There were six over-arching themes: (1) dealing with public health restrictions; (2) navigating changing health policies; (3) adapting to alternative ways of receiving social support; (4) dealing with impacts on their own mental health; (5) managing the new and changing information; and (6) being resilient and optimistic. Seventeen sub-themes were developed within these 6 themes and illustrative quotes are presented in Table 3 to demonstrate theme development. Themes were categorised to differentiate major disruptors to the pregnancy and postpartum period and sub-themes aimed to categorise the indirect impacts that occurred within the major themes.
Characteristics of contributing studies
After applying the sampling framework (data richness score ≥4), 36 sampled studies were included for data extraction and analysis. Thirteen out of 36 studies had a score of 5 (51-63), with the remainder scoring 4 (9, 18, 63-84) (S5). Most studies (N=27/36, 75%) used specific qualitative methodologies, six were mixed-methods studies, two were cross-sectional studies, and one was a case series report.
Studies were conducted across many countries, with almost one-third (N=10/36, 28%) of studies published from the UK (Table 2). Participants were women who were pregnant or had given birth during the pandemic. Additionally, some studies were included as they reported on a specific sub-population of pregnant and postpartum women, for example women from ethnic minority groups, those with pre-existing comorbidities, and those who were COVID-19 positive. Some studies also included results from women with babies who were greater than 6 months of age, and any findings directly from these participants were omitted from analysis where possible.
The number of participants in studies that conducted interviews ranged from 3 to 84, and studies using qualitative data from open-ended questions or survey data included responses from 16 to 4,611 participants. Sampled studies were generally of high quality and assessment of methodological limitations indicated that 29 studies were assigned “no or very minor concerns”, six studies were assigned “minor concerns” and one study was assigned “moderate concerns”.
Theme 1: Dealing with public health restrictions
The rapid introduction of public health restrictions has had adverse effects on mental health, social isolation, and the pregnancy experience. Women had to navigate these restrictions and adapt accordingly, realising quickly that their pregnancy and postpartum experience was going to be very different from their expectations.
Sub-theme 1.1. Limited support networks from health care system and providers (High confidence). Support networks were limited. Women felt that they were “on their own”, “unimportant or irrelevant” or treated as “second class citizens” after birth, because of a lack of physical supports from healthcare providers (55, 56, 65, 71, 75, 76, 78). Limited or no access to physical and social support networks was commonly cited as a reason for deteriorating mental health.
Sub-theme 1.2. Balancing exposure risk and need for healthy behaviours (High confidence). Women balanced COVID-19 exposure risks by shielding, either because of health providers recommendations (18, 60) or because they felt it was needed to protect their baby (59, 61, 62, 64, 84). Women delayed or postponed antenatal appointments (53, 60, 63, 64, 76), opted for induction of labour (78), or waited until labour was quite advanced before attending hospital (55, 62, 71). These decisions were due to pandemic-induced fear, and the perceived risk of infection in a high-risk environment such as the hospital (18, 69, 83).
Sub-theme 1.3: Missing out on social opportunities (High confidence). Women felt sad, unseen and heartbroken that they were not able to have social opportunities, especially sharing their newborns with family and friends (9, 55, 58, 61, 67, 69, 75, 79, 80). On postnatal wards, women with older children were disappointed that their nuclear families could not visit and bond with their newborn in the early postpartum period (63, 69, 70, 83). While this was disappointing for many, one woman described still feeling well-supported, “we were supposed to have a baby shower, the weekend after everything shut down … definitely got a lot of gifts in the mail and people who drop things off …. [we] feel like even though he’s being born in this super crazy time and he doesn’t necessarily get to meet people in person, that they are excited about him and want to support us” (52).
Sub-theme 1.4: Breastfeeding challenges and triumphs (High confidence). Women that struggled with the lack of support around breastfeeding said, "when it came time for breastfeeding, I had no idea what to do or any challenges that could come. There were so, so, so many questions and I felt so confused during everything” (71). Lactation consultations through virtual remote care was considered inadequate by most women (58, 61, 65, 77, 79), especially when practical hands-on education and assistance was needed (62, 65, 66, 76). These challenges led some women to cease breastfeeding early (56, 65, 77).
Conversely, public health restrictions enforcing women to stay at home allowed some women to practice responsive breastfeeding, without concern for social obligations or visitors (56, 61, 65, 72, 79, 82). Some women valued this flexibility - “there’s no right or wrong way. You know, at the end of the day the ultimate goal is that my baby needs to be fed.… you know, feed him breast milk, breast milk, or formula. He’s fed. He’s happy. Sweet. That’s done. Job done! The important thing is actually [to] be kind to yourself, you know?” (56).
Theme 2: Navigating changing health policies
The ever-changing nature of the pandemic created periods of uncertainty. Women and their families were expected to accept and adapt to changing health policies which directly impacted their antenatal, labour and birth and postnatal experiences.
Sub-theme 2.1: A birthing experience filled with uncertainty and unknowns (High confidence). Many women reported that, given the constantly changing policies, they were unsure what to expect for their labour and birth (9, 51, 62, 71, 79). Limitations included not being able to have a water birth, use a bath or the shower, access nitrous oxide gas during labour (51, 63, 78) and others could not have their desired support people present (62, 71). In some cases, women opted for medicalised interventions to retain a sense of control - choosing a caesarean birth to ensure their partner was present at birth (71, 78). Women struggled with the prospect of early discharge, lacking confidence and fearing reduced support at home, with some feeling pushed out of the hospital (51, 66, 71, 78). Some women chose to leave hospital early due to the lack of support or poor experiences while in hospital (71). Conversely, some women welcomed early discharge, wanting to be away from the hospital and to be reunited with family members (56, 83). Women who tested positive to COVID-19 early in the pandemic described additional challenges, such as a lack of certainty on how care was going to be managed (62). They felt this restricted their autonomy over their labour and birth choices.
Sub-theme 2.2: Reduced support and partner presence healthcare settings (High confidence). Due to the public health restrictions in hospitals, women often missed having their partner and family supports. For example, “one of my coping mechanisms is having my partner there to hear the same things I am hearing because I kind of shut down sometimes when I get too upset. It’s always good to have that second person listening… and walking out with strength of unity” (18, 51, 53, 58, 61). The inability for some women to have their partners present negatively impacted women’s birthing experience, confidence on the postnatal ward and many expressed the sense of being “robbed of this experience” (68, 77, 84, 85).
Sub-theme 2.3: Transitioning to telehealth, virtual and remote care (Moderate confidence). Public health restrictions limited face-to-face health care appointments with a maternity care provider (67). Negative telehealth experiences were expressed predominantly by first-time mothers, with many saying, “over the phone just doesn’t do it like… you don’t get to look into somebody’s eyes and to trust them and for them to say, you’re okay” (61), adding to their anxieties. Positive encounters with telehealth were associated with the increased accessibility to health services and generally preferred by multiparous women (59, 67, 73). Whilst many were glad that telehealth services were available, this woman highlighted the inequities, “I think I would question the accessibility of that. Not everyone has a smartphone and expecting people to be able to receive a video call is not necessarily the most inclusive thing” (62) indicating that some women may have fallen through the gaps of maternity care.
Sub-theme 2.4: Barriers to accessing health services (High confidence). The closure of so-called non-essential services, such as, physiotherapists, chiropractors, pools and gyms indirectly impacted women (58, 78). This often increased women’s anxiety, stress, feelings of helplessness and frustration (18, 67, 71, 78) and postnatal depression (63). This also limited opportunities to receive reassurance from healthcare providers, reducing women’s confidence (51, 61, 62, 76). Typically, women accessed networks for information and support, such as, family and friends with midwifery clinical expertise, or referred to recent pregnancy experience (52, 59, 79, 82). Women had to advocate strongly for physical assessments for themselves and their newborns (78).
Theme 3: Adapting to alternative ways of receiving social support
Support networks, such as, family and friends, peer support groups (e.g. mother’s groups), and formal support from maternity care providers provide the foundation for a healthy and positive pregnancy and postpartum period. The COVID-19 pandemic forced women to adapt and seek support in different ways.
Sub-theme 3.1: Accessing support through different avenues (Moderate confidence). Support from family and friends was accessed in different ways, for example, utilising video call technologies to be able to see faces helped with the grief of not being able to be present (18). Women who were able to establish pregnancy and mother’s groups during the pandemic were grateful that they had these supports. Alternatively, women created or sought support through online social media platforms (55, 59, 75, 84), to share a sense of camaraderie that they were not alone in their experiences (52, 62). In these forums, women shared information about COVID-19 developments, updates to hospital policies, and utilised others as sounding boards for advice. Some women reported greater support from partners who had transitioned to working from home (56, 58, 65, 72, 79). Although virtual technologies allowed women to bridge the gap of social distancing, they wanted the physical connection with others.
Sub-theme 3.2: Desiring connection with family and friends (High confidence). Women felt they needed intergenerational support to raise their newborns, and this was especially important during difficult times. Many had planned for parents to come and support them (84), as they believed that, “the older generation have more experience on what babies need or what they feel… with my other two [children]… they knew exactly what would make them feel better” (51). Some women struggled without the additional support, the lack of sleep impeded their physical wellbeing (55, 77, 79), and the isolation from family impacted their mental health (9, 51, 55, 69, 71, 77). In some cases, women were able to “quarantine with family”, providing women with a “strong support network” as they transitioned into motherhood (70). Over time and as public health restrictions eased, women felt government responses did not consider new mothers and babies and they called for “social bubbles” for families to receive the additional support (56, 76).
Theme 4: Dealing with impacts on their own mental health
The COVID-19 pandemic placed a significant toll on pregnant and postpartum women’s mental health at all stages of the pandemic. Public health strategies failed to include protective measures for mental health, as such many women reported increased levels of fear, anxiety, stress, loneliness and depression.
Sub-theme 4.1: Managing anxiety due to virus-related fears and concerns (Moderate confidence). Women often experienced anxiety exacerbated by the pandemic, for example, “as a new mom you are already so nervous, so adding a pandemic to that pile of anxiety and worry” (75). This was related to possibility of infection, particularly in hospital and healthcare settings (9, 53, 60, 63, 69), and the need to protect their unborn or newborn baby (64, 76, 83). Some faced additional challenges as migrants from another country, “I found it very hard when you’re coming to the country without knowing anyone and the coronavirus, lockdown was very difficult, I was very depressed. I was very anxious… I feel worried a lot” (57).
Sub-theme 4.2: Feeling lonely and isolated (High confidence). Loneliness and isolation were commonly reported as women faced motherhood alone without their usual support systems. One woman said, “it was quite sad that I couldn’t even share my pregnancy experience with anyone, and I feel like I missed out” (67). Feelings of loneliness was especially felt by mothers who were not able to have their partners present during birth or postnatally (55). Women were not able to build supportive peer networks in their antenatal and postnatal periods (51, 56, 77-79, 81, 84), with one woman saying, “there’s nothing like just meeting people or, just naturally building friendships when you go to baby groups and things (56)” emphasising the importance of developing social relationships. Cancellation of appointments and lack of face-to-face care added to feelings of “abandonment” and “being forgotten” (9, 71, 75-77).
Theme 5: Managing new and changing information
Due to the novelty of COVID-19 and lack of information about adverse effects, maternity care services had to rapidly adapt as new data came to light. Women described the need to search, access and filter useful information, a process which was challenging for many.
Sub-theme 5.1: Constantly changing advice and information (High confidence). The constantly changing advice was distressing (63). These changes meant a lot of uncertainty, one woman said, “at 34 weeks I had a telephone appointment and I tried to ask what the changes in hospitals were, because of COVID and talk about the birth plan. She basically said, ‘everything is changing so quickly there is no point in us even talking about that now. Wait until your next appointment’” (62). This limited women’s ability to adequately plan and prepare for the birth. Some women described following the updates from government officials and hospitals overwhelming (58). As restrictions eased, women described the frustrations they had with the slow adaptations by health services, “when I got to the hospital, they didn’t know about the restrictions having been lifted … That was really frustrating because I was like why? Why does this hospital not know?” (63) and the differences between health services, “restrictions have still not been lifted in ‘Hospital A’ whereas they have been eased in both ‘Hospital B’ and ‘Hospital C’” (9).
Sub-theme 5.2: Inadequate information from healthcare providers (Moderate confidence). Women felt there was not enough information from healthcare providers, “I think there was a lot of confusion; there was no good communication about what was happening to appointments. You weren’t really sure; were they happening on the phone [telehealth], when were you going to get the call? There was very little communication. So, I always felt a bit uneasy about that…” (62). Some information was contradictory (71) for example, “I’ve found the disconnect between the information that my GP was getting and that the [hospital] was getting - they weren’t getting the same” (63). Women wanted clear information that was easily accessed by the lay person (9, 18, 55, 58, 59, 67, 73, 74, 79). They also wanted uncertainty to be acknowledged, “it would have been useful to have some generic information that went out to women in that situation… statements from a medical professional to put people’s minds at ease” (67).
Theme 6: Being resilient and optimistic
Many women were self-reliant and took it upon themselves to remain positive and proactive throughout the perinatal period.
Sub-theme 6.1: Self-help strategies to overcome challenges of the pandemic (High confidence). Women developed their own strategies to find solace and support (62). When asked what advice they had for other women in similar situations, advocacy for oneself was frequently reported (58, 61-63, 74, 75, 82, 84). In contrast, another woman regretted not voicing her concerns, “I have naively trusted that the hospital gives me the information I need … Then I realized afterwards that there were many moms who were much angrier than me and said much more; insisted much more… and I simply did not; I regret it a bit” (74). Women reported coping using different strategies, such as being outdoors and active (18, 52, 67), limiting news and access to social media platforms (60, 67, 75, 84), seeking professional help (54, 77), informing themselves about the virus (54, 61), drawing on their own faith and religion (52, 60) and self-reassurance that they were doing fine (52, 56, 64). Many complied with public health restrictions, however there were some women that decided their mental health and physical wellbeing was more of a priority and broke public health restrictions to seek support from family and friends (56, 58, 77). Despite the challenges faced during the pandemic, some women reported high resilience, positive childbirth and postnatal experiences, and feeling empowered by their ability to overcome challenging circumstances (54, 67, 78).
Sub-theme 6.2: Making the most out of the positive encounters (Moderate confidence). The lack of visitors on the postnatal ward and in homes was described by women as “pleasant”, “relaxing” and a “blessing in disguise” as women were able to recover and establish undisrupted routines with their newborns (61, 67, 76). A commonly reported positive outcome of limiting social obligations was the ability to establish successful breastfeeding, one woman said, “I was inundated with visitors with my first child and often could not feed responsively… With my second child, there is none of that pressure and I can really see an enormous difference both is his feeding and in my mental health” (65). Women also described health services as “peaceful”, as there were fewer people in waiting rooms, appointments were quick, social distancing was enforced and use of PPE limited the possibility of transmission (18, 51, 61, 63, 79, 84).
Sub-theme 6.3: Information seeking and desire for more information (Moderate confidence). Women obtained information from official government documents, guidelines released by professional bodies, the news, social media and platforms run by professional academics (58, 59, 66, 76, 84). Reasons to seek information included: to clarify any uncertainties about risk and infection and to keep up to date with COVID-19 guidelines and to be informed about changes to hospital policies (51, 52, 58, 60, 62). Even once women were provided with information, poor communication and follow up left women feeling dissatisfied (67). One woman shared advice about engaging with different information sources - “you can’t just trust them – you’ve got to decipher through what’s true and what’s not… Is that actually having a positive influence on me, and my mental and physical health, or not? And if it’s a no, well why am I engaging in this?” (84).