Childbirth has become increasingly medicalised, which may impact on the mother’s birth experience and her newborn infant’s physiology and behaviour. Although associations have been found between a mother’s subjective birth experience and her baby’s temperament, there is limited qualitative evidence around how and why this may occur.This qualitative study aimed to explore mothers’ childbirth and postnatal experiences, perceptions of their baby’s early behavioural style, and whether they saw these as related.A qualitative semi-structured interview schedule collected rich in-depth data. Twenty-two healthy mothers over 18 years of age and with healthy infants aged 0–12 months born at term, were recruited from Southwest regions of England and Wales. Thematic analysis was performed on the data.Mothers experienced childbirth as a momentous physical and psychological process. However, they did not necessarily perceive the birth as affecting their baby’s early behaviour or temperament. While some mothers drew a direct relationship, such as linking a straightforward birth to a calm infant, others did not make an explicit connection, especially those who experienced a challenging birth and postnatal period. Nevertheless, mothers who had a difficult or medicalised birth sometimes reported unsettled infant behaviour. It is possible that mothers who feel anxious or depressed after a challenging birth, or those without a good support network, may simply perceive their infant as more unsettled. Equally, mothers who have been well-supported and experienced an easier birth could be more likely to perceive their baby as easier to care for.Childbirth is a physical and psychological event that may affect mother-infant wellbeing and influence maternal perceptions of early infant temperament. The present findings add to prior evidence, reinforcing the importance of providing good physical and emotional support during and after childbirth to encourage positive mother-infant outcomes. Interventions during childbirth can be life saving for mother and baby. However, some interventions entail risks, where the potential adverse impacts of childbirth complications and interventions on mother and infant health and wellbeing are well-established –3. CertaAlongside these physiological impacts of childbirth, the mother’s psychological experience may have a lasting impact. For instance, intrusive procedures such as emergency caesarean section (CS) increase the risk of her developing postpartum depression (PPD) after the birth . FurtherDespite these potential associations of the mother’s childbirth experience and her infant’s behaviour via maternal mood disorders, little is known about the possible effects of subjective maternal childbirth experience on longer term infant temperament development, perceived or otherwise. Although no direct evidence was found, Taylor and colleagues  suggesteTherefore, the birth experience may affect infant behaviour in the longer term. Indeed, our recent quantitative study of approximately a thousand mothers  found thA qualitative semi-structured interview study .Participants were mothers recruited from Southwest England and Wales. Mothers were eligible to participate if they over 18 years of age, were in good physical and mental health, and had a single infant under 12 months. Exclusion criteria were major physical or mental maternal illness, unwell infants, multiple/ preterm/ low birth-weight infants , and infA short semi-structured interview schedule  using opSocio-demographic information was also collected, including age, highest level of educational qualification, occupation, intention to return to work, marital status, and number of children.A convenience sample of mothers from Southwest England and Wales were recruited via adverts placed in health centres, mother and baby clinics, breastfeeding support groups and social media. Purposive sampling was later employed to recruit both younger and formula feeding mothers. Data were collected between January and October 2015. Data collection stopped when it was judged that no new and meaningful concepts were being ‘generated’ from the data . Thus, nFace-to-face interviews were considered the most effective way to capture maternal accounts of their birth stories and perceptions of their baby’s behaviour . The intNo research hypothesis was disclosed, and the researcher’s impartiality was emphasised . AfterwaInterviews were transcribed verbatim in full and personal identifying information was removed prior to analysis. Participant responses were analysed thematically following the six steps set out by Braun and Clarke . The theA thematic analysis was carried out to analyse and arrange the data systematically into themes and subthemes. Credibility of themes and inter-rater confirmability of coding were established through consultation with a second coder (AB). Lincoln and Guba’s criteria of ‘Trustworthiness’ , 47 wereWhilst this study is based in qualitative methodology, it was also considered interesting to note the proportion of mothers who believed their infant’s behaviour was related to the birth. Quantifying qualitative data is performed by researchers wishing to further explore data derived from open-ended questioning , 49. HowThe study was designed based on an initial interest in the topic by the first author after her own birth experiences and was further developed after reading the research literature.The study was conducted with the awareness that past experiences can influence one’s interpretation of events, and thus, with a decision to approach the study and the data with an open mind, to welcome mothers’ own interpretations of their experiences, and to closely adhere to the data in the reporting , 45. To Initially, 23 mothers took part, though one was subsequently excluded as she had previously experienced a stillbirth and was visibly distressed during the interview. Therefore, the final sample consisted of 22 mothers . Sociodemographic information is presented in Of the 22 mothers who met all the inclusion criteria, there were three planned inductions, two planned caesareans, and eight unplanned inductions or accelerations of labour. Nine women had spontaneous physiological births, seven of which were waterbirths. With the exception of planned interventions, mothers appeared to be more likely to report their baby’s behaviour as unsettled after a difficult or medicalised birth (n = 6), and more likely to report calm, settled newborn behaviour after a straightforward birth (including a planned induction or caesarean) without unexpected complications (n = 10). However, less than half the mothers (n = 10) perceived the birth as affecting their baby’s behaviour, and several (n = 4) felt ambiguous.Nine childbirth themes were identified relating to mothers’ perceptions of how they felt they were affected by objective/physical birth events  and subjective/ psychological factors , as well as how these factors may have influenced their baby’s behaviour post birth. In addition, mothers spoke about the postnatal days and bonding with their baby, which generated two more themes. Consequently, maternal birth story data are presented in three categories with corresponding themes and subthemes: (1) Physical birth experience, (2) Psychological birth experience, and (3) Postnatal days with baby .The themes and subthemes are presented in full below. Each theme is represented by direct maternal quotes, first on how they felt that variable affected her own experience, and then on how some mothers felt it may have affected their baby.The physical birth experience refers to the mother’s reported experience of events, such as what happened during the birth. This included how they felt they were affected by the type of birth, the birth and postnatal environments and the pain relief method. Mothers also commented on how they were affected psychologically throughout their descriptions of these physical birth themes. It is notable that all the mothers who experienced challenges and thus appeared to have more negative perceptions of their birth (n = 8), had undergone a medicalised birth with one or several interventions. Meanwhile, 75% of mothers who had experienced their birth as ‘positive’ (n = 8) had a spontaneous physiological birth (n = 6). The two remaining women who experienced their birth as positive had planned interventions (one caesarean section and one induction). However, as the sample is too small for these numbers to have any statistical significance, the themes are explored qualitatively.a) Perceptions of birth mode. Many mothers described how the type of birth they had  affected their perceptions of their birth experience. Spontaneous physiological labour and birth could be experienced as empowering, enabling mothers to feel confident post birth.“It sort of burns a bit but it’s not pain… ‘cause you can feel something happening… It just happened. I couldn’t stop it… My birth was incredible! I’m very lucky… I got in the pool and little K was born fifteen minutes later.” Conversely, obstetric interventions could lead to distress in some instances, leaving the mother feeling helpless or in increased pain.“I didn’t progress at all… then they gave me the top up (synthetic oxytocin)… it just overstimulated my uterus… absolute agony.” Despite neonatal distress and her baby’s admission to the Neonatal Intensive Care Unit [NICU], this mother did not believe there was any connection between the birth experience and her baby’s very active temperament. Although she reportedly had feeding problems and sickness for the first few weeks, the mother said that her baby soon settled into easier feeding and sleeping routines.“She’s a really contented happy baby… She’s really active… She wants to do everything, she wants to be in everything. She’s just so content, she just plays by herself… I don’t think it’s anything to do with that cos while I was pregnant she was quite a busy bod then. I think it was just in her nature.”.” One mother who experienced an operative birth said it felt easier at first but more challenging during recovery.“I had a really easy and pleasant few hours with her whereas a lot of mums are taken off for stitches or in another room, or in lots of pain. I didn’t have that, but then I think the day after when most people start to feel a lot better, I felt so much worse.” Nevertheless, this mother felt that her baby had benefitted through having a calm caesarean:“Yes. There was a calm mummy and a calm daddy and a happy atmosphere. No pain, no upset, cuddles straight away, music in background… She didn’t have any of the trauma of birth and just immediately she had all my love and attention… and all Ed’s love and attention. And even when I was in pain the next day she got so many cuddles from Ed and his parents… So her character is calm, happy and interested.” Mothers who had planned interventions (such as a planned induction or a planned caesarean) seemed more likely to view their birth more positively overall than those who had unplanned interventions, although this was not always true.“I didn’t feel any pain, but I feel like I wasn’t prepared enough for how much I might feel, ‘cause you can feel each layer dragging back… horrible…” Although this mother had a difficult birth and postnatal experience, and her baby had trouble breastfeeding initially, she did not feel that the birth had affected her baby.“I couldn’t breastfeed which I wanted to do but he wasn’t latching on and I was in agony anyway, so I was expressing… I don’t know. He stayed sort of calm like when he was born so I don’t think so really—obviously things could have gone wrong but they didn’t for him. I was worried the antibiotics would affect him but they didn’t. No thrush…” b) Qualities of the birthing environment. The birth environment could also affect mothers’ perceptions. Notably however, although some experienced fear and lack of control in hospital, many found hospital reassuring.“I really felt I needed just to know that people were with me if anything happened… It was brilliant.” Mothers who actively chose to birth in hospital felt much happier about the birthplace than those who had not actively participated in this choice, but instead felt they had succumbed to pressure during labour. Such hospital transfers could be experienced as very distressing.“I had planned a pool birth in the midwife led (unit) but when I went back they sent me up a floor  … I was absolutely devastated that I couldn’t go down… I’d laminated me birth plan!” “homely… more natural”. Several mothers who birthed in a midwife led unit praised the high quality of care, finding it “It was a fantastic experience really… The midwife care was brilliant and the facilities there are great… So the midwife caught her and then just passed her over to me (laughs) and then S cut the cord.” This mother believed the positive birth experience may have benefitted her baby’s temperament.“Pretty much everything that’s around her that has helped her to feel safe and secure and calm. And yeah, maybe that started off with having a well and truly sort of straightforward arrival.” The homebirths in this sample (n = 2) were both waterbirths which involved little pharmacological pain relief and no obstetric interventions. They were perceived as calm and positive experiences, despite the midwife not arriving in time for one of them.Yeah, it felt very calm in the house, really calm… I was in bed until pretty much he was coming down… I was very relaxed… it wasn’t even too painful.” “This mother felt that being relaxed herself during the birth may have contributed to her baby also being relaxed.“It was a very calm birth, and he was pretty calm coming out… he was very settled… I think that a waterbirth is definitely a relaxing way, definitely relaxing for me, so it must have some impact on them.” c) Perceived effects of pain relief. The type of pain relief used during labour, or a lack of pain relief when requested, could affect the overall birth experience. Participants reported variable experiences. Although it did not agree with everyone, many enjoyed the mildly analgesic effects of Entonox (gas and air).“I loved it (Entonox), it was fantastic after nine months of sobriety (laughs), it was really great.” Some mothers who had not initially wanted any pain relief were relieved to have an epidural after hours of ‘agony’.“Once they’d put the epidural in my back, the rest of the experience was just amazing… for 8 hours I just sat there… and really enjoyed it. Then they said, ‘I think you should push,’ and I pushed for ten minutes…” This mother did not find her baby affected by any aspect of her birth experience, including the epidural.“I don’t think so, but I don’t know. She had a pretty easy coming into the world. Whether my stress hormones in the earlier part of labour got through I don’t know… but she didn’t get distressed, no.” Experiences of pethidine in this sample were either neutral or negative.“It just made me sleepy, really really sleepy. I can’t say that it really took away much pain, but it just made me just completely relaxed…” “I didn’t really think much of that (pethidine) because it just made me feel like I wasn’t there, had no control, but I still had pain.” One mother described contractions under the influence of pethidine as a sudden shock.“I think I went into transition phase whilst I was asleep. I woke up and just screamed like blue murder… you know, like one of those really like… blood curdling screams…” Two mothers thought their baby’s early behaviour could have been affected by the pethidine.“No, the only thing that I was worried about in the beginning was she slept loads and loads and loads and I was worried that it was something to do with the pethidine. She slept like a ridiculous amount in the beginning and they had to say like, ‘Have you fed your baby? Wake her up!’” “She’s definitely a more clingy baby than my first. She does not like to be put down, she doesn’t lie down, she’s quite sicky… She won’t settle away from me. My mum thinks it’s all the chemicals she had.” Alternative techniques and non-medical forms of pain relief sometimes helped mothers to cope without side effects. Methods of relaxation such as hypnobirthing were not always perceived as providing the relief originally envisaged.“The only thing I really took away from the hypnobirthing was the breathing. The breathing got me through.” Waterbirths were generally found to be relaxing, although this feeling did not always last.“The first contractions in the pool were so blissful, then the novelty wore off… very quickly I needed to push.” Mother 3 went on to describe her baby’s behaviour as ‘easy’.Oh, he’s been so calm and content and he’s been very easy… He is generally very happy, smiles a lot, is very good at being passed around… very calm. (Mother 3)“As can be seen from the descriptions above, the mothers’ psychological birth and postpartum experiences were quite connected to and interwoven with their physical birth experience. The subjective psychological experience often dominated birth stories.a) Emotional states during childbirth. Emotional states during the birth were important to mothers and stayed with them afterwards. Some mothers appeared to have actively enjoyed giving birth.“It was very much my body did it, and like I enjoyed feeling it.” “I didn’t feel any pain, so I was just going with it. I was enjoying it, in the moment… All this bit I remember like it was the best thing I’ve ever done. It was amazing like. The whole like established labour and actually getting him out was amazing.” However, lack of labour progression could lead to fear, especially if this meant medical aid in the form of unexpected interventions.“So maximum dosage (of synthetic oxytocin) and the surgeon was ready behind the curtain–they were polishing their cutlery…” This mother was not sure whether her emotional state during the birth had affected her baby.“Yeah, I think in the early days, I do think umm…(pause) it’s really hard to say. I don’t know whether she was affected, or I was affected… It was just a bit on edge that birth… just a bit on edge.” One mother claimed to feel calm once labour commenced, despite her initial fear and anxiety.“I phoned my mum and I said, ‘I’m so scared I feel really calm.’ You know when they tell you to write a birth plan, they tell you to prepare yourself, pack your bags, everything… I suddenly felt like everything was out of my control and it almost relaxed me completely… because I no longer could control it, I think, if that makes any sense.” b) Expectations. Maternal expectations of the birth and postnatal period was an important theme. Mothers appeared to be more accepting and viewed their birth experience in a more positive light when they felt mentally prepared .“Well, I had to be induced because of my diabetes so we went into hospital on the Saturday… A little cut and the head popped out. It was lovely.” High expectations of a positive birth experience could lead to acute disappointment post birth.because I used to be super fit and healthy and run half marathons and I thought, yeah, I can do this. I thought I’m the sort of person who’s got a body that can deliver a child… Wrong way round!” “… Mothers who were unexpectedly kept in hospital post birth because they or their baby needed medical treatment could also find this very difficult.“That was the worst week, well five days, of my life. It really traumatised me, that stay in hospital… which is really hard because when you speak to some people they say, ‘Oh we loved it, you know, the support we got from the midwives…’ I said quite often, ‘This is worse than prison. In prison you get an Xbox, and you get a TV, and you don’t have a baby that’s waking you up every half an hour.’” Although this mother had a waterbirth, she felt the long labour may have affected her baby’s wellbeing and behaviour alongside his medical issues and five days in NICU post birth.“I think so… Yeah… I think his difficulties feeding were affected by the birth… the length of it… I felt like he would have suffered for quite a long time…being squashed and stuff, because it was going on for so long… Yeah, I can’t really put my finger on why it would have affected him but I’m sure it would…” (Mother 10)Mothers who felt they had experienced an unpredictably difficult birth which involved feelings of trauma, could suffer conflicting emotions postnatally.“And I think as a result of that as well I didn’t feel I could bond with him at all well… We really struggled with him the first couple of weeks. ‘Have I done the right thing having a baby?’ All this jazz.” This mother attributed her baby’s difficulties breastfeeding to the forceps, pain and distress.“I put it (breastfeeding problems) down to the fact that, because he was forceps… when I was trying to put him on the boob, I was pressing the back of his head and neck, not realising… So I felt really upset that I was really useless and couldn’t do it.” In contrast, mothers appeared to fare better postnatally if their prenatal expectations of childbirth had been met.“I found both births really empowering… quite euphoric. They gave me a sense of achievement.” Although this mother did not connect her baby’s contented behavioural style to the birth.“Sleep was good. He’d sleep for 5–6 hours at a time… he’s quite a content little baby…as long as he’s fed he will self soothe, let me leave the room, go to anybody… No, I don’t think so… I think cos I didn’t have a traumatic birth…but I think if I had experienced trauma it may have affected him.” c) Health professional authority. Several women reported agreeing to interventions for their baby’s safety without feeling they were given sufficient information, time or opportunity to make an informed decision.“And then everything I didn’t want to happen happened which was, I didn’t want to have stirrups or anything like that, and the next thing was they took the gas and air away and said I wasn’t pushing hard enough…” However, this mother saw no connection between a traumatic birth experience and their baby’s behaviour in the early postnatal period, despite acknowledging her baby’s discomfort.“No, not directly I don’t think. If he’d been born naturally premature, we may have got a bit more support… Looking back there wasn’t a time when he wasn’t crying… He’d feed little and often ‘cause he was so uncomfortable as well… He wasn’t sleeping and nor was I…” One mother explained how she felt coerced into agreeing to unwanted interventions.“If the doctors decide this is the way they want you to do it it’s very hard not to. If something then happened… I’d never forgive myself.” On occasion, women’s privacy was violated, sometimes leading to deep psychological distress.“They broke my waters–they didn’t ask. Suddenly there was stuff coming out of me. I did not know what was happening … They were telling me, ‘Keep your legs open, keep your legs open’, though my natural instinct was to curl up in foetal position to protect myself.” Even standard interventions such as electronic foetal monitoring could be restrictive and uncomfortable, and again, mothers did not always feel fully consulted beforehand or that they had any choice. ‘Not allowed’ was a common phrase used to describe this lack of control.“I wanted to do it on all fours… ‘cause I was connected to all the machines I wasn’t really allowed to move…” “And I said, ‘Well I’m having a waterbirth’ and he (Dr) said, ‘Oh no you’re not, you’ve gone over 24 hours now’… so I lost the plot and burst out crying…” d) Support. Support during labour and birth as well as postnatally seemed essential to women’s overall wellbeing. Mothers who received emotional support felt well cared for, which appeared to positively affect their perceptions of the whole birth experience.“She (midwife) was brilliant… She really looked after me afterwards… She even washed me… Yeah, she was very, very special.” A well-supported birth experience could positively influence a mother’s postnatal mental state and her perceptions of her baby, which this mother believed were associated.“He’s really happy, he’s really placid as well… Urm, well yeah and particularly my um emotions I suppose… like I felt confident and calm and happy…and I still do.” Fathers who were able to remain in the birth room throughout labour could also play an important supportive role.“My husband was doing all the things he’d learnt… supporting me, um rubbing my back, making sure I was drinking. He also did some of the things he wasn’t taught to do which was um get lots of kidney dishes because I was vomiting a lot (laughs).” This mother thought her baby’s temperament may have benefitted through the type of birth she had, and felt they were well set up to bond immediately.“We didn’t really have any drugs, so she came out as alert as she was going to be. It was quite nice to know that we could bond straight away, and she was a hundred per cent rather than dosed up on pethidine or something.” Health professional postnatal support, especially for breastfeeding, was appreciated by new mothers, particularly if they were finding it difficult to get established.“I was lying to the midwife, saying she was latching on ‘cause I was so desperate to go home… then this lovely Columbian midwife saved the day. She literally grabbed my boob and flung it in her (baby’s) mouth (laughs). So that’s how it’s done!” “She’s just amazing –I call her the boob whisperer ‘cause… She calmed me more than anything… She just chilled me out and I didn’t feel like she was judging me because I can’t do it.” e) Neglect. However, busy maternity wards could lead to intermittent midwifery care. Women who had such experiences could feel abandoned and neglected and become fearful about something happening to them or their baby. One mother ended up giving birth without any pain relief due to lack of staff attendance, though she and her partner had requested it several times.“Yeah, we kept getting left a lot in the room on our own with nobody–it was quite scary… The pain was like getting worse and worse. I was getting really dizzy and sick, but… they wouldn’t give me any pain relief ‘cause they just thought I was really whingey.” Despite her frightening experience both during and after labour, this mother saw no connection between the birth and her baby’s unsettled behaviour.The first few weeks he was just constantly sick, constantly in pain and screaming…. (he’s) jittery. He does it all the time, it’s like he’s startled and his hands sort of shake.” (Mother 17)“Neglectful care provoked conflicting emotions, ranging from empathy with overrun staff to personal distress. This could occur in the postnatal ward as well. While mothers tried to be considerate of the busy midwives, at times their own and their baby’s needs were left unmet.“The antenatal care was good but the postnatal care… I was left in dirty sheets, I had to shower myself and at times I had to sit on the floor in the shower because I couldn’t stand up… One night I was left with a drip in one arm but the baby over the other side…” f) Separation. Women were sometimes separated from their partners during night inductions when the partner was sent home .“I was just on my own, honestly, it’s horrible… I think your partner should be with you… I was quite lonely… I didn’t sleep…” One woman remarked on the feeling of emptiness when unexpectedly left alone after the birth.“Then I was left on my own in that room for 2 hours. It was strange after all that, and all the people, suddenly completely alone.” Mothers who were separated from their baby and partner post birth could feel distraught.“I was taken… to have a shower and he went with his dad to NICU… I suddenly panicked–Where’s my husband and my baby?”This mother felt that her baby’s behaviour may have been disrupted by the stressful circumstances around the birth and the way this affected her.“I think so yeah… I know it definitely affected me (laughs), and that in turn probably affects him as well—and that I was just so tired—but I can’t specifically say what… I think his difficulties feeding were affected by the birth… and also he was taken away from me straight away…” Although Mother 10 also acknowledged that it may have been direct postnatal circumstances (i.e. being in NICU) that affected her baby’s wellbeing and behaviour at the beginning.“He was waking a lot in the night to feed. And then probably from about two months old he’s been a really laid-back baby. He’s been really calm… (In NICU) they were doing obs. every half hour which was very disruptive for him… he’d scream and cry… He didn’t have a very nice start.” In addition to their birth stories, mothers spoke frequently about their postnatal time with their baby.a) Baby mirrors mother. Some mothers perceived their baby’s behaviour as a response to their own internal state.“Part of me wonders if her behaviour’s been affected by my reaction to the birth if that makes sense… she is very different to the first in terms of her neediness…” Mother 19 believed her baby’s post birth behaviour reflected how she herself had felt during childbirth.“I suppose having a chilled out relaxed-ish birth might help–I wasn’t stressed out at all. It helps the baby not feeling any stresses from the mum. Yeah, he’s a very chilled out little boy.” Some spoke about having a traumatic birth and an unsettled infant, although these mothers were often unsure whether there could be a connection between the two.“It was traumatic, horrific… first they did an internal examination… I felt… kind of exposed… I spent the whole night in absolute agony… like someone ripping my insides apart…. They broke my waters… I didn’t know what was happening…” Mother 1 also described her baby’s behaviour and early motherhood as very challenging, although she did not perceive this to be associated with the birth.Very angry when he’s changed or bathed… he screams his head off. Feeding… was a battle. It feels like the hardest job I’ve ever had.” “Mothers who had a spontaneous physiological birth could also at times find it challenging.I don’t think I had a traumatic birth, but… being told nothing was happening and thinking, I can’t cope with it if that’s the case…” “This mother went on to describe how she experienced her baby’s behaviour as ‘difficult’ due to her own state of mind after the birth.“I think I found her quite difficult because I was a little bit shell-shocked after the birth… in the early days… I mean we did have some days in the early days where she was really hard to console for no reason other than maybe feeling a bit colicky…” b) Maternal caregiving. One mother felt her unsettled newborn baby become calmer through keeping them close after a difficult birth experience.“I don’t know whether she was affected, or I was affected, but I did just cuddle her and mollycoddle her for a long time… She was contented on me… So yeah, we were quite stuck.” Mothers were generally responsive to their baby’s needs and willing to do things differently if needed.“I co-sleep with this one which I never did with my first, mostly because it’s the only way I can get some rest.” This could mean that other family members were sometimes excluded in the early days.“I didn’t really let others in as much to hold her and carry her round and things when she was a tiny baby ‘cause I just felt like she just needed to be back in the womb (laughs).” This study conducted an in-depth exploration of maternal perceptions of childbirth and their infant’s behavioural style post birth. Notably, fewer than half of the mothers perceived their baby’s behaviour to have been influenced by their birth experience. After outlining a challenging or traumatic birth, some mothers proceeded to describe their newborn as unsettled, without attributing this in any way to the birth. It is possible that these mothers did not perceive or wish to acknowledge a potential association between the birth and their baby’s behaviour because of guilt, disassociation, or denial after a difficult birth experience . AlternaFor others whose descriptions of their experiences appeared to align with their perception of their newborn baby as relatively ‘calm’ or unsettled’, the relationship, if it did exist, could be multifaceted. For example, mothers who felt positive during pregnancy may have had easier births and more settled infants due to reduced maternal anxiety—benefitting both the birth experience  and her Although many mothers perceived no connection between their birth experience and their baby’s behaviour, some who reported an easy, straightforward birth, such as a calm and well-supported waterbirth, connected this experience with their babies seeming content settled. In contrast, others perceived that difficult birth events, such as forceps delivery, might be linked to their baby’s unsettled behaviour due to residual pain and distress. The mother’s psychological experience of birth may play a role here but there are also potential physiological links. Prior research shows higher levels of umbilical cord cortisol in infants experiencing obstetric complications, especially assisted birth , 7, 54.Moreover, infants are affected by their mother’s raised cortisol levels during labour . MaternaThe birth environment seemed to influence mothers’ sense of wellbeing during childbirth. Although many women found being in hospital reassuring, some mothers who experienced an in-labour transfer from home or MLU to hospital reported becoming distressed. In some places, midwifery services appeared to be stretched despite the most recent National Institute for Health and Care Excellence (NICE) recommendations of one-to-one care for all labouring women . InconsiPain relief could affect mothers and infants in complex ways, with some mothers praising the positive benefits of Entonox or epidural, but with others feeling no effective pain relief after pethidine . Two motA few mothers reported initial breastfeeding problems after combinations of pethidine, synthetic oxytocin and/or epidural, which together may block endogenous oxytocin production: the essential hormone for effective birth and breastfeeding . These fThe potential pathway between mothers’ experiences of childbirth and descriptions of their baby’s early temperament might also be explained through the mother’s psychological birth experience and subsequent postnatal state. The psychological experience incorporates both physiological and emotional responses to the birth. For example, experiencing fear during childbirth may increase maternal cortisol production, which increases perceptions of pain  and passWhether or not they perceived any connection, mothers with more positive birth experiences which went smoothly and where they felt well-supported, listened to and cared for, tended to describe their infants as calmer and more settled than mothers who seemed to have had a less positive experience. Negative childbirth experiences could stem from unmet expectations and how mothers felt they were treated by caregivers during labour, birth or postnatally. ‘Mistreatments’ of women during childbirth have been defined as: awareness of staff shortages, feeling inadequately supported or neglected, feeling their birth choices were disrespected, not being ‘allowed’ to bring their partner into the bathroom, lack of informed consent, painful vaginal examinations, and health professionals refusing to provide adequate pain relief . AlthougMothers sometimes reported feeling distressed or fearful during unplanned obstetric complications or interventions. These mothers appeared more likely to report experiencing initial difficulties with their infant’s feeding or sleeping behaviours, adjusting to motherhood and bonding with their baby. This would align with the theoretical model in our previous paper which proposes a potential pathway from the birth experience to postnatal maternal mood, mother-infant bonding and infant behaviour . In contMothers’ expectations of childbirth also seemed to influence their postnatal mood and could be connected to the way they perceived the birth and early motherhood –80. MothPerceived ‘health professional authority’ could occur when women experienced a loss of control. This sometimes happened around hospital transfers or unwanted interventions such as continuous foetal monitoring, which is standard hospital practice despite the lack of evidence to support it. Some participants who were not fully informed or felt ‘coerced’ into consenting to unplanned interventions had regrets around their birth, potentially impacting their early experiences of motherhood and the way they perceived their newborn. ‘Lack of control’ has been cited as the most common factor in traumatic childbirth (54.6%), seconded by intense pain (47.4%) . A SwissConsistent with prior research –85, how Separation from her partner or baby could also colour maternal perceptions of the birth and her newborn baby’s behaviour. Flacking and colleagues , 87 founEarly postnatal events could at times affect maternal wellbeing and mothers’ confidence in coping and caring for their baby. Mothers who had more positive birth experiences were more likely to report immediate skin-to-skin contact and successful breastfeeding. We know that breastfeeding initiation and duration can be affected by use of pharmacological pain relief such as pethidine or epidural , or by h‘Skin-to-skin’ contact after childbirth encourages endogenous oxytocin release in mother and infant, enabling the newborn to exhibit instinctive behaviours such as the ‘breast crawl’ . It has A few mothers who experienced a traumatic birth perceived their baby as difficult, needy or clingy, especially in the early postnatal period. Some mentioned that their own physical and emotional state may have been recognised and reflected by their baby. We know that negative postpartum maternal mood can affect infant temperament and development  and may Some participants tried to compensate and help to settle their babies after a traumatic birth by ‘keeping them close’. Wolke  highlighWhile this study deepens our understanding of mothers’ perceptions of how their physical and psychological birth experiences may affect the temperament of their infant, thus adding to the existing body of literature , it is not without limitations. Although maternal reports are considered to contain some level of accuracy regardless of birth experience –111, thiDespite concerted efforts to recruit a representative sample across Southwest regions of England and Wales, the study had little sociodemographic diversity. For instance, all participants were British Caucasian, and most had achieved a higher level of education. Furthermore, the majority of mothers in this study  breastfed their infants–a much higher proportion than reported elsewhere . TAlthough many mothers did not perceive any explicit connection between their birth experience and their baby’s behaviour, others spoke of a potential link between the two. As found in our previous qualitative study of maternity care providers , the fin 14 Dec 2022 <div> PONE-D-22-24651 </div>  <div> Does a mother’s childbirth experience influence her perceptions of her baby’s behaviour? A qualitative interview study </div>  <div> PLOS ONEDear Dr. Williams,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.Please submit your revised manuscript by Jan 28 2023 11:59PM. 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If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.[Note: HTML markup is below. Please do not edit.]Reviewers' comments:Reviewer's Responses to Questions <font color="black"> Comments to the Author1. Is the manuscript technically sound, and do the data support the conclusions? </font> The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: PartlyReviewer #2: Partly********** <font color="black"> 2. Has the statistical analysis been performed appropriately and rigorously?  </font> Reviewer #1: N/AReviewer #2: N/A********** <font color="black"> 3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. </font> The Reviewer #1: YesReviewer #2: Yes********** <font color="black"> 4. Is the manuscript presented in an intelligible fashion and written in standard English? </font> PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: Yes********** <font color="black"> 5. Review Comments to the Author </font> 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. Reviewer #1: Please see uploaded attachment.I have made extensive comments, but this doesnt detract from the fact that this is a potentially important and valuable paper. I do hope the authors are not put off from resubmitting as a result of the issues I have raised.Reviewer #2: Introduction: Well written, provides relevant previous research. I think that the justification for carrying out the study could be strengthened more. Especially as there is a lot of rich data reported that doesn't just relate to infant behaviour. You could talk about how important women's experiences of birth are, because of the data that shows the long term impact, therefore you will be adding to this body of research, identifying types of practice that are associated with good care, which has the ability to improve care and change practice. The results focus a lot on feeling prepared, so you could also discuss the importance of good antenatal care and birth education, and birth expectations and experiences research.https://www.sciencedirect.com/science/article/pii/S0266613815000078?casa_token=v6ULrCszbjEAAAAA:sd86yyjPygL-tgH6o1qumGARn-kA6lEz07cGUOgriONnbz89I3qlljrKI0rQSgVpj1obguy-;https://www.sciencedirect.com/science/article/pii/S0266613821001972?casa_token=I4NqVIXHftUAAAAA:XU2cIZSco3k3e6tTpBGhs6Vm0NOn2H8033EQGJg2mBsoGRiYn6ozLRrGDlolNJIQa2Yguelp; including your study, so is the point of this part of the study to add to this body of research? It isn't entirely clear what the justification of this part of the study is, considering it would be methodologically better to answer this from a quantitative perspective, especially regarding part 3 (associations), so I think this part of the study needs more justification.Regarding the second part of the study, about birth and infant's behaviour, there is already research that drugs and type of birth can affect baby/breastfeeding Method: Interview schedule. My main comment is about why you asked "how were you induced?". Were all women who took part induced? Or was this question only asked to women who were induced? Could you make this clearer. The first prompt for Question 3 is also grammatically incorrect. Can you clarify this one please.https://blogs.bmj.com/bmj/2018/02/08/humanising-birth-does-the-language-we-use-matter/) I would advise changing natural to "physiological"I do not agree with the labels of your categories . Due to the importance of language, . Then you should go onto say it is extra important that maternity care is improved because the results suggest that birth experience MAY impact infant behaviour, but more research is needed.You can also talk about the need for good preparation, good antenatal care, good support. All of which has been found by previous studies, and your study supports.********** <font color="black"> 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. </font> Reviewer #1: NoReviewer #2: No**********https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, AttachmentFIN review PLOS_22_24651 oct 2022.docxSubmitted filename: Click here for additional data file. 16 Mar 2023Response to Reviewers Dear ReviewersThank you for your helpful, constructive and supportive comments. For ease of reference, we have captured our responses and accompanying changes in the itemised list below. Please note that cited page numbers correspond to the manuscript file with track changes. General comments to both reviewersWe have adjusted wording throughout the paper to be more cautious when talking about mothers’ perceptions of infant behaviour after childbirth. Reference to quantitative methodology has been reviewed and adapted to reflect the largely qualitative approach to the study. Outcomes are no longer categorised and wording has been adjusted in relation to ‘natural’/‘clinical’ births throughout the paper.Reviewer 11. This is an interesting paper, addressing an important area. It is well written, with good logical progression, and is generally comprehensive. However, I do have some comments and questions about some aspects of the text. Fundamentally, the paper seems to be trying to address too many issues at once. I would suggest that the team carefully consider the primary focus and trim the paper down so that that focus is very clear and consistent.Response: The focus has been narrowed throughout the paper to emphasise mothers’ own perceptions and thoughts about their birth and their infant’s early temperament.2. I have made a number of comments about the small sample size. This is not a problem if there are sound and saturated themes, and the claims are being made about the nature of these themes. However, in this case, a number of claims of causation/association are made in the data, and these do need larger sample sizes and more representative samples in order to be substantiated. Response: Part 3 has been removed from the original results section, and Part 2 has been incorporated within the mothers’ birth stories. Any references to ‘patterns’ or associations in the data have been removed. Data saturation has been explained further . 3. Fit between the aims and the methodological approach: The text seems to suggest that there is already evidence of an association between birth experience and women’s perceptions of infant behaviour. Given this existing information, what this study seems to add is a description of what women believe about the nature of their experiences and perceptions of infant temperament. I would be inclined to take out suggestions of empirical cause and effect, as that is not really the epistemological focus of qualitative research. However, exploring whether mothers believe that the two are related, as in the second part of the text below, is appropriate: so I suggest that this is the emphasis throughout, as in the proposed amendments to the aim below:“Consequently, the aim of the current study was to further explore how mothers’ subjective childbirth experiences might influence and their perceptions and interpretations of their baby’s behaviour, and whether they believed that the two were related.”This framing encompasses the results reporting both what the women say they believe, and the ‘researchers view’ in which you provide a critique of what they say they believe in the light of how they talk about their perceptions. It may be useful to structure the paper a bit more clearly at these two different levels of analysis . Response: We have further considered the fit between the aims and methodological approach and edited accordingly throughout . The focus of the study is now more about mothers’ perceptions of their birth experience and their infant’s behaviour, as well as discussing any perceived or potential links between the two. ‘Causative’ aspects have also been removed, and the relationship between mothers’ descriptions and beliefs is discussed.4. Reflexivity is an important corner stone of qualitative research, as it enables the reader to understand which lens(es) are applied to the design, data collection, analysis and interpretation of the study, from the perspective of the researcher pre-suppositions before the study started. A paragraph or two describing the standpoints and beliefs of the research team members in relation to the topic of the paper would add considerable to the credibility and rigour of the study. For instance, the assumption in the abstract and in some parts of the text is that childbirth interventions are associated with traumatic birth. While this is true for some women, there is good evidence that the more important factor overall is how women are treated during labour and birth. Reflecting on this may change both the framing of the issue and the solutions proposed… Did the team look for disconfirming data during the analysis? Response: A reflexivity section has been added (page 7), and we have also emphasised how it is the way women are treated during labour and birth more than the birth itself which seems to affect how mothers feel about their birth and their baby’s behaviour. ‘Disconfirming’ examples have also been added to the results section. 5. This is generally well explained, and the approach to thematic analysis is appropriate. However, I wonder why the data were analysed by birth perceptions as a group and then by perceptions of infant behaviour as a group, rather than looking ‘vertically’ across each birth and infant perception story by individual, to illustrate the nuances of the different patterns of experience and perception? As above, I am not sure about the relevance of the quantification of the data where this occurs.Response: Part 3 has been removed, and Part 2 has been incorporated within the mothers’ birth stories. Quantitative data has been replaced with more in-depth analysis of the mothers’ quotes. 6. P 8 The statement is made that the analysis applies Lincoln and Guba’s concept of ‘thick description’, with transferability applying to similar contexts. The key reference for thick description should really be Geertz: for example, Geertz, C. (1973). Thick Description: Towards an Interpretative theory of culture. The Interpretation of Cultures, 3-31. This refers to more than just describing the data, and includes a wider analysis of the underlying relations, interactions, semiotics and etc of the context in which the individuals in the research are situated. I’m not sure this was done in the current study?Response: Thank you for highlighting this. As we predominantly followed Lincoln and Guba’s  criteria of trustworthiness, the reference to ‘thick description’ has been removed accordingly. Instead, we focus on Lincoln and Guba’s  criteria of credibility, transferability, dependability, and confirmability.7. P8 Do the experience categories of ‘positive’ mean that only positive things were said, negative only negative, and mixed everything else? This is a rather reductionist approach in qualitative terms. I’m also not sure if the coding of positive or mixed or negative birth or easy mixed or difficult infant behaviour was done on the basis of one final question about the overall birth experience, or on the researchers’ interpretation of the whole set of responses from each woman. Response: As explained previously, reference to categories and coding of data has now been removed. Instead, a more in-depth analysis of the mothers’ quotes – including ‘disconfirming’ data – has been incorporated throughout. 8. The demographics seem to cover a good range. Are they representative of the population? What about ethnicity? This is covered in the limitations but it might be worth making a note about the sample representativeness at the outset of the results, to remind the reader. Response: A additional note about sample representativeness has been included in the first paragraph of the results section on page 7.9. Data collection: The questions and example prompts given in Table two are appropriate. How long did the interviews last (the range would be useful here)?. Response: Approximate interview length has been captured in the Participants section (Page 4). 10. The following statement is a good indication of the trustworthiness of the analysis. How was it ascertained that no new or meaningful concepts were being generated?: “Data collection stopped when it was judged that no new and meaningful concepts were being ‘generated’ from the data [40].”Response: This sentence is now justified by the one that follows and further details about data saturation have been included in the second to last paragraph on page 6. 11. The results make good use of quote material. Table 3: Part one doesn’t look like themes that have emerged from the data – they are demographics. How many had each of these experiences? (to interpret the credibility of the claims made later). Part two is a bit more nuanced: but what about Joy? Delight? Did these not feature? Response: The original themes of ‘birth mode’ and ‘birth environment’ have been renamed to reflect the topics as the mothers spoke about them . We have also included a short data summary paragraph to establish how the mothers gave birth (top of P9). We have changed the name of the original subtheme ‘fear’ to ‘Emotional states’ in order to include representation of more nuanced emotions, including ‘joy’. Additional quotes have also been added. 12. Given the current debates in the UK about terminology for types of labour and birth, there may be a risk in dichotomising assumptions about ‘natural’ and ‘clinical’ birth, and of making assumptions about place and type of birth on very small samples. Indeed, the key point seems to more about the fit or gap between expectations and experience than about place or type of birth? Women’s experiences related to different types and places of birth are already well described in various studies – the contribution to knowledge here seems to be more about whether women say that the way they perceived their labour and birth overall has influenced the behaviour of their infants. Indeed, there does seem to be some disconfirming data for the claims made about type of birth (p17) in the account of a ‘natural’ birth that was then associated with distress  postnatal care than the mode of birth): Mother 10, natural hospital birth, baby in Neonatal Intensive Care Unit [NICU] post birth)Response: Physical and psychological birth experiences, as well as styles of infant behaviour, are no longer categorised into specific groups but instead talked about more generally. The study is now more about whether women say that the way they perceived their labour and birth overall has influenced the behaviour of their infants. Additional disconfirming data has been incorporated throughout. 13. Table 5 speaks to the topic but the ‘n’ is needed, and ‘birth mode’ or ‘pain relief’ are demographics not themes – ‘Baby mirrors mother’ or ‘maternal caregiving’ are closer to a thematic concepts. Response: The terms ‘birth mode’ or ‘pain relief’ have been changed accordingly, reflecting mothers’ personal experiences and perceptions around these birth events . Table 5 has been removed as Parts 2 and 3  have been folded into Part 1. The ‘n’ is given for details of the birth and infant behaviour in the ‘Data summary’ on P9. 14. N of how many? Words such as ‘often’ are used throughout, or statements such as ‘waterbirths were…’. Does this mean the majority of respondents said these things? How many waterbirths were there? I would suggest that throughout the text should be more cautious. For example: P23 ‘…..often enabled their baby to be calm and settled’ is better as ‘some who reported overall positive births linked this experience with their babies being calmer and more settled’ Response: As mentioned above, the ‘n’ is given for details of the birth and infant behaviour in the ‘Data summary’ on P9. We have also adapted more cautious wording throughout  and when we refer to possible rather than definitive outcomes of an experience .15. And the opposite with the following quote about forceps and the behaviour of the baby: Conversely, birth complications sometimes led to pain, distress and unsettled baby behaviours. I would suggest this is changed to: ‘some women suggested that specific birth events (such as forceps delivery) might be linked to specific baby behaviours’Response: Wording has been amended throughout to align more with mothers’ perceptions of birth events and infant behaviour rather than an interpretation of patterns in the data .16. In both cases, in terms of disconfirming data, were there any accounts from women with a birth coded as ‘positive’ or ‘negative’ who said anything different to the statements above?Response: Yes, and additional disconfirming data has been included to illustrate . Whilst reference to ‘positive’ or ‘negative’ (coding) have been removed, there is naturally still reference to mothers who had more positive or negative types of experience for one reason or another – often linked to supportive care or conversely, perceived neglect. 17. P24 I’m not sure why this quote is used with reference to labour pain/pain relief: She’s definitely a more clingy baby than my first. She does not like to be put down, she doesn’t lie down, she’s quite sicky... She won’t settle away from me.” It maybe that a longer section of this quote shows that the mother is associating this behaviour with labour pain/use of pain relief, and, if so, the quote needs to be expanded to show this. Response: The quote has been expanded to provide additional context. 18. P25 It is good to see a counterfactual case here – but is the mother associating the baby’s colic with her birth experience? Or is she just saying that she (the mother) found it a bit harder to cope than she might given her birth experience? “I think I found her quite difficult because I was a little bit shell-shocked after the birth… in the early days… She was really hard to console for no reason other than maybe feeling a bit colicky…”  Response: This quote now follows Mother 8’s birth story: “Some mothers who had a spontaneous physiological birth also found it challenging” and “I don’t think I had a traumatic birth, but… being told nothing was happening and thinking, I can’t cope with it if that’s the case…” ’. Prior to the above quote about baby’s behaviour, we have inserted: ‘This mother went on to describe her baby as unsettled, although she did not contemplate any connection between the birth and her baby’s behaviour.’19. P27 As noted above, I would suggest that, at least based on the data from this study, mode of birth/interventions are not part of the psychological experience measure, but that this should be built on the mothers’ perceptions. The sample size in this study is not big enough to be certain that mode of birth/interventions are definitively associated with the outcome, in the absence of other contextual aspects. Response: As captured elsewhere, a more qualitative angle has now been adopted. 20. P29 The following comment is interesting, but the ‘n’ is very small for a statement of association, and the demographics are not necessarily representative. Any statement like this needs to be made very cautiously, and with the imperative that the findings need to be verified with a much larger sample: Notably, no mother who had a spontaneous physiological birth described her baby’s behaviour as difficult, with the majority describing an easy baby. Conversely, almost half of all clinical births were associated with a description of a difficult baby, with less than a quarter describing their baby as easy. Response: In line with changes explained above, content has been realigned to focus on mothers’ perceptions of their birth, baby’s behaviour and their thoughts regarding potential links between the two. 21. Table 9 also interesting, but, again, it should be noted that this is a small and skewed sample, and the assumptions need to be checked with larger samples. It isn’t quite clear what the direction of effect is. Does a difficult baby reify the birth experience as negative, or vice versa? Response: No longer applicable as Table 9 has been removed along with this section. 22. Based on prior studies, the statement below is important, but, based on an n of two, it cannot be transferable from this study. It would be better to frame this as ‘Two women had planned interventions (one CS and one induction) and both reported positive perceptions’. ‘…The remaining 25% of mothers with positive perceptions of their birth (n = 2) had experienced a planned intervention, such as a planned induction or CS’.Response: As explained previously, the emphasis is now on mothers’ perceptions of their experiences and infant’s behaviour – with the results section modified accordingly.23. Discussion: The discussion could be shorter. There are also some new findings here. Some of the assumptions seem to be quite far from the actual data, or, at least, don’t seem to take account of possible alternative explanations. This is less likely to happen when the team have previously considered their reflexivity positions, and deliberately searched for disconfirming data. For example, in relation to the two comments below: what about the counter-factual? Might the fact that the newborn is perceived to be unsettled be linked to something else other than the birth? Difficulties in feeding, lack of postnatal support, maternal worry about financial security, for instance: meaning that there is no cognitive dissonance in their accounts in relation to infant behaviour and the birth?: P30 - After outlining a physically traumatic birth, some mothers proceeded to describe their newborn as unsettled, without attributing their baby's behaviour in any way to the birth. This might be due to maternal guilt, disassociation or denial after a difficult birth experience [52], and therefore, may not have wished to perceive or disclose a potential association between the birth and their baby’s behaviour P31 - Consequently, the lack of consistency in maternal responses could be caused by cognitive dissonance stemming from a desire to believe that their baby had experienced a positive start to life regardless of the type of birth they had experiencedResponse: The discussion has been streamlined throughout, and the phrase ‘cognitive dissonance’ has been removed. Instead, we have included other ‘possible alternative explanations’ as suggested . 24. P32 Yes, the statement below is correct, the numbers are too small to make any claims – I would suggest deleting this comment, or reframing it as I have suggested: Although the sample numbers are too small to draw any definitive conclusions, the n = waterbirths were generally associated with maternal perceptions of calmer infants, while the n= unsettled forceps birth infants were considered to have residual pain and distress.Response: We have amended as follows: ‘Although many mothers perceived no connection between their birth experience and their baby’s behaviour, some who reported an easy, straightforward birth, such as a calm and well-supported waterbirth, connected this experience with their babies seeming content settled. In contrast, others perceived that difficult birth events, such as forceps delivery, might be linked to their baby’s unsettled behaviour due to residual pain and distress.’ .25. P32 The concept of Potential Triggers is interesting in the discussion, and P33 - the findings underpinning the statements made below are only represented by one or two quotes (or no direct quotes). The highlighted phrases in the first para indicate where strong claims are made that should be rendered much more nuanced and tentative (and there are similar observations for the other paras selected): Birth environment was considered important in relation to maternal and infant wellbeing. Noisy, brightly lit environments increased maternal stress whereas births taking place at home or in a MLU were generally reported as more physically comfortable and psychologically positive experiences. Women who experienced an in-labour transfer from home or MLU to hospital could find it difficult to acclimatise to their new environment, particularly if the transfer involved interventions which raised their stress levels. Unexpected or traumatic circumstances affected maternal reports of infant behaviour. Therefore, the birth environment seemed to have profound psychological as well as physical impacts on the mother and infant.Midwifery services were often stretched despite the most recent National Institute for Health and Care Excellence (NICE) recommendations of one-to-one care for all labouring women [51]. Inconsistent care and noticeable staff shortages on the postnatal ward were experienced as distressing, with staff shortages on wards known to negatively impact on quality of care . The resulting maternal distress could adversely impact newborn infant behaviour. In contrast, women who had a calm, supportive birth were more likely to attribute their baby’s calm, settled behaviour to the birth environment. Response: We have amended the discussion section throughout, including revising wording to ensure claims are more nuanced and tentative. 26. Do the data actually say this?: P35 c) Health professional authority; Perceived ‘health professional authority’ occurred when women experienced a loss of control. Participants who were not fully informed or felt ‘coerced’ into consenting to unplanned interventions often had regrets around their birth.Response: These are substantiated by the data, and we have since added additional information/quotes to make this clearer: “And then everything I didn’t want to happen happened which was, I didn’t want to have stirrups or anything like that, and the next thing was they took the gas and air away and said I wasn’t pushing hard enough…”  “If the doctors decide this is the way they want you to do it it’s very hard not to. If something then happened… I’d never forgive myself.” “They broke my waters – they didn’t ask. Suddenly there was stuff coming out of me. I did not know what was happening … They were telling me, ‘Keep your legs open, keep your legs open’, though my natural instinct was to curl up in foetal position to protect myself.” 27. There are other statements in the discussion that don’t seem to relate to the findings above. I suggest you check for and amend or remove these throughout. I would suggest as above that the focus of the discussion stays on maternal perceptions of their births and the behaviour of their infants. Response: We have now amended the discussion to be more consistent with the data, either by removing ‘claims’ or by adding illustrative quotes. The focus of the discussion now better aligns with maternal perceptions of births and their infant’s behaviour.28. P40 The limitations section is rather long. Also, in qualitative terms, and given the aim of this paper to understand women’s reported experiences, I don’t think the following is a limitation, since the whole point (as I understand it?) is to capture women’s subjective experiences: However, parents may also be influenced by prenatal expectations, and their emotional involvement naturally precludes them being entirely objective observers of their infant’s temperament. The limitations about the sample are accurate but are not always reflected in the discussion of the meaning and potential transferability of the study findings.Response: We have shortened, simplified and reworded this section based on your comments. 29. P39 suggest changing: Whilst this study deepens our understanding of how physical and psychological birth experiences may affect early infant temperament…To: Whilst this study deepens understanding of women’s perceptions of how their physical and psychological birth experiences may affect the temperament of their infant… Response: Amended accordingly. 30. P40 – While it may be true that what the researcher sees as ‘difficult’ is not necessarily in line with the woman’s perception and that women MAY be engaging in self-deception for self-protection, this is an assumption that values the researcher interpretation over what the woman herself says. In fact, the woman may feel no need for self-protection – she may simply be telling it as it is from her perspective. Both points of view need to be discussed here. Response: Both points of view are now discussed, with mothers’ perspectives taking precedence throughout. We have also amended conclusions to focus on implications for making maternity care improvements to support mothers better during childbirth and postnatally. 31. It is important to explain and reference in the discussion how better one-one care and emotional support during childbirth help with women’s perceptions of their birth, their infant’s behaviour, and any associations between these two, if this is to be a key conclusion of the study.Response: In line with this, we have explained further how better one-one care and emotional support during childbirth (as opposed to neglect) might help with women’s perceptions of their birth and their infant’s behaviour . Reviewer 21. Introduction: Well written, provides relevant previous research. I think that the justification for carrying out the study could be strengthened more. Especially as there is a lot of rich data reported that doesn't just relate to infant behaviour. You could talk about how important women's experiences of birth are, because of the data that shows the long-term impact, therefore you will be adding to this body of research, identifying types of practice that are associated with good care, which has the ability to improve care and change practice. The results focus a lot on feeling prepared, so you could also discuss the importance of good antenatal care and birth education, and birth expectations and experiences research.Response: Further justification has been added to the abstract and introduction sections. We also mention birth expectations and experiences research in the introduction and discuss this more fully in the discussion section as well. Although the mothers were not specifically asked about antenatal preparation, we have referred (where appropriate) to the concept in the discussion . https://www.sciencedirect.com/science/article/pii/S0266613815000078?casa_token=v6ULrCszbjEAAAAA:sd86yyjPygL-tgH6o1qumGARn-kA6lEz07cGUOgriONnbz89I3qlljrKI0rQSgVpj1obguy-;https://www.sciencedirect.com/science/article/pii/S0266613821001972?casa_token=I4NqVIXHftUAAAAA:XU2cIZSco3k3e6tTpBGhs6Vm0NOn2H8033EQGJg2mBsoGRiYn6ozLRrGDlolNJIQa2Yguelp; including your study, so is the point of this part of the study to add to this body of research? It isn't entirely clear what the justification of this part of the study is, considering it would be methodologically better to answer this from a quantitative perspective, especially regarding part 3 (associations), so I think this part of the study needs more justification.2. Regarding the second part of the study, about birth and infant's behaviour, there is already research that drugs and type of birth can affect baby/breastfeeding Response: Thank you for these additional references (now references 88 and 89), which we have included in the discussion section under Postnatal days with baby . Our study adds mothers’ qualitative experiences  to the body of existing evidence. To clarify that it is a qualitative study, we have now removed parts 2-3 of the original results section (see response to Reviewer 1 comments). Instead, we interweave the perceived infant behavioural outcomes with the mothers’ birth experience stories.3. Method: Interview schedule. My main comment is about why you asked "how were you induced?". Were all women who took part induced? Or was this question only asked to women who were induced? Could you make this clearer.Response: In relation to the ‘Semi-Structured Interview Schedule for Mothers with example prompts’, we have added some additional text to clarify that these are examples of prompts rather than set questions. For example, ‘If you were induced, how were you induced and how did that feel for you?’, 4. The first prompt for Question 3 is also grammatically incorrect. Can you clarify this one please?Response: Thank you. This has now been corrected. https://blogs.bmj.com/bmj/2018/02/08/humanising-birth-does-the-language-we-use-matter/) I would advise changing natural to "physiological".5. I do not agree with the labels of your categories . Due to the importance of language, . 11. The maternal caregiving theme is not very strong and may require more description/examples.Response: We have added extra text and examples to the maternal caregiving theme. 12. Part 3 - there is a lot of methodology here and I would argue this should be in the method section.Response: As mentioned above, we have reconsidered the different methods applied to the data and narrowed the focus of the study to be more in keeping with its qualitative aims and objectives. Therefore, Part 3 has been removed. 13. Page 26, first paragraph, there is a double F on the word For.Response: This has been corrected, thank you. 14. Discussion: Provide a description of what was positive and negative about women's birth experiences, as this is a large part of your results.Response: Although they are no longer categorised, we now describe more fully how mothers can have more positive or negative experiences of childbirth and the care they received in the final paragraph on page 28. 15. I think your discussion potentially goes too far in trying to work out the relationship between women's birth experiences and infant behaviour, especially when this is a qualitative study and you cannot really draw these conclusions, especially with a sample of only 22 women. The discussion should focus more on women's experiences of birth, and how they thought it impacted their baby. Their experiences were affected by their type of birth and the way they were treated during birth, which adds to a large body of evidence on this already. More focus should be made about the coercion and neglect women experienced, which goes against the initiatives of multiple organisations . Then you should go onto say it is extra important that maternity care is improved because the results suggest that birth experience MAY impact infant behaviour, but more research is needed. You can also talk about the need for good preparation, good antenatal care, good support. All of which has been found by previous studies, and your study supports. Response: We amended the focus from trying to draw conclusions about the relationship between women's birth experiences and infant behaviour, to discussing how women experienced their labour, birth and postnatal days and how they felt this may have affected their baby’s wellbeing and behaviour post birth. As suggested, we have also added parts to the discussion under ‘psychological birth experience’ about the coercion and neglect experienced by some women - in direct opposition to current recommendations and intrapartum guidelines by NICE (2017) and the WHO (2018), both of which inform the White Ribbon Alliance . As mentioned above, the importance of good preparation and antenatal care is also now also included.AttachmentPower, Williams & Brown_Response to Reviewers_12.03.2023.docxSubmitted filename: Click here for additional data file. 27 Mar 2023Does a mother’s childbirth experience influence her perceptions of her baby’s behaviour? A qualitative interview studyPONE-D-22-24651R1Dear Dr. Williams,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact Kind regards,Adetayo Olorunlana, Ph.D.Academic EditorPLOS ONEAdditional Editor Comments :Reviewers' comments: 28 Mar 2023PONE-D-22-24651R1 Does a mother’s childbirth experience influence her perceptions of her baby’s behaviour? A qualitative interview study Dear Dr. Williams:I'm 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. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staffon behalf ofAssociate Professor Adetayo Olorunlana Academic EditorPLOS ONE