Thirteen studies met inclusion criteria (see Fig. 1). Characteristics of included studies are summarised in Table 2. One study was assessed as having no methodological limitations and 12 studies were assessed as having minor methodological limitations. See Supplementary File 2 for full details of the assessment of methodological limitations for each study.
Findings
Five themes, with 14 subthemes, of women’s experiences of perinatal anxiety and stress were identified (See Table 3 for Summary of themes and subthemes). From the findings presented here, key review findings (n = 15) were developed and confidence in these findings were assessed using GRADE CERQual (See detailed assessments in Supplementary File 3).
Theme one: Social Support
A consistent theme in 11 studies was the influence of social support on anxiety and stress during both pregnancy and the postpartum period (Table 3). Overall, women received different types of social support from peers, partners and families, including emotional, physical and informational support.
Partner support. In six studies, women discussed a lack of support from their partners and expressed a need for greater support (Table 3). Lack of partner support and poor communication was recognised as a key stressor by pregnant women: ‘During that time (pregnancy) my husband was not around, he had travelled… and I needed him’ (King Rosario 2016). Women were often upset with their partners for not being present, helpful and understanding of their concerns (Chang et al. 2015; Copeland & Harbaugh 2019; Atif et al. 2019; Ayers et al. 2019). One woman reported how stressful and difficult it was being a mother without adequate support from her partner: ‘At first it was hard because my boyfriend was scared of her and I didn’t have a lot of help. I had to do it all on my own’ (Copeland & Harbaugh 2019).
Peer support. In three studies, women discussed the importance of peer support in reducing feelings of distress and anxiety (Table 3). Social support from other women who were or had been pregnant themselves was described as particularly helpful ‘I think the biggest support and the biggest help people get is other mums that are going through exactly the same thing’ (Harrison, Moore & Lazard 2020). Women who had similar emotional experiences were seen as sources of reassurance and normalisation, which helped women feel confident, more tolerant of uncertainty, and less anxious and stressed (Evans, Morrell & Spiby 2017; Harrison, Moore & Lazard 2020).
Family support. Family was another important source of support for women discussed by women in eight studies (Table 3). One woman described her ‘up and down relationship’ with her own mother and outlined: ‘My mom, she drives me up a wall but she’s my rock’. (Copeland & Harbaugh 2019). Conversely, a source of stress for pregnant women was being told what to do by their family; ‘I think what stresses me out is when people try to tell you what you can and can’t do. You know ‘you don’t need to eat that’ (Chang et al. 2015). Similarly, women discussed stress related to their family giving unsolicited advice, as outlined by the authors of one study: ‘they are told that they should embrace traditional philosophy while they are pregnant and during parenting’ (Affonso et al. 1993).
Theme 2: Women’s experiences of healthcare
The impact of women’s experiences of healthcare on perinatal anxiety and stress was identified in nine studies (Table 3).
Perceived poor care from healthcare professionals (HCPs). Poor care from HCPs was discussed as a major contributor to anxiety and stress by pregnant women and mothers. Women consistently reported dissatisfaction with the level of HCP support provided as expressed by one woman following her birthing experience: ’I was hyperventilating and although I’d had oxygen mask in theatre... I was given no such support in my after care. I felt neglected and terrified’ (Ayers et al. 2019). Some women described HCP behaviours as ‘offensive’ (Affonso et al. 1993), ‘intimidating’ (Affonso et al. 1993), ‘dismissive’ (Evans, Morrell & Spiby 2017) and ‘insufficient’ (Razurel et al. 2011). Women’s existing worries were often exacerbated following interactions with their HCP (Ayers et al. 2019; King Rosario 2016). For example, one woman felt anxious following insensitive treatment by a HCP: ‘‘He then went to say: ‘I have two big problems with you – your age and the fact it’s an IVF pregnancy…the way he said it was awful’’ (Ayers et al. 2019). Women also reported feeling anxious when HCPs would not provide them with adequate information, or they felt information was being withheld (King Rosario 2016, Harrison, Moore and Lazard 2020): ‘It’s almost like they treat you a bit like a child... like you can’t hear anything scary because you won’t be able to cope with it’ (Harrison, Moore & Lazard 2020). While women’s experience of care from HCPs was largely negative, women reported positive relationships with their HCPs in one study using words such as ‘supportive’ and ‘helpful’ to describe their nurses (King Rosario 2016).
Access to healthcare services. In four studies, women expressed frustration and dissatisfaction with the quality of healthcare services available during pregnancy and postpartum (Table 3). One mother expressed dissatisfaction with the healthcare services available in public hospitals: ‘In my previous delivery, I went to a public hospital and tolerated bad circumstances... I don’t want my previous experience be repeated’ (Arfaie et al. 2017). Similarly, in one study, although women mentioned that they had access to a wide range of services during pregnancy, they felt the quality of services available was a major problem (King Rosario 2016).
Childbirth experience. Women in four studies described the experience of childbirth as anxiety provoking (Table 3). For women, particularly those experiencing a first pregnancy, perceptions of childbirth were characterised by uncertainty and women felt they could not truly establish a sense of certainty or control until their baby was born (Arfaie et al. 2017; Atif et al. 2019; Evans, Morrell & Spiby 2017). One woman voiced her fears of arriving late to the hospital: 'I am permanently anxious and ask myself what will happen if I don’t arrive at hospital on time? What may occur if I arrive late and my amniotic sac ruptures’ (Arfaie et al. 2017).
Theme 3: Factors that impact on coping
This theme examines some of the factors and behaviours that may facilitate or hinder women’s coping during pregnancy and the postpartum period.
Behavioural strategies. Women used a range of behavioural strategies to cope with their anxiety and stress, including comfort eating and talking. In one study, women discussed engaging in comfort eating when stressed; ’I eat more when my kids are stressing me out. I go straight to the kitchen’ (Chang et al. 2015). Conversely, women in four studies found talking about their anxiety and stress helpful (Atif et al. 2019; Bloom, Bullock & Parsons 2012; Chang et al. 2015; Evans, Morrell & Spiby 2017). One woman spoke about the importance of talking to effectively manage her stress: ‘I have to talk about it. If I don’t say nothin’ about it, I’m just going to let it all build up ... as long as you have someone to talk to, it’s not as hard to cope with’ (Bloom, Bullock & Parsons 2012). Some women struggled to talk about their anxiety and stress, which often led to feelings of loneliness and isolation. As the authors of one study explained: ‘They keep their personal stress to themselves and feel they have no one to tell who will understand their dilemmas’ (Affonso et al. 1993).
Faith. Pregnant women in three studies relied on faith as a method of coping with their anxiety and stress (Table 3); ‘All I do is to separate myself from everyone and offer my prayers to God. This makes me stay relaxed and calm’ (Atif et al. 2019). One woman, anxious because she felt her stomach was not growing enough to have a healthy baby, discussed turning to prayers as a method of coping: ‘Honestly, my other help was from prayers only. When I pray I get peace of mind. I stopped worrying’ (King Rosario 2016).
Information. In two studies (Table 3), women reported anxiety and stress arising from the conflicting, confusing and inconsistent information they had been exposed to throughout pregnancy and the postpartum period. Mothers reported feeling anxious when their children did not conform to guidelines; ‘(milestones) put pressure on you…why is my baby not doing this? And then you start to Google if he doesn’t sit by this month what’s wrong with him?’ (Harrison, Moore & Lazard 2020). Receiving conflicting advice also made women feel they did not know who to trust; ‘The midwife said one thing, the doctor said another, the two antenatal classes (I went to) gave exact opposite advice... I don’t know who to listen to’ (Harrison, Moore & Lazard 2020). One woman expressed the need for more readily available information to help manage her anxiety: ‘Just like more information about what happens after you have the baby… like a little factsheet because I think that’s why you get the anxiety isn’t it’ (Harrison, Moore & Lazard 2020).
Theme 4: Social Norms and Expectations
In 10 studies (Table 3), women discussed anxiety and stress due to feeling pressure to adhere to perceived social expectations and ideas about pregnancy and early motherhood.
Being a ‘good mother’. In four studies (Table 3), women spoke about feeling judged, particularly in terms of their ability to be a ‘good mother,’ if their experiences did not fit with perceived social expectations. Women discussed feeling expected to embody unrealistic ideals of motherhood that did not recognise the realities of pregnancy and motherhood. For example, ‘I feel... like a failure… the fact that I could not breast feed raised the question in my mind about my ability to be a mother’ (Razurel et al. 2011). Stress related to the concept of being a ‘good mother’ was also tied to women’s ability to financially support themselves and their children; ‘I just stress that I can’t give her what she needs… I worry a lot about money’. (Razurel et al. 2011)
Mental health stigma. Norms and the stigma associated with perinatal mental illnesses were a source of anxiety and stress, and a barrier to seeking help in four studies (Table 3). Women felt embarrassed about their mental health difficulties, often hiding their symptoms due to the fear that they would be perceived as a ‘bad mother’ (Harrison, Moore & Lazard 2020). For example: ‘…being a “good mother” is not compatible with mental illness; and having anxiety must make you a “bad mother” (Harrison, Moore & Lazard 2020). One woman described social pressures to feel and act a certain way; ‘…about your friends giving the perception that everything’s wonderful, you almost feel like you have to be’ (Evans, Morrell & Spiby 2017).
Role changes and responsibilities. Adjustment to and assimilation of a motherhood identity was a source of anxiety and stress for women in nine studies (Table 3). Women in three studies felt stressed about adjusting to life with a baby and felt over-burdened by roles and responsibilities (Atif et al. 2019; Ayers et al. 2019; Affonso et al. 1993). Mothers experienced stress juggling responsibilities with a new baby, and many verbalized struggles and difficulties with time management; for example: ‘I feel I am neglecting him [older child] while I am dealing with her [baby]…the overriding factor is guilt’ (Ayers et al. 2019). Other women described the role of being a mother as ‘rough’ (Ayers et al. 2019), ‘difficult but rewarding’ (Copeland & Harbaugh 2019),’frustrating’ (King Rosario 2016) and ‘overwhelming’ (Atif et al. 2019). Women also expressed lack of confidence in their abilities to be a mother; many felt out of their depth and uncertain about their choices and actions (Rowe & Fisher 2015).
Theme 5: Women’s and Baby’s health
The health of both woman and baby was discussed in six studies (Table 3).
Women’s health. Women in three studies experienced health problems in pregnancy and the early postpartum period that led to anxiety and/or distress (Table 3). For instance: ‘I felt bad and I was ill. About my health, after seeing myself very thin since... though it (was) for all my pregnancies but in this one it was severe with a lot of stress’ (King Rosario 2016). Women experienced anxiety because they faced difficulties taking care of their own needs, i.e. self-care (Copeland & Harbaugh 2019; Stevenson et al. 2016; King Rosario 2016). One mother expressed that she did not ‘have time to take care of myself’ (Copeland & Harbaugh 2019). Additionally, many women expressed anxiety over making sure their body was as healthy as possible; ‘Appropriate weight gain: too much, too little, when it happens, etc., eating the right foods, getting the right nutrition’ (Stevenson et al. 2016).
Baby’s Health. Women in four studies felt anxious and stressed about their child’s health in-utero and after childbirth (Table 3). For instance, concerns over the health of their unborn baby included; ‘...an underlying fear that something will happen to the baby. .. I don’t think I’ll relax till he/she is here’ (Stevenson et al. 2016). Older maternal age was also a factor affecting women’s anxiety about the health of their unborn baby; ‘My age is a big factor in the odds of having a baby with a genetic disorder’ (Stevenson et al. 2016). Women also perceived infant health problems as a major source of stress and discussed struggling to cope with their baby’s health problems, leading to feelings of despair and helplessness. For example, ‘My eight week old daughter has colic... for hours she squeals on and off. I find it hard not to get irritable… I know this is not her fault and that she needs comfort but I feel useless’ (Ayers et al. 2019).