Desired but Unattained Breastfeeding: A Qualitative Exploration of Maternal Perceptions in a Cultural–Religious Context

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript reports a qualitative, phenomenologically framed study of 30 women (15 Christian, 15 Muslim) in a multicultural Spanish enclave in North Africa who intended to breastfeed but discontinued. Semi-structured interviews were analysed with Braun and Clarke thematic analysis, yielding four themes and a comparison of how the two cultural-religious groups experience and attribute breastfeeding failure. The topic is timely, the setting is distinctive, and the cross-cultural comparison is a genuine contribution. However, several methodological and reporting issues currently limit the extent to which the interpretive claims, especially the cultural contrast, are supported by the data.

1. The study is framed as phenomenological within an interpretivist paradigm, yet the analysis follows Braun and Clarke thematic analysis and the phenomenological tradition (descriptive/Husserlian vs interpretive/hermeneutic) is never specified. There is no account of bracketing or reflexivity, or of how a phenomenological attitude was operationalized. Please either reconcile the design by naming the specific phenomenological approach and its analytic implications or reframe the study as qualitative descriptive/thematic. Add a reflexivity statement addressing the researcher's position as a midwife and mother. Note also that theoretical saturation is a grounded-theory concept; data saturation or informational redundancy is the appropriate term here.

2. An average interview length of about 10 minutes is difficult to reconcile with a phenomenological aim of exploring lived experience in depth. Please justify how depth and saturation were achievable at this length, report the range of durations, and discuss the implications for data richness as an explicit limitation.

3. In this setting many participants, particularly Muslim women, may use Tamazight/Riffian or Moroccan Arabic. The manuscript does not state the language(s) of the interviews, whether interpreters were involved, or how quotations were translated into English and quality-assured. Because the central claims concern cultural-religious meaning, unreported language and translation procedures are a significant threat to credibility and to the group comparison. Please specify interview language(s), translation and back-translation procedures, and who performed them.

4.  Quotations are attributed to codes that exceed the stated sample of 15 per group (for example MW16, MW26, CW19, CW20), although only 15 Muslim and 15 Christian women were enrolled. This raises concerns about data integrity or an unexplained coding scheme. Please reconcile the coding system with the sample size and correct all identifiers throughout the text and Table 3.

5. The headline contrast, Muslim women internalising failure as maternal identity versus Christian women externalising it to context, is a strong and potentially essentialising claim drawn from 15 plus 15 short interviews. Group differences may be confounded by education, parity, socioeconomic status, or translation. Please present sociodemographic characteristics split by group to assess comparability, temper causal and cultural attributions, and explicitly address the risk of reinforcing cultural stereotypes.

6. All transcripts were coded by a single investigator, with triangulation added afterwards by two team members; no member checking, audit-trail detail, or qualitative software is described, and SPSS v15 (2006) was used for descriptive statistics only. For a comparative analysis, a systematic approach such as framework matrices, together with a fuller account of coding, disagreement resolution, and reflexive team discussion, would strengthen dependability.

7. The principal investigator is a midwife and mother who conducted all interviews, and participants were recruited through the Women's Health Unit; yet the rigour section states that no prior professional or personal relationship existed with participants. Please clarify whether the interviewer had provided clinical care to participants and how dual-role and social-desirability biases were mitigated.

8. The manuscript does not report how long women breastfed before stopping, or how failure was defined (never established vs early cessation). Please define these terms and report cessation timing, which is central to interpretation.

9. Moderate to high religious practice is asserted without an instrument or operational definition, despite being central to the argument. Please describe how religiosity was assessed.

10. The education categories in the Results text (for example 6.7% intermediate-level training) do not match Table 2, where 6.7% corresponds to high socioeconomic status rather than an education category. Please reconcile Table 2 and the text.

11. Several in-text citations do not match the reference list: Kehinde et al. is cited as [44] but Kehinde is reference 42; Xiaoling-Zheng is cited as [46] but is reference 44 (the surname is also misspelled Xialing-Zheng); Campino-Valderrama is cited as [47] but is reference 46. Please verify and correct all citations against the reference list.

12. SPPS in the Abbreviations list should read SPSS; consider a current SPSS version or justify the use of v15.

13. Anonymisation is inconsistent: the city is described as a Spanish city in North Africa, but references [10] and [43] identify Melilla. Decide on naming or anonymisation consistently.

14. The copyright line reads 2025, while the article year is 2026.

15. Table 3 largely duplicates Figure 1 and the in-text quotations; consider consolidating to reduce redundancy.

16. Template artifacts remain, for example, the 6. Patents heading and the Academic Editor placeholder.

17. The statement in 2.3 that no generative AI was used in design or analysis sits oddly beside the later disclosure of ChatGPT for language editing; consider consolidating these statements to avoid an apparent inconsistency.

Comments on the Quality of English Language

The manuscript needs careful English editing. Several sentences are incomplete or run-on, including the opening sentence of the Discussion and of Section 4.1, where a coordinating conjunction appears to be missing.

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This qualitative phenomenological study explores the perceptions and experiences of 30 women (15 Christian, 15 Muslim) who experienced undesired breastfeeding cessation in a multicultural Spanish city in North Africa. The study identifies four main themes: emotional experiences, reasons for cessation, structural barriers, and social environment influences. The authors highlight cultural-religious differences in how breastfeeding failure is internalized—Muslim women more frequently framing it as a failure of maternal identity, while Christian women more often attribute it to external factors. The study's strength lies in its comparative cultural-religious approach within a unique multicultural setting.

Major Strengths:

• The comparative design between Christian and Muslim women in a unique multicultural context is innovative and addresses a gap in the literature
• The phenomenological approach is appropriate for exploring subjective maternal experiences
• The study provides rich qualitative data with illustrative quotations that support the thematic analysis
• The cultural-religious dimension adds valuable depth beyond the existing literature on breastfeeding cessation

Major Weaknesses:

1. Methodological Concerns: The study reports an average interview duration of only 10 minutes. This is exceptionally brief for phenomenological research exploring complex emotional experiences. Semi-structured interviews of this length likely yielded superficial data, compromising the depth necessary for phenomenological analysis. The authors should justify this duration or acknowledge it as a limitation.
2. Data Analysis Transparency: The description of thematic analysis is insufficient. While Braun and Clarke's approach is cited, the authors do not provide details about: (a) how themes were developed (inductive vs. deductive coding), (b) the coding process, (c) how disagreements between researchers were resolved beyond stating "consensus was reached," or (d) how many researchers coded the data and their inter-rater reliability.
3. Inclusion/Exclusion Criteria Ambiguity: The study excludes women with "physical and/or mental conditions preventing participation," but it's unclear whether women with diagnosed postpartum depression were excluded or whether their experiences were captured. Given that postpartum depression is a key finding in the results, this ambiguity is problematic.
4. Thematic Overlap: The distinction between themes 3 ("Contextual and structural barriers") and 4 ("Influence of the social environment and support networks") is not always clear, as several subthemes (e.g., "lack of effective professional support") could fit in either category.
5. Cultural Generalizations: The authors make repeated claims about differences between Muslim and Christian women without acknowledging within-group diversity. For example, the statement that "Muslim women tend to internalize... whereas Christian women more frequently attribute it to external factors" relies on broad generalizations from a small sample (n=15 per group) without considering variations in religiosity, acculturation, or other intersecting factors.
6. Limited Discussion of Religious Framework: Despite the cultural-religious focus, the discussion provides minimal exploration of how specific religious teachings (e.g., Islamic teachings on breastfeeding duration from the Qur'an) might shape maternal expectations and experiences. This is a missed opportunity.

Specific Comments by Section

Abstract

• Line 22: The statement "differences emerged in how breastfeeding cessation was interpreted" is vague. Consider specifying the key difference (internal vs. external attribution) directly in the abstract.

Introduction

• Lines 58-62: The statistics on breastfeeding rates in Spain and Europe are presented without citation. While the WHO is mentioned, specific sources for the Spanish data (66% at 3 months, 46.9% at 6 months) should be provided.
• Lines 67-71: The transition from epidemiological data to cultural factors is abrupt. Consider adding a sentence explaining why cultural-religious differences might be expected (e.g., differing norms around maternal roles, religious obligations regarding infant feeding).
• Lines 79-82: The statement that "successful breastfeeding is often experienced as rewarding" is an oversimplification. Existing literature documents ambivalent experiences even among successful breastfeeders. The authors should nuance this claim.

Methods

• Lines 106-108: The sample size of 30 is adequate for qualitative research, but justification for this number (beyond "saturation") is needed. How was saturation determined? Were there any themes that did not reach saturation?
• Lines 113-117: Purposive sampling criteria are listed but not explained. How were participants with diverse characteristics actually selected? The authors state "recruited through consultations with a midwife," which suggests convenience sampling rather than true purposive sampling. This discrepancy should be addressed.
• Lines 121-124: The statement that interviews were conducted by "the principal investigator, a female midwife and mother" is presented as a strength (facilitating trust). However, the interviewer's positionality could also introduce bias. The authors should discuss how they managed potential bias (e.g., reflexive journaling and bracketing).
• Line 127: Interview duration of "approximately 10 minutes" is concerning. Please clarify whether this is accurate. If so, this severely limits data richness and should be acknowledged as a major limitation.
• Table 1: Interview questions are appropriate but somewhat leading (e.g., Question 6 "Do you feel guilty?" could prime participants). The authors should note this limitation.
• Lines 154-157: The use of SPSS for descriptive analysis is appropriate, but the version (SPSS 15) is outdated (released ~2006). Please verify this is correct and whether it affected analysis capabilities.
• Lines 168-174: The pseudonymization process is described adequately, but the authors should specify who had access to the identifying information and how long it will be stored.

Results

• General: The thematic structure is clear, and quotations effectively illustrate findings. However, the analysis of differences between Muslim and Christian women is presented in separate paragraphs for each theme, which makes comparison difficult. Consider integrating the comparative analysis more directly.
• Line 241: The statement "Most participants reported a moderate to high level of religious practice" appears twice (also at line 228). This repetition should be corrected.
• Table 2: This table is incomplete and does not display all variables mentioned in the text (e.g., socioeconomic status categories are not shown beyond the text stating 90% medium, 6.7% high, 3.3% low). The table also appears to have formatting errors with merged cells. Please provide the complete table.
• Lines 280-285: The finding that Muslim women describe suffering as "internalized maternal failure" while Christian women incorporate "contextual elements" is compelling but requires more nuance. Provide more quotations that demonstrate these patterns, not just the differences in emphasis.
• Section 3.2: The authors present the finding that "breastfeeding discontinuation was generally experienced less as an autonomous decision and more as an imposed outcome." This is a key insight that should be developed further in the discussion.
• Lines 359-363: The observation that Muslim women emphasized isolation while Christian women emphasized structural barriers is important but could be better supported with representative quotations that illustrate the contrast more directly.

Discussion

• Lines 445-448: The statement that "the physical and physiological challenges of breastfeeding are broadly shared" is a key finding. However, this contradicts the earlier emphasis on cultural differences. The authors should clarify how shared challenges and cultural differences coexist.
• Lines 453-457: The concept of "silent grief" (Jackson et al.) is appropriately cited, but the authors could develop this further. How does this concept apply differentially to Muslim vs. Christian women?
• Lines 491-493: The finding that "Muslim women tend to discontinue breastfeeding driven by family support networks" while "Christian women tend to discontinue due to lack of support from the healthcare system" is the study's most novel contribution. This should be the centerpiece of the discussion and linked more explicitly to the cultural contexts.
• Lines 505-510: The call for "more realistic information about breastfeeding" is well-supported by the data. However, the authors should specify what kind of information (e.g., prevalence of difficulties, realistic timelines, and strategies for overcoming challenges).
• Lines 508-511: The authors critique healthcare professionals for promoting formula feeding. While this is supported by some citations, the authors should acknowledge the clinical reasoning behind these recommendations (e.g., concerns about hypoglycemia, jaundice) and advocate for balanced, evidence-based decision-making rather than blanket criticism.
• Lines 518-520: The concept of breastfeeding as "maternal instinct" is mentioned but not fully explored. How does this concept vary between cultural groups? This could be a separate subtheme.
• Lines 520-524: The finding that Christian women attended antenatal education more frequently is presented without discussion of why this might be the case. Could this reflect differential access, cultural norms, or healthcare utilization patterns?
• Lines 530-533: The discussion of "cultural barriers to accessing support" (citation 43) is relevant but not adequately explained. What specific cultural barriers did Muslim women experience? This should be developed further.
• Lines 540-550: The discussion of grandmothers' influence is important but limited. Grandmothers can be both supportive and undermining. The authors should discuss how healthcare professionals can engage grandmothers positively.
• Lines 548-550: The comparison with minority ethnic groups (Aboriginal, Torres Strait Islander, and Papua New Guinea) is interesting, but the relevance to the current study's context (Christian-Muslim comparison in Spain) is unclear. These references feel somewhat tangential.

Strengths and Limitations

• Lines 554-560: The authors appropriately acknowledge the limitation regarding other minority groups (Jewish, Roma, Hindu) not being represented. However, this is a significant limitation given the stated multicultural context. The authors should be more explicit about how this limits the generalizability of findings.
• Lines 560-562: The statement "participants may not have been entirely truthful" is a generic limitation that applies to all qualitative research. This could be reframed to address how social desirability bias might have differentially affected Muslim vs. Christian women.
• Lines 564-567: The heterogeneous sample is appropriately presented as a strength. However, the authors should acknowledge that heterogeneity can also make thematic patterns harder to identify. How did the researchers ensure that differences between groups were not confounded by other variables (e.g., socioeconomic status, parity)?

Conclusions

• Line 574-578: The conclusion that "healthcare and social environments play a crucial role" is well-supported but somewhat generic. The authors should specify concrete recommendations (e.g., culturally adapted educational materials, training for healthcare providers in cultural competency, and integration of family members in breastfeeding support).
• Lines 584-586: The call to "move towards care models that explicitly integrate the cultural dimension" is appropriate but vague. What would such models look like in practice? Provide specific examples.

References

• The references are recent (mostly 2019-2025) and relevant, which is a strength.
• Reference 2: The citation to "Ministerio de Salud del Salvador" seems geographically irrelevant to a study conducted in Spain. The authors should provide a WHO or Spanish Ministry of Health reference for the breastfeeding recommendations.
• Reference 49 (O'Brien et al., 2014): The SRQR standards are appropriately cited. The authors should ensure all SRQR items are addressed in the manuscript.
• Self-citations: The authors cite two of their own previous studies (references 26, 43). This is acceptable but should be justified. Are these the only studies on this specific population?

 

Phenomenological Analysis

The authors claim a phenomenological approach, but the analysis appears to be more consistent with thematic analysis or conventional content analysis. Phenomenology requires specific analytical strategies that are not clearly demonstrated in the manuscript. First, phenomenology requires epoche or bracketing, in which researchers set aside their assumptions and prejudices to engage with participants' experiences openly. The authors do not describe any bracketing strategies. Second, phenomenology requires intentional analysis of lived experience, focusing on how phenomena are experienced in consciousness. The authors' analysis focuses on identifying themes across participants, which is more characteristic of thematic analysis. Third, phenomenology aims to identify invariant structures or essences of experiences. The authors do not claim to have identified such structures. These departures from the phenomenological method suggest that the study may be better characterized as qualitative descriptive research using thematic analysis.

The authors should either strengthen the phenomenological analysis by explicitly demonstrating these elements or reframe the study as a qualitative descriptive study using thematic analysis. The latter may be more appropriate given the current analysis and would not diminish the value of the study. Many qualitative health researchers use thematic analysis to explore experiences and perceptions, and this approach is well-accepted in the field.

Cultural Essentialism

Throughout the manuscript, the authors present differences between "Muslim women" and "Christian women" as if these are homogeneous categories. This approach risks reinforcing cultural stereotypes and obscuring diversity within each group. Women within each religious group vary in their level of religiosity, cultural practices, socioeconomic status, education, and individual experiences. The authors' sampling strategy attempted to capture some of this diversity, but the analysis does not adequately reflect it.

The authors should acknowledge diversity within each religious group in their analysis. They could discuss how other factors, such as level of religiosity, age, education, and parity, may intersect with religious identity to shape breastfeeding experiences. This would provide a more nuanced picture of the factors that influence breastfeeding cessation and would avoid presenting religious groups as monolithic categories.

The authors should also use more cautious language when describing group differences. Terms such as "tended to," "appeared to," and "suggested" would be more appropriate than categorical statements that imply absolute differences. This would acknowledge that the patterns observed are tendencies rather than universal characteristics of all women in each group.

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript addresses a relevant and underexplored topic by examining mothers’ experiences of desired but unattained breastfeeding, with particular attention to cultural and religious dimensions. The qualitative focus is potentially valuable, and the inclusion of Muslim and Christian women from a multicultural setting provides an interesting context for understanding how breastfeeding experiences may be interpreted differently. The manuscript is generally well structured, the research question is relevant, and the four thematic domains are clearly presented with illustrative quotations. The authors also provide ethical approval, informed consent procedures, a description of purposive sampling, and measures intended to enhance qualitative rigour. However, substantial methodological and interpretive issues should be addressed before the manuscript can be considered for publication. In particular, the relationship between the phenomenological design and the thematic analysis requires clarification; the very short interview duration raises concerns regarding the depth of the phenomenological exploration; the procedures used to establish saturation are insufficiently described; and several conclusions concerning differences between Muslim and Christian women appear stronger than the data presented can adequately support. The manuscript would benefit from a more reflexive and cautious interpretation of cultural-religious differences.

1. The manuscript identifies the study as phenomenological and situated within an interpretivist paradigm, but the analysis is described primarily as inductive thematic analysis following Braun and Clarke. The authors should provide a stronger methodological justification explaining why thematic analysis was selected as the analytic approach within a phenomenological study and identify the specific phenomenological tradition informing the research. At present, the philosophical orientation, methodological design, and analytic strategy are not sufficiently integrated. The authors should also clarify whether the study is intended to be phenomenological, interpretative phenomenological, descriptive phenomenological, or simply a qualitative thematic study informed by an interpretivist perspective.
2. The manuscript reports that the average duration of each interview was approximately 10 minutes. This is a major concern given that the stated objective is to explore mothers’ lived experiences “in depth” using a phenomenological approach. Ten-minute interviews may be insufficient to generate the depth of experiential data normally expected from phenomenological inquiry, particularly for a sensitive and complex topic involving maternal identity, guilt, grief, cultural beliefs, social pressure, and healthcare experiences. The authors should provide the minimum and maximum interview duration and explain how sufficient depth was achieved despite the short average duration. They should also clarify whether interviews were interrupted, whether follow-up questions were used, and whether participants were encouraged to elaborate on emerging experiences.
3. The manuscript states that data collection continued until “theoretical saturation” was reached, but subsequently describes inductive thematic analysis. The authors should define what they mean by theoretical saturation, explain how it was assessed, and identify at what point saturation was considered to have been achieved. It would also be useful to provide information about whether saturation was assessed separately within the Muslim and Christian groups. Given that the analysis is based on Braun and Clarke’s thematic approach, the terminology surrounding saturation should be carefully reconsidered and aligned with the specific version of thematic analysis employed.
4. This is perhaps the most important issue in the manuscript. The authors repeatedly state that Muslim women tended to internalise breastfeeding cessation as maternal failure, whereas Christian women more frequently attributed difficulties to external factors, social pressure, or lack of support. These are potentially important observations; however, the manuscript sometimes presents them as relatively stable cultural differences. The sample includes only 15 women in each group, recruited from a single healthcare setting, and religious affiliation was self-identified. The manuscript also indicates that most participants reported moderate to high religious practice, but the extent to which religiosity, ethnicity, nationality, socioeconomic circumstances, parity, education, employment, family structure, and previous breastfeeding experience differed between groups is not sufficiently explored. The authors should therefore avoid language that may essentialise Muslim or Christian women. Rather than attributing differences directly to religion or culture, the discussion should acknowledge that the observed narratives may reflect an interaction between religion, family structure, social norms, healthcare experiences, migration/ethnic background, socioeconomic circumstances, parity, and individual biography.
5. The two groups may differ in characteristics that could influence breastfeeding experiences independently of religion. The manuscript provides overall sociodemographic information, but does not adequately demonstrate the distribution of potentially relevant characteristics between the two groups. For example, parity, employment status, previous breastfeeding experience, mode of delivery, infant health conditions, and antenatal education could substantially influence breastfeeding continuation. The authors should either provide a comparative table of relevant characteristics by cultural-religious group or explicitly explain why such comparisons were not undertaken. More importantly, the discussion should avoid interpreting group differences as primarily cultural-religious without considering these alternative explanations.
6. The principal investigator conducted all interviews and is described as a female midwife and mother. This may facilitate rapport, but it can also influence the interview process, participants’ responses, and interpretation of data. The manuscript should provide a more substantive reflexivity statement addressing the researcher's professional position, personal assumptions regarding breastfeeding, relationship to the study setting, and potential influence on data collection and analysis. The current statement that there was no prior professional or personal relationship with participants is useful but does not adequately address researcher positionality.
7. The manuscript states that the principal investigator coded the transcripts and that two additional researchers participated in analytical meetings. However, the actual analytic process is insufficiently detailed. Please explain how initial codes were generated, how codes were developed into themes, whether coding was inductive throughout, how disagreements were handled, whether a coding framework was developed, and how the final themes were defined and named. The authors should also clarify whether the analysis was conducted separately for Muslim and Christian participants before comparing themes across groups.
8. Some results refer to medical interventions, medication compatibility with breastfeeding, infant weight gain, hypoglycaemia, dehydration, and mother-infant separation. These are important issues, but the qualitative study captures participants’ perceptions and narratives rather than independently verifying whether specific clinical decisions were appropriate. The discussion should therefore distinguish between “participants reported that healthcare professionals advised…” and assertions that a clinical intervention was inappropriate. This is particularly important in statements concerning medication, formula supplementation, and hospital protocols.
9. The conclusion that breastfeeding experiences are culturally mediated is reasonable within the limits of the study. However, some statements imply broader causal conclusions than the design permits. The authors should emphasise that the study identified perceived differences in narratives within this specific sample and context rather than demonstrating that Muslim and Christian women generally experience breastfeeding cessation differently. The conclusions should also more explicitly acknowledge that the study was conducted in one Spanish city in North Africa, with 30 participants recruited through one healthcare setting. The authors already acknowledge limited transferability, but this limitation should be reflected more strongly in the wording of the main conclusions.
10. The introduction is generally coherent and establishes the relevance of the topic, but some epidemiological statements require more precise and preferably more current primary or authoritative sources. For example, the WHO-related breastfeeding statistics should be checked carefully and supported by the most appropriate original source rather than relying on a national policy document hosted on the WHO platform.
11. The manuscript alternates among “failure,” “cessation,” “discontinuation,” and “desired but unattained breastfeeding.” The terminology should be carefully harmonised because “breastfeeding failure” can unintentionally reproduce the normative framing that the study itself seeks to critique.
12. Several questions explicitly mention guilt, pressure, distress, postpartum depression, cracked nipples, and other possible explanations. The authors should explain how they ensured that these prompts did not excessively direct participants toward predefined themes.
13. The quotations are useful and support the four themes, but several paragraphs immediately move from participant narratives to broad cultural interpretations. Consider separating descriptive findings from interpretive claims more clearly.
14. The manuscript states that SPSS version 15 was used for descriptive analysis. This is acceptable for basic descriptive statistics, but the relevance of this software should be explained briefly, particularly because the primary study is qualitative. In addition, the abbreviation list contains “SPPS,” which appears to be a typographical error and should be corrected to “SPSS.”
15. The manuscript states in the ethical section that no GenAI was used in the study design, data collection, analysis, or interpretation, while the later “Use of Artificial Intelligence” and Acknowledgments sections state that ChatGPT was used for translation review and language editing. These statements should be revised to eliminate ambiguity and consistently distinguish AI-assisted language editing from use of AI in the research process.
16. In addition to the limitations already acknowledged, the authors should discuss the short interview duration, single-site recruitment, purposive recruitment through one midwife, possible selection bias, the exclusion of women with language barriers, and the potential influence of researcher positionality.

The manuscript addresses an important and timely topic and has clear potential to contribute to the literature on breastfeeding experiences and culturally responsive maternal care. Nevertheless, substantial revision is required, particularly concerning methodological coherence, depth of qualitative data, saturation, reflexivity, and the interpretation of differences between Muslim and Christian participants. I recommend a major revision before the manuscript can be considered further.

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I thank the authors for their careful and substantial revision. The revised manuscript addresses the main methodological and interpretive concerns raised in the first round, and the changes have meaningfully strengthened the study.

In particular, I note the following as fully resolved:

The reframing of the design from a phenomenological study to a qualitative descriptive study within an interpretivist paradigm is now coherent across the title, abstract, and Methods, and the replacement of "theoretical saturation" with "informational redundancy" is correct and clearly justified. The addition of the reflexivity statement, together with the transparent disclosure that the principal investigator had provided postpartum care to all participants, resolves the earlier inconsistency regarding the investigator–participant relationship and appropriately addresses dual-role and social-desirability bias.

The language and translation procedures are now specified (interviews in Spanish, no interpreters, expert translation of quotations, back-translation not performed), which was essential given the cultural-religious focus. The sociodemographic data are now stratified by group in Table 2, and the interpretive claims have been consistently tempered: the risk of essentialising is directly acknowledged, and the unmeasured confounders (parity, employment, mode of birth, prior breastfeeding experience) are recognised as limiting the attribution of differences to cultural-religious affiliation. The account of coding, disagreement resolution, and team consensus is now adequate, and the AI-use statements have been consolidated. Table 2 and the Results text are now consistent, and the participant identifiers have been brought within the enrolled sample.

These revisions are, in my assessment, sufficient, and I am happy to see the manuscript progress.

Comments on the Quality of English Language

The manuscript needs careful English editing. Several sentences are incomplete or run-on, including the opening sentence of the Discussion and of Section 4.1, where a coordinating conjunction appears to be missing.

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have successfully addressed 41 of the 43 points raised in the initial review, which is an impressive response rate. The manuscript now reads as a coherent, methodologically transparent, and ethically grounded qualitative study. The shift to a qualitative descriptive design within an interpretivist paradigm is appropriate and has been consistently applied throughout the text. The cautious framing of group differences as "patterns observed within this sample" rather than categorical distinctions represents a significant improvement in scholarly rigour and ethical sensitivity.

Nevertheless, two major concerns from the initial review, the methodological approach  and the risk of reinforcing cultural stereotypes, have been addressed only partially. While the authors have adopted the recommended framing, some residual issues persist in the Discussion section, where the interpretive leap from observed patterns to explanatory cultural-religious mechanisms remains under-theorised.

 

Theoretical Underpinning of the Comparative Framework

Comment 43 Revisited: The authors have appropriately revised language throughout to present differences as "patterns observed within this sample." However, the Discussion section continues to engage in what might be termed "implicit cultural determinism", that is, while the authors explicitly disavow inherent group characteristics, the interpretive logic of the Discussion still organises findings primarily around cultural-religious categories, with other potentially explanatory variables (parity, socioeconomic status, education, employment, previous breastfeeding experience) relegated to limitations.

Recommendation: The Discussion would benefit from a more explicit engagement with intersectionality. Rather than presenting cultural-religious affiliation as the primary organising framework with other factors acknowledged as limitations, the authors should reconceptualise the analysis to recognise that what are being labelled as "Muslim" or "Christian" patterns may equally reflect socioeconomic gradients, differential access to healthcare, or variations in family structure. Consider the following:

Current framing (paraphrased): "Muslim women reported more family pressure; Christian women reported more healthcare-related barriers."

Suggested reframing: "In this sample, participants who identified as Muslim more frequently described family members as influential in breastfeeding decisions, while participants who identified as Christian more frequently described healthcare and employment-related circumstances. These patterns may reflect the intersection of cultural-religious identity with other social determinants, including family structure, socioeconomic position, and healthcare access, that were not systematically examined in this study."

This revision would align the Discussion more closely with the authors' stated commitment to avoiding categorical distinctions and would strengthen the theoretical sophistication of the analysis.

 

The "Informational Redundancy" Justification

Comment 11 Revisited: The authors have appropriately replaced "theoretical saturation" with "informational redundancy" and clarified that this was assessed within each group. However, the justification remains somewhat circular and insufficiently detailed for a comparative qualitative study.

The description states: "Informational redundancy was considered to have been observed when additional interviews no longer contributed substantively new information relevant to the study aim." This does not specify:

• How many interviews were conducted before redundancy was judged to have occurred in each group
• Whether redundancy was assessed independently within Muslim and Christian groups or whether the judgment was made across the sample
• Whether any themes failed to reach informational redundancy
• Whether the assessment was made by the principal investigator alone or through team discussion

Recommendation: Provide a more detailed account of the redundancy assessment process, including:

1. The point at which redundancy was judged to have occurred within each group (e.g., "After the 11th interview in the Muslim group and the 12th in the Christian group, no new codes were identified across two consecutive interviews.")
2. Whether any subthemes were identified in only one group and whether these reached redundancy
3. That the assessment was conducted collaboratively by the research team

This level of detail is important for readers to evaluate the adequacy of the sample and the rigour of the analytical process.

 

Discrepancy Between Data and Discussion Claims

Comment 27 Revisited: The authors have specified that the Discussion now refers to "common breastfeeding difficulties, realistic expectations regarding the establishment of breastfeeding, and practical strategies for managing challenges." However, the authors' data do not appear to directly support several claims made in the Discussion regarding what participants said about their needs.

For example:

• The Discussion states that participants called for "more realistic information about breastfeeding," yet the interview questions did not ask about what information participants would have wanted, nor did the Results section present findings on participants' unmet informational needs.
• The Discussion recommends "culturally adapted educational resources," yet no participant is quoted describing a desire for culturally specific materials, they described wanting more practical help, clearer guidance, and less conflicting advice.

Recommendation: The authors should either:
(a) Revisit the transcripts to identify direct evidence for the claim that participants specifically wanted "more realistic" or "culturally adapted" information, and present this evidence in the Results, or
(b) Reframe these as researcher-generated recommendations derived logically from the findings, explicitly distinguishing between what participants said and what the research team concludes would be helpful. For example: "While participants did not directly request culturally adapted materials, the differences observed in their accounts suggest that standardised information may not adequately address the diverse circumstances of women in this multicultural setting."

 

Reconsideration of the "Silent Grief" Concept

Comment 25: The authors have appropriately declined to assign different forms of grief to each group, which is methodologically sound. However, the concept of "silent grief" is cited but not sufficiently explained or critically examined.

Jackson et al.'s concept of "silent grief" refers to the emotional distress accompanying breastfeeding cessation that is not socially recognised or validated. The authors use this concept to interpret participants' emotional experiences, yet the Discussion does not fully explore:

• How participants described their grief as "silent", were there accounts of not being heard, not being understood, or having their distress minimised?
• Whether participants found ways to express their grief or whether it remained unacknowledged
• The role of healthcare professionals in either validating or dismissing this grief

Recommendation: Develop this section by engaging more deeply with Jackson et al.'s theoretical framework and examining how participants' narratives reflect (or diverge from) the concept of silent grief. If the data do not directly support this conceptualisation, acknowledge this as a limitation of the application.

 

The "Maternal Instinct" Concept

Comment 29: The authors state that they "did not create an additional subtheme because the data did not support a sufficiently distinct cultural-group pattern around 'maternal instinct'." This is a reasonable decision. However, the concept of breastfeeding as a natural or instinctive process appears in participants' narratives (e.g., "something that is supposed to be natural, something all mothers do") and warrants more analytical attention.

Recommendation: Rather than treating "maternal instinct" as peripheral, consider whether this concept could be integrated into the analysis of idealised breastfeeding expectations. The authors note in the Discussion that breastfeeding is "idealised," but this theme does not appear in the Results section. The authors might consider a more explicit analytical thread examining how participants' narratives reflect the tension between idealised breastfeeding (as natural, instinctive, maternal) and their lived experiences of difficulty and failure.

 

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript addresses a relevant and timely topic by exploring mothers’ lived experiences of desired but unattained breastfeeding from a cultural-religious perspective. The study presents a clear research objective and an appropriate qualitative phenomenological design. The methodological approach is adequately described, including participant selection, semi-structured interviews, inductive thematic analysis, researcher triangulation, and strategies to ensure qualitative rigour.

The results are clearly structured around four main themes and are appropriately supported by illustrative quotations from participants. The comparison between Muslim and Christian women provides an interesting cultural dimension and contributes to a more nuanced understanding of the emotional, social, and structural factors associated with breastfeeding discontinuation.

The discussion is well integrated with the existing literature and appropriately contextualises the findings. The manuscript also acknowledges relevant limitations and clearly identifies implications for culturally sensitive and woman-centred care.

The conclusions are consistent with the study objective and findings, particularly regarding the importance of realistic antenatal information, empathetic support, and culturally responsive models of breastfeeding care.

Overall, the manuscript is well organised, scientifically sound, and relevant to nursing and maternal health practice. I have no substantive concerns that would prevent publication. I therefore recommend acceptance of the manuscript in its present form.

Author Response

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Author Response File: Author Response.pdf