Women’s Experiences and Perceptions of Anxiety and Stress During The Perinatal Period: A Qualitative Evidence Synthesis


 Background. The perinatal period, from pregnancy to the first year postpartum, is a transitional period that can result in anxiety and stress for some women. Perinatal anxiety and stress can adversely impact the physical and psychological health of women and children. Understanding women’s lived experiences of perinatal anxiety and stress is essential to better support women. The aim of this qualitative evidence synthesis was to examine women’s experiences and perceptions of, and barriers and facilitators to coping with, perinatal anxiety and stress.Methods. Databases CINAHL, EMBASE, MEDLINE, PsycINFO and Maternity and Infant Care were searched from inception to June 2020. Eligible studies included women who were pregnant or up to one year postpartum and examined women’s experiences of anxiety and/or stress during the perinatal period. Data were synthesised using thematic synthesis.Results. Of 20,318 identified articles, 13 studies met inclusion criteria and were included in this review. Five key themes emerged: Social support, women’s experiences of healthcare, social norms and expectations, factors that impact on coping and mother and baby’s health.Limitations. Studies were predominantly conducted in high-income countries.Conclusion. This review provided a comprehensive synthesis of perinatal anxiety and stress. Findings indicate that increased support for perinatal mental health in antenatal and postpartum care is needed. Addressing unrealistic expectations and conceptualisations of motherhood is also important to better support women. Enhancing women’s social support networks and provision of clear and consistent information are also essential to support women and minimise stress and anxiety in the perinatal period.


Background
The perinatal period, de ned here as the period from pregnancy to the rst year postpartum, is a time of transition, including profound changes that can lead to anxiety and stress for some women (Matvienko-Sikar et al. 2020;Rallis et al. 2014). Perinatal anxiety and stress are highly correlated through distinct constructs, that can result from low material resources, poor social support (Vijayaselvi et al. 2015), work/family responsibilities (Schetter & Tanner 2012), and pregnancy complications (Bayrampour et al. 2018). Perinatal anxiety affects approximately 17% of women (Fairbrother et al. 2016); while up to 84% of women experience perinatal stress (Woods et al. 2010). Perinatal anxiety and stress can negatively impact women and children's health (Matvienko-Sikar et al. 2020; perinatal anxiety and stress are associated with increased risk of preeclampsia, miscarriage, low infant birth weight, and preterm delivery (Fairbrother et al. 2016;Deklava et al. 2015). Perinatal anxiety and/or stress are also associated with maternal behaviours such as alcohol consumption (Westerneng et al. 2017), breastfeeding (Doulougeri, Panagopoulou & Montgomery 2013), and smoking (Rodriguez, Bohlin & Lindmark 2000). Adverse child outcomes include increased risk of poor cardiovascular health (Plana-Ripoll et al. 2016), obesity (Tate et al. 2015), self-regulation and neurodevelopmental di culties (Van den Bergh et al. 2005).
Given the adverse consequences perinatal anxiety and stress has for maternal and child outcomes, supporting women during this period is essential. Effects of interventions designed to target anxiety and/or stress during the perinatal period are inconsistent however (Taylor, Cavanagh, & Strauss 2016;Matvienko-Sikar et al. 2016;Marc et al. 2011); this inconsistency, coupled with the multiple potential sources of perinatal anxiety and stress, highlights the need to better understand women's experiences of perinatal anxiety and stress (Staneva et al. 2015). Research on anxiety and stress in the perinatal period has been largely quantitative to date however, with limited qualitative research exploring women's lived experiences of perinatal anxiety and stress (Clauson 1996;Fallon et al. 2016). Understanding women's lived experiences of anxiety and stress is essential to inform the development and delivery of effective interventions to help women cope with perinatal anxiety and/or stress (Staneva et al. 2015). To date, one qualitative evidence synthesis (QES) of women's experience of psychological distress has been conducted (Staneva et al. 2015). This review focused on pregnancy only, thus missing the longitudinal nature of anxiety and stress during the transitional perinatal period.
The aim of this QES was to comprehensively explore women's lived experiences and perceptions of anxiety and stress across the perinatal period and to examine coping strategies for perinatal anxiety and stress.

Methods
The review protocol was registered on the PROSPERO registry (CRD42020193757). The PRISMA and ENTREQ statements guided the review conduct and reporting (Moher et al. 2009;Tong et al. 2012).

Criteria for considering studies for this review
Types of studies Studies utilising qualitative data collection and analysis methods were included. Studies utilising mixed methods were only included if the qualitative data collection and analysis were explicitly described, and ndings and interpretations were provided at a su cient depth. There were no restrictions based on language.

Search methods
The following electronic databases were searched in July 2020: CINAHL, EMBASE, MEDLINE, PsycINFO and Maternity and Infant Care (See Table 1 for search terms used).

Selection of studies
Titles and abstract screening, and full text screening were conducted in duplicate (blinded); any discrepancies were resolved by consensus discussion. Data was extracted using a standardised data collection form (See Supplementary le 1).

Assessment of methodological limitations
The critical appraisal skills programme (CASP) was used to assess methodological limitations of individual studies. One reviewer (blinded) conducted assessment; half of all appraisals were checked by a second reviewer (blinded), with full agreement.

Data synthesis
The RETREAT criteria (Review question, Epistemology, Time/Timeframe, Resources, Expertise, Audience & Purpose, Type of Data) were used to consider the appropriate synthesis methodology. Thematic synthesis was chosen to allow for a transparent and inductive synthesis of primary studies (Thomas & Harden 2008). Data analysis was managed using QSR NVIVO. Initial line-by-line coding was conducted, with all codes then evaluated to assess consistency of interpretation. Descriptive themes were developed and applied to the review aims and questions; similarities and differences across descriptive themes were evaluated to generate analytic themes (Thomas & Harden 2008). (blinded) independently conducted all stages of synthesis with support from (blinded) and (blinded).

Assessment of con dence in the ndings
The GRADE CERQual (Con dence In The Evidence From Reviews Of Qualitative Research) approach was used to assess the con dence in each nding in terms of adequacy, relevance, coherence and methodological limitations (Lewin et al. 2018). Con dence in all study ndings was assessed by one reviewer (blinded) using the GRADE CERQual approach, with one third of the review ndings crosschecked by (blinded).

Results
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 identi ed (See Table 3 for Summary of themes and subthemes). From the ndings presented here, key review ndings (n = 15) were developed and con dence in these ndings were assessed using GRADE CERQual (See detailed assessments in Supplementary File 3).
Theme one: Social Support A consistent theme in 11 studies was the in uence 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 ( 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' . Women who had similar emotional experiences were seen as sources of reassurance and normalisation, which helped women feel con dent, more tolerant of uncertainty, and less anxious and stressed (Evans, Morrell & Spiby 2017;. 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' . 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' ).
Theme 2: Women's experiences of healthcare The impact of women's experiences of healthcare on perinatal anxiety and stress was identi ed 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 terri ed' . Some women described HCP behaviours as 'offensive' , 'intimidating' , 'dismissive' (Evans, Morrell & Spiby 2017) and 'insu cient' ). Women's existing worries were often exacerbated following interactions with their HCP . 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'' . 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' . 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 rst 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 (

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'   (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' ).
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' . 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 con icting, 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 con icting 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' . 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 t 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' . Stress related to the concept of being a 'good mother' was also tied to women's ability to nancially support themselves and their children; 'I just stress that I can't give her what she needs… I worry a lot about money'.  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 di culties, 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 Ayers et al. 2019;Affonso et al. 1993). Mothers experienced stress juggling responsibilities with a new baby, and many verbalized struggles and di culties 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' . Other women described the role of being a mother as 'rough' , 'di cult but rewarding' (Copeland & Harbaugh 2019),'frustrating' (King Rosario 2016) and 'overwhelming' . Women also expressed lack of con dence 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 ( 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 nd it hard not to get irritable… I know this is not her fault and that she needs comfort but I feel useless' ).

Discussion
Unrealistic social norms and expectations, social support, poor healthcare experiences and concerns about health were identi ed as in uencing experiences of perinatal anxiety and stress. Based on the GRADE CERQUAL approach, assessment of con dence in our ndings is moderate to high due to the high volume of good quality, coherent studies relevant to this review question.
In line with previous research (e.g Lazarus & Rossouw 2015), this review identi ed that socially constructed ideas of motherhood and unrealistic expectations of pregnancy and motherhood can lead to anxiety and stress when women's experience does not meet their expectations (Choi et al. 2005). This review also found that most mothers reported concerns related to adjusting to the role of becoming a mother, either for the rst time or in the context of multiple children. Across studies, women felt overwhelmed by challenges of changing roles and responsibilities, and di culties of, balancing competing demands of motherhood and self-care.
The nding of a perceived overabundance of information available could increase anxiety by shifting the focus to women's responsibility to educate themselves to get it right (Haslam, Lawrence, & Haefeli 2003). Lack of access to realistic and unbiased information about pregnancy and motherhood also resulted in differences between expectations and reality which, as discussed, contributes to perinatal anxiety and stress. Prioritisation of women's mental health, including informing women that is it not unusual to feel overwhelmed is therefore critical.
Social support during the perinatal period was, unsurprisingly, identi ed as important for in uencing women's feelings of anxiety and stress. In this review, women felt dissatis ed with the level of support from their signi cant other which is consistent with previous work (Kroelinger & Oths 2000). Male partners also experience distress during the perinatal period, potentially impacting their ability to support their partner (Darwin et al. 2017). Supporting paternal perinatal mental health therefore has bene ts for men and provides opportunities to maximise effective support for mothers (Darwin et al. 2017). A strong desire to talk and engage with peers about aspects of pregnancy and motherhood to help cope with feelings of anxiety and stress was also identi ed in this review. This is in line with suggestions that observing that other women experience similar feelings is critical to reducing stigma associated with perinatal mental illnesses (Whit eld 2010). Moreover, our ndings revealed that the family was both a source of support and a major source of stress for women, con rming previous ndings (Raman et al. 2014). Generally, women felt less supported in the postpartum period than during pregnancy in terms of health care support. This re ects previous ndings that inattention, poor care from HCPs and inadequate hospital facilities are particularly problematic (Bhavnani & Newburn 2010;Brown, Davey & Bruinsma 2005). Review ndings also indicated that women's negative experiences of the healthcare system were related to poor perceived quality of services available, suggesting a need for greater investment in resources available in antenatal and postnatal care. Increasing investment in antenatal and postnatal resources is di cult to achieve however (Busse, van Ginneken & Wörz 2011).
In addition to interpersonal and structural supports, supporting women to engage in effective coping strategies is important for perinatal anxiety and stress (Dunn et al. 2012). Similarly, to previous research (Mann et al. 2010 Thomas et al), engaging with faith and/or talking to others were identi ed as strategies women already use to reduce anxiety and stress. The nding that some women comfort eat to cope with perinatal stress may re ect a negative coping mechanism because overconsumption of food during pregnancy increases the risk of excessive weight gain and gestational diabetes (Vieten et al. 2018).Women's perceptions of their infants as susceptible to compromised health was also identi ed as a source of anxiety and stress in this review, which is in line with previous ndings highlighting associations between fear of the unknown during pregnancy and labour and anxiety and stress (Haines et al. 2012;Melender & Lauri 1999). Women also reported a range of post-childbirth complications and described anxiety and stress related to their health concerns. This is important given that potential bidirection relationships between perinatal mental health and health status have received little research, policy, and clinical attention (Thomas et al. 2014). Greater consideration of maternal and infant health impacts on maternal perinatal mental health in future research and practice is therefore needed.

Strengths and Limitations
This review used a comprehensive literature search strategy to maximise the identi cation of relevant articles and used of the GRADE CERQual to provide overall levels of con dence for each of the review ndings. However nearly all included studies were conducted in high income countries and cultural differences in experiences of anxiety and stress may not therefore have been captured despite the inclusion of papers in any cultural setting (Fleuriet & Sunil 2014). Despite the predominant focus on developed countries, the primary studies in this review included diverse ethnic and socio-economic groups, enhancing the generalisability of our ndings.

Conclusion
This review highlights that women experience perinatal anxiety and stress due to inadequate social support, poor healthcare experiences, unrealistic social norms and expectations, and health related concerns. There is a need for greater focus on perinatal anxiety and stress in research and practice. At a structural level, supporting HCPs to support women's mental health (i.e. through appropriate training) is essential. At the societal level, addressing socially constructed ideas of motherhood that contribute to unrealistic expectations, is an important step towards better supporting women. Finally, enhancing women's social support networks and provision of clear, consistent information are essential to support women and minimise anxiety and stress in the perinatal period.