Table 4 Summary of qualitative review findings table including GRADE-CERQual assessment of confidence
Overarching theme | Sub-theme | Summarised review finding | GRADE-CERQual Assessment of confidence | Explanation of GRADE-CERQual Assessment | Reference ID # |
|---|---|---|---|---|---|
1. Dealing with public health restrictions | 1.1. Limited support networks from health care system and providers | Social distancing meant that women could not have frequent face-to-face interactions with healthcare providers. Women expressed feelings of neglect, being forgotten and missing out on opportunities to share experiences with other people in similar situations. | High confidence | Minor concerns regarding methodological limitations (reflexivity, aim and research design, data saturation, data analysis, new areas of research), No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and Minor concerns regarding relevance (some studies did not clearly indicate age of babies or studied specific sub-populations of women). | [1, 2, 4, 7, 9, 12,13,14,15,16,17,18, 21,22,23,24,25,26, 28, 32, 33, 36] |
1.2. Balancing exposure risk and need for healthy behaviours | Stressors of the pandemic evoked reactive health behaviours such as shielding in their homes (staying at home), limiting movement outdoors and avoiding healthcare settings. Heightened anxiety and changing health restrictions especially around labour and childbirth times influenced women’s decision making. | High confidence | Minor concerns regarding methodological limitations (reflexivity, recruitment, data saturation, data analysis and new areas of research), No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and Minor concerns regarding relevance (some studies did not clearly indicate age of babies or studied specific sub-populations of women). | [1, 3, 9,10,11, 13,14,15,16, 18, 21, 23, 25, 31, 33,34,35,36] | |
1.3. Missing out on social opportunities | Women mourned the loss of rituals and traditions during their pregnancy and postnatal period, missing out on the ability to celebrate new life with family and friends. Women also mourned the missed opportunity to meet other mothers and babies, missing out on social interactions that would have been usual pre-pandemic. | High confidence | Minor concerns regarding methodological limitations (aim, data saturation, reflexivity, analysis, in-depth discussion, statement for new areas of research), No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and Minor concerns regarding relevance (some studies did not clearly indicate age of babies or studied specific sub-populations of women). | [4, 5, 7, 9, 12, 14, 17,18,19, 22,23,24,25,26, 29, 31,32,33,34,35,36] | |
1.4. Breastfeeding challenges and triumphs | Breastfeeding infants during the pandemic had its own set of challenges and triumphs. For women who were struggling to establish breastfeeding and needed additional support, this was limited due to limited face-to-face consultations. Women able to establish a breastfeeding routine described the lockdown and public health measures as a blessing in disguise as they had more undisrupted time to bond with their babies and were able to feed on demand. | High confidence | No/Very minor concerns regarding methodological limitations, No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and No/Very minor concerns regarding relevance. | ||
2. Navigating changing health policies | 2.1. A birthing experience filled with uncertainty and unknowns | Limited knowledge surrounding the impacts of the virus affected how women accessed healthcare and the trust they had in healthcare providers. Limited education, uncertainty about plans, choice of pain management and support people during labour and visitors on the postnatal ward caused stress and anxiety. Women were unable to plan ahead or maintain control over their labour and childbirth. | High confidence | Minor concerns regarding methodological limitations (design, data saturation, reflexivity and new areas of research), No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and No/Very minor concerns regarding relevance. | |
2.2. Reduced support and partner presence in healthcare settings | The policies implemented limiting support people and partners throughout the perinatal period were described by women as unfair, anxiety and stress provoking, and traumatic. Women expressed their sadness and grief in partners missing milestones throughout pregnancy, as well as missing their advocators and support in labour and childbirth. On the postnatal ward, midwifery support was available, described as both lovely for mothers who coped well, and lacking compassion for mothers who felt minimally supported. Available support was appreciated but it was not the same as having their partners. | High confidence | No/Very minor concerns regarding methodological limitations, Minor concerns regarding coherence (some contributing studies included the additional impacts of lack of support from partners and barriers to receiving additional support), No/Very minor concerns regarding adequacy, and Minor concerns regarding relevance (some studied specific sub-populations of women and some focused on different levels of support). | [1, 2, 7, 9,10,11,12,13,14,15,16, 18,19,20,21,22, 25,26,27,28,29,30,31, 34,35,36] | |
2.3. Transitioning to telehealth, virtual and remote care | Telehealth, virtual and remote care increased accessibility and allowed women the option of receiving care without the burden of attending hospitals and healthcare settings. It was accepted as “better than nothing”, however many women considered it “useless” and “inappropriate” for appointments to check pregnancy milestones, assess breastfeeding and inadequate when women and newborns needed to be checked physically. Many questioned the quality of care provided, found it challenging to navigate and lacked the support and reassurance from healthcare providers. | Moderate confidence | No/Very minor concerns regarding methodological limitations, Minor concerns regarding coherence (some studies included positive experiences of telehealth), Minor concerns regarding adequacy (some contributing studies provided thin data), and Minor concerns regarding relevance (some studied specific sub-populations of women and some focused on different levels of support). | [1, 2, 6,7,8, 13, 14, 16, 18, 19, 25, 26, 28, 31,32,33,34, 36] | |
2.4. Barriers to accessing health services | Closure of non-essential services and educational classes, as well as constantly changing healthcare policies reduced the support women received. Healthcare providers were hard to reach, would often delay, postpone or cancel appointments. Post-birth, women were not provided with enough information about how and where to access support if required and felt that the onus was placed on themselves to stay informed. The biggest concern for new mothers was whether or not their newborns were thriving given the lack of check-ups. | High confidence | Minor concerns regarding methodological limitations (unclear research design, data analysis, reflexivity statement, lacked an in-depth discussion and did not provide statement for new areas of research), No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and Minor concerns regarding relevance (some studies did not clearly indicate age of babies). | [1, 3, 6,7,8, 13,14,15,16, 19, 24,25,26, 28, 29, 31, 32, 34, 36] | |
3. Adapting to alternative ways of receiving social support | 3.1. Accessing support through different avenues | Virtual technologies were used to access remote emotional support from family and friends, and social media platforms were used to access peer support. For some women, they had increased support from partners as they were at home more. Although supports were readily available remotely and online, almost all women reported that, “it was not the same” as being able to be physically present with people. | Moderate confidence | Minor concerns regarding methodological limitations (aim, data saturation, data analysis, reflexivity, discussion and lacking statement for new areas of research), Minor concerns regarding coherence (some findings were extrapolated from sub-population groups), No/Very minor concerns regarding adequacy, and Minor concerns regarding relevance (some studies did not clearly indicate age of babies or studied specific sub-populations of women). | [1, 3,4,5,6,7, 11, 14, 15, 17, 19,20,21, 24,25,26, 29,30,31, 35] |
3.2. Desiring connection with family and friends | Women felt sadness and heartbreak that their family and friends were not able to be physically present during their pregnancy and early postnatal period. They desired and needed practical support from their families and friends, for their mental health, physical wellbeing and as carers for older children. Postnatal women felt they were an afterthought in the government’s plan to return to a COVID-safe society. | High confidence | No/Very minor concerns regarding methodological limitations, No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and Minor concerns regarding relevance (some studies did not clearly indicate age of babies or studied specific sub-populations of women). | [1, 2, 4, 6, 9, 12,13,14,15, 17, 19, 21,22,23,24, 26, 27, 29, 33,34,35] | |
4. Dealing with impacts on own mental health | 4.1. Managing anxiety due to virus-related fears and concerns | Limited information about the adverse effects of COVID-19 infection on pregnant women, the unborn fetus and newborns caused heightened levels of anxiety, stress, fear and worry. The mental health burden increased as there was constant concern about the risk of infection and transmission. Attending hospitals or healthcare settings for check-ups were considered high-risk and dangerous settings. | Moderate confidence | Minor concerns regarding methodological limitations (study design, recruitment, data analysis, reflexivity, in-depth discussion and lacking statement for new areas of research), No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and Minor concerns regarding relevance (some studies did not clearly indicate age of babies or studied specific sub-populations of women). | [1,2,3, 7, 9,10,11,12, 15, 16, 18, 19, 21,22,23,24,25,26,27,28, 31, 33,34,35,36] |
4.2. Feeling lonely and isolated | Social isolation from family, friends, peers and society placed a burden on the mental health of pregnant and postpartum women. The increased sense of loneliness and isolation, and the inability to see or meet with family and friends was believed to increase depression in women. The inability to receive adequate supports from care providers, further exacerbated the isolation women felt and had an impact on their physical wellbeing. Some described this experience as being forgotten or abandoned by the health care system. | High confidence | Minor concerns regarding methodological limitations (research design, recruitment, data saturation, reflexivity, data analysis, in-depth discussion and lacking statement for new areas of research), No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and Minor concerns regarding relevance (some studies did not clearly indicate age of babies or focused on different levels of support and behaviours). | [1,2,3, 7,8,9, 12,13,14,15,16, 18, 21, 22, 24,25,26,27, 29, 30, 32,33,34,35,36] | |
5. Managing the new and changing information | 5.1. Constantly changing advice and information | Managing conflicting information during the pandemic was challenging. The constant change to public health restrictions and hospital protocols and policies meant that definitive answers for labour and childbirth could not be given to women as they changed frequently. Women received non-specific information from hospitals and healthcare providers and felt they were not well informed, yet at the same time were overwhelmed by the information from governments, hospitals with their updated protocols and media reporting COVID-19 related news. | High confidence | No/Very minor concerns regarding methodological limitations, No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and No/Very minor concerns regarding relevance | |
5.2. Inadequate information from healthcare providers | Limited information about the adverse effects of infection combined with poor communication of these unknowns placed a greater distrust in maternity care providers and impacted women’s ability to make informed decisions. Women had to navigate contradictory information within policies and protocols, with discrepancies in information provided at the community level, to what was being enforced in hospital settings. Women would have preferred if uncertainties were better communicated, information was consistent and clear for the lay person | Moderate confidence | No/Very minor concerns regarding methodological limitations, Minor concerns regarding coherence (experiences of navigating information and communication from healthcare providers varied), No/Very minor concerns regarding adequacy, and Minor concerns regarding relevance (some studies did not clearly indicate age of babies, studied specific sub-populations of women or focused on different responses to the pandemic). | [1, 2, 5,6,7, 11, 13, 14, 16, 19,20,21,22,23,24, 26, 29,30,31, 33,34,35,36] | |
7. Being resilient and optimistic | 6.1. Self-help strategies to overcome challenges of the pandemic | Women described having resilience and optimism in their reactions to public health measures and challenges during the pandemic. Women highlighted the need be conscious of and take care of their mental health and made active decisions to protect this. Women commented on their need to be advocates, encouraging other women to speak up to ensure they were receiving the best care for themselves and their newborns. Different coping strategies were used to ensure women preserved their mental and physical wellbeing. | High confidence | Minor concerns regarding methodological limitations (recruitment, data saturation, reflexivity, data analysis, in-depth discussion and lacking statement for new areas of research), No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and Minor concerns regarding relevance (some studies did not clearly indicate age of babies, studied specific sub-populations of women or focused on different support levels and behavioural responses). | [1,2,3, 5, 7, 11, 12, 15, 18,19,20,21, 23,24,25,26,27, 31, 33, 35, 36] |
6.2. Making the most out of the positive encounters | Despite the challenges of the pandemic, women found silver linings throughout the perinatal period. Adherence to public health restrictions meant women had fewer social obligations allowing them to settle into their role as a mother and establish routines with their newborn. Fewer disruptions allowed families time to bond with the newborn and establish successful breastfeeding. For some, health services were described as a peaceful place to be. | Moderate confidence | Minor concerns regarding methodological limitations (aim, recruitment, data saturation, reflexivity, in-depth discussion and lacking statement for new areas of research), Minor concerns regarding coherence (some silver linings were regarded as a negative experience for some women), No/Very minor concerns regarding adequacy, and No/Very minor concerns regarding relevance. | [1,2,3,4, 6, 7, 11, 15, 17, 18, 20, 25,26,27, 29, 30, 33, 35, 36] | |
6.3. Information seeking and desire for more information | Information overload, filtering and weighing up options impacted their mental health. Women were careful to ensure the information they encountered was accurate and was not misleading. | High confidence | No/Very minor concerns regarding methodological limitations, No/Very minor concerns regarding coherence, No/Very minor concerns regarding adequacy, and No/Very minor concerns regarding relevance |