected on your preunderstanding throughout your study (under Methods) as your preunderstanding can create bias and reduce validity. You could as well state if your e.g. profession could create potential bias.

Reply: We have added a paragraph about our preunderstanding and professions.

General reflections:

The manuscript should be grammar checked as there are several typos and edited in the use of English, as some wordings could be improved. Several places in the manuscript authors’ names of references could be deleted as seems redundant text and will improve the reading of manuscript, e.g. for example, Feenstra et al and for example Gianni et al. Replace with only the reference in Vancouver style.

Reply: We have made a language review by another professional language reviewer, see attached certificate. We have corrected the references.

Line 40: You need to include the method of data analysis in the methods section of the abstract.

Could include the themes identified in the results section of the abstract.

Reply: We have added the analysis methods and identified themes in the abstract.

Introduction: The introduction was supported by relevant literature however there is a need to provide references for statements made in lines 58, 64-65.

Reply: Thank you, we have added references.

Material and methods: The design is appropriate for the study. Though it was stated that 270 mothers were used for the study in the abstract as well as the results section of the manuscript, the inclusion criteria were not explicitly stated in relation to both mother and infant characteristics. For example, category of preterm infants - extremely, preterm, very preterm or moderate to late preterm. The sampling technique was also not stated. Measures used to ensure validity and reliability of the items in data collection instrument for the quantitative part of the study as well as those used to ensure trustworthiness in the qualitative part should be included.

Reply: We have added information on inclusion and exclusion criteria in the method section. We included breastfeeding mothers of all preterm infants < 37 weeks. We sampled data via questionnaires, which is stated in the method section. The method section have been clarified.

Line 87-89: The statement is not necessary.

Reply: We have modified the sentence.

Line 90-91: Please revise the sentence.

Reply: We have revised the sentence.

Line 94-95: Instead of “breastfeeding period” please revise it to read “the first year of life”.

Reply: Thank you; we have changed the sentence.

Line 99: It will be appropriate to define the terms exclusive breastfeeding and partial breastfeeding as used in the study.

Reply: We have added a definition of breastfeeding.

Line 102: How was the breastfeeding satisfaction analyzed using the visual analogue scale?

Reply: We used a Mann-Whitney U-test. We have clarified the analysis section.

Line 105-106, 111-112: What is the difference between the two questions stated?

Reply: It is the same question. We wanted to describe that we collected qualitative data from the free text alternative on the stated question.

Line 111: Please clarify which set of questions were asked at the different points.

Reply: We have revised the measure section.

Results

Line 117-118: Please revise this sentence for clarity.

Reply: We have revised the sentence.

Line 124: Was this the only condition for conducting a Mann -Whitney U test analyses? You need to assess the data to see if they meet the assumptions for parametric testing or not before selecting the appropriate statistical test.

Reply: We have revised the sentence.

Line 125: Chi-square test is used to measure association between two categorical variables and not for measurement of differences.

Reply: We have revised the sentence.

Line 129: Only one open ended question (line 109-110), has been stated in the manuscript. What was the second open ended question?

Reply: It was a free text option on the question “If you have ceased breastfeeding, did you breastfeed as long as you wanted”. As stated in the measurement section under qualitative data. We have also revised the paragraph.

Line 134-137: There is a need to clearly define each of the alphabets or letters being used to describe participants and breastfeeding cessation for readers to understand.

Reply: We have revised the sentence.

Line 138-140: Please revise the statement for clarity.

Reply: We have revised the sentence.

Line 149-150: For the written comments about breastfeeding cessation did participants provide more than one specific comment? (165 comments from 149 participants)

Reply: Yes they did.

Table 1. The numbers in the table do not add up to the total number of participants

Reply: Thank you, we have corrected the numbers.

What was response rate in terms of the questionnaire sent out. Where the questionnaires self-administered?

Reply: We have added a flowchart over included and excluded participants and response rate to the questionnaires (figure 1). The questionnaires were self-assessed.

Table 1: “Partial breastfeeding 12 months after birth”. This percentage seems inaccurate, what was the denominator used for this calculation?

Reply: Thank you. There were missing data on 42 mothers, we have added this information in the table.

Table 2: Low maternal educational level…These numbers in the brackets do not sum up to 100%. What does this mean? If the numbers that responded to each question item are not same, you can put the total numbers beside the item.

Reply: Thank you for pointing out table 2. We have added data on both groups in each analysis to make it easier to interpret and to see associations with cessation of breastfeeding and if the mothers breastfeed as long as they wanted or not.

Were multiparas involved in this study? If yes, were there any differences found in breastfeeding cessation between primiparas and multiparas?

Reply: Both primipara and multipara mothers participated in the study. There was a difference in exclusive breastfeeding at discharge between primipara and muiltipara mothers participating in this study where more multipara mothers breastfeed exclusively. There were no statistically difference in the later follow-ups.

If different categories of preterm infants were involved in the study, were there any differences in terms of breastfeeding cessation?

Reply: There was no differences in cessation of breastfeeding at any of the follow-ups between infants born <32 or 32-36 weeks of gestational age participating in this study.

Line 172: Two open ended questions meanwhile there is only one in the manuscript.

Reply: There is two questions asked where the mothers could wright in free text, we have clarified the section in the measure section.

Line 174: Please reframe this sentence to clarify the main theme.

Reply: We have revised the sentence.

Line 179: “Negative feedback”. What exactly does this mean?

Reply: We have revised the sentence.

Line 182-183: If participant stopped breastfeeding at 3 months why the use of letter ‘p’ at 3 months. Please clarify.

Reply: Thank you for noticing that, it was a typo that we have corrected.

Line: 185 -186: Please move this statement upwards, i.e., after the first two statements and before the statement beginning with "From the mothers’ descriptions ..." (line 177)

Reply: We have moved the statement.

Line 189: “There was a difference in this theme” This is unclear, please revise

Reply: We have revised the sentence.

Line 219: Please be specific, “this pain was because the infant teeth came in”. Do you mean the infants with teeth were biting on the breast?

Reply: We have revised the sentence.

Line 220- 221: “In addition, the infant health such as cowmilk protein allergy…” This statement seems unclear please consider revising.

Reply: We have revised the sentence.

Line 224: If participant ceased breastfeeding at 8 months why is the same participant categorized as practicing exclusive breastfeeding at 12 months?

Reply: Thank you for noticing that, it was a typo that we have corrected.

Line 246: Why was the quote of the participant referenced as [16]?

Reply: Thank you for noticing that, we have removed the reference.

Line 260: Mothers who did not breastfeed as long as they wanted were “less active …….” Did you observe this or this is an information they told you? Please clarify.

Reply: We observed that. We have revised the sentence.

Line 248- 250: The sentence looks incomplete.

Reply: We have revised the sentence.

Line 263 What is the meaning of “harmonious breastfeeding”?

Reply: We have clarified the sentence.

Line 264: How powerful can these words be when they are describing their experience?

Reply: We have revised the sentence.

Line 266: ……. “of pre-determined biologically given end “this section seems unclear, please revise.

Reply: We have revised the sentence.

Line 270: What does it mean for the mother to be “unreflective in relation to her own body”?

Reply: We have revised the sentence.

Discussion

Line 306: You need to cite more than one reference as you made mention of “studies”

Line 307: Same comment as line 306 above

Reply: We have added references.

Line 314: “The mothers did not seem to do anything active about their milk supply” What does this mean and what were the expectations in such situations?

Reply: We have clarified the sentence.

Line 318: “Cessation of breastfeeding is a fact” revise this phrase.

Reply: We have revised the phrase.

Line 332- 333: “……the cultural influence and that mothers seem……” This information was not reflected in your results.

Reply: We have removed the information.

Line 334: In what ways can mothers be strengthened?

Reply: We have clarified the sentence.

Line 343: Approximation of 35 weeks of breastfeeding to 12 months needs to be clarified.

Reply: We have clarified the sentence.

Line 345: ….. “when it was cultural acceptable to cease breastfeeding, this information did not reflect in your results.

Reply: We have removed the sentence.

Line 346: To what extent is breastfeeding for 2-4 years in non-industrial populations comparable to Sweden? Please expand the point for clarity especially with respect to the early cessation of breastfeeding reported in Sweden.

Reply: We have added two sentences for clarity.

Line 348-349: Hypothesis? Please provide references for the statements made.

Reply: We have removed the hypothesis.

Line 354: “A limitation is that comments left by mothers were relatively short”. If this is addressed as a limitation, how does the qualitative data adds up to the strength of your study as earlier described in line 352?

Reply: We have revised the sentence.

Line 355: “width and depth”, What does this mean in the context of your study?

Reply: We have revised the limitation section.

References: All references used were accounted for in the list of references, however there is a need to cross check reference number [16] since it was used as in text citation for a quote by a participant (Line 246).

Reply: We have removed the reference.

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

30 Apr 2020

Cessation of breastfeeding in mothers of preterm infants – a mixed method study

PONE-D-20-00937R1

Dear Dr. Ericson,

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

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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With kind regards,

Joann M. McDermid, MSc, PhD, RDN, FAND

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

5 May 2020

PONE-D-20-00937R1

Cessation of breastfeeding in mothers of preterm infants – a mixed method study

Dear Dr. Ericson:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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on behalf of

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Academic Editor

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