Table 2. Framework of themes emerging from the data.

Descriptive theme (Review finding)	Studies contributing to the review finding	CERQual grading	Supporting data	Analytical theme
Value feelings of overwhelming joy and happiness–The birth of a baby can generate feelings of great happiness and joy and, for primiparous women in particular, unexpected sensations of overwhelming love (rarely or never experienced before).	7 studies–[26], [27], [33], [34], [41], [42], [47]	Low	‘Being a mother is wonderful so far. I think it will be really, really good. If I had known before, I would already have had a baby. It’s been really good, I am very happy. It is so good! There is nothing negative about it.’ [34]	Riding the emotional rapids
Coping with periods of low mood, depression and loneliness–For some mothers the postnatal period is permeated with feelings of isolation and loneliness sometimes coupled with a sense of loss for their previous pre-natal self. Such emotions sometimes alternate with feelings of joy and love leaving them feeling conflicted. Some mothers also experience a loss of control and feelings of guilt for not being a "good mother".	11 studies–[25], [26], [28], [32], [33], [34], [37], [42], [46], [47], [53]	Moderate	‘One thing that is hard to understand, one thing you’re not prepared for is the feeling of loneliness. I had this idea about us becoming a family, more than me becoming a mother, but then he had to work a lot, and the hours felt really long, and I felt very alone. I remember thinking, here I am, the baby is crying, it’s dark outside, and there is actually no-one who really understand what I’m going through.’ [32]
Anxiety and fear about new responsibilities–For some mothers, the responsibility of taking care of a baby is experienced as overwhelming or shocking. Mothers describe anxiety and worry about their baby's safety and wellbeing, and about aspects of baby care (e.g. feeding, whether to use dummies/pacifiers, how to soothe infant crying). Perceived social expectations to be a "good mother" and assumptions that other women are more competent mothers can generate feelings of anxiety.	11 studies–[30], [31], [34], [36], [37], [45], [46], [47], [53], [57], [59]	Moderate	I wish there was a little switch. You suddenly realise there’s no going back. It’s not like a CD. If you don’t like that you can take it back. It’s now. This is for real. And that’s the worst part of the first couple of weeks. It’s like, ‘Oh my God, I’m now responsible. I can’t take it back. I can’t drop it off somewhere.’ It’s just that realisation. [57]
Coping with feelings of acute fatigue and exhaustion–Women experience extreme tiredness and exhaustion, often compounded by a lack of sleep which can impact on many aspects of life. This can leave women feeling stressed and unable to focus or retain information (including information and advice given by health professionals).	13 studies–[26], [29], [34], [35], [37], [38], [40], [42], [44], [47], [49], [53], [55]	Moderate	‘It's not just physical tiredness. It's also emotional tiredness. It's the sleep that I am missing but it's also this new situation, all these impressive events . . . one has to adapt to this new situation and overcome the experience of the delivery. And one has to get to know the child.’ [35]
Adjusting to new routines within local, cultural context–Women describe challenges in establishing and/or adjusting to new routines and letting go of old ones. There may be competing demands e.g. between new routines centred around the baby and societal structures (baby-unfriendly society) or economic considerations (need to go back to work). Some women have cultural beliefs and practices pertaining to the postnatal period that they value and these may conflict with advice from healthcare providers.	16 studies—[26], [28], [33], [34] [36], [37], [40], [41], [45], [47], [48], [49], [52], [56], [57], [58]	High	“I was alone with my baby, in such a chaotic situation. I found myself wasting a lot of time. I just wandered around at home and couldn’t do anything while all the house chores were left undone.” [33]	Dancing around the baby–social and relational adaptation
Prioritizing the needs of the baby–Women tend to prioritize the needs of their baby above all else, sometimes at the expense of intimate concerns like their close relationships and their own self-care needs but also in relation to practical activities like domestic chores and household maintenance. Some experienced mothers were aware of this focus (after previous births) and actively decided not to put the baby's care needs above everything else.	9 studies—[35], [37], [38], [40], [42], [48], [49], [50], [58]	Low	‘I just realize that his needs are more important than mine and I’ll find another time to sleep. It’s just kind of an understanding of what’ s more important is probably the way I cope with it’ [49]
Recognition of personal growth–Women experience positive changes in their wellbeing ranging from an increased confidence and competence in their ability to mother to previously unacknowledged feelings of responsibility, calmness and perseverance, particularly amongst first-time mothers. Sometimes women are aware of an increase in their own sense of self-worth and express this in terms of being less selfish, more compassionate and more valued as a woman or as part of a family.	11 studies—[27], [32], [33], [34], [41], [42], [47], [49], [50], [55], [57]	Moderate	‘So I am a person who has changed a lot. I was stressed out and jumpy but I became a lot calmer after I had her. She has calmed me down.’ [50]
Challenges of breastfeeding–Women value breastfeeding and want support to be available. However, they often find the practical reality of breastfeeding at odds with their expectations and experience anxiety, frustration and sometimes pain in their attempts to establish the practice.	8 studies–[30], [34], [36], [38], [44], [46], [48], [54]	Moderate	‘With the caesarean section, the milk was cut off [. . .], I had a terrible time not breastfeeding because I wanted to breastfeed, then you realize that well, it has come like this [. . .]. But at that moment [. . .] the world comes to you [. . .] and you say "why cannot I breastfeed?”‘ [44]
Dealing with changes in sexual behaviour–Women have to deal with a variety of different sex related issues in the postnatal period and would like more information from health professionals, particularly about when to resume sex and access contraceptive resources. Women may experience changes in their sex drive (positive or negative), painful sex, unsatisfactory sex or feel reluctant to have sex at all in case they become pregnant again. Some women feel embarrassed or ashamed about having sex in the same room as the baby, feel anxious about satisfying the needs of their partner or feel too exhausted for sex.	8 studies–[26], [29], [40], [41], [48], [50], [51], [52]	Low	‘When it [finally] happened, yeah [I had interest]. But not so much in the beginning. Like, no that’s the last thing … Everything is closed for business. Off limits. I gotta heal man’. [29]
Redefining identity and relationships–Some women find the transition to motherhood difficult and feel insecure with the new identity. They struggle with the loss of the 'familiar self' and their desire to spend some time alone time and this can cause tension in their relationships with partners or parents	9 studies—[26], [27], [33], [41], [43], [51], [56], [58], [59]	Moderate	‘‘He thinks that you are not listening to him; he says ‘when I talk you don’t listen. Since you had that child, you have been ignoring me, it’s only about that child, nothing else.’ I cannot help him; I don’t know how I can do that! There is really no way to help him because most of the time I am with my child’ [41]
Developing a relationship with the baby–Women want to form an immediate relationship with their baby and try to achieve this by lots of contact and stimulation (e.g. gazing, hugging, kissing and singing) sometimes finding it difficult to leave the baby alone. Recognizing, understanding and responding to different crying cues is particularly important for first time mothers as a way of facilitating this relationship. Women who deliver their baby via caesarean section appreciate immediate skin to skin contact as a way of initiating a relationship with their baby.	9 studies—[34], [35], [36], [37], [47], [48], [54], [55], [58]	Moderate	‘I readily realize when she just wants to be occupied or doesn't want to be alone, when she is bored or feels really bored, when she doesn't want to be by herself, or if she has really had enough. I realize if she just wants some occupation, or when she is frustrated because something does not go her way. Just, when she is hungry, when she cannot sleep or when she just wants to cry.’ [36]
Importance of practical and emotional support from partner, family and elders–Most women greatly value the multiple levels of support they receive from their partner, parents and, in certain contexts, community elders. Women appreciate practical help with the baby's care needs and household tasks as well as emotional support to help them deal with the myriad of emotions that arise during the postnatal period. Some women occasionally report negative experiences (e.g. lack of breastfeeding support, interference or undermining behaviour).	18 studies–[26], [27], [28], [30], [31], [32], [33], [36], [37], [38], [41], [47], [49], [53], [54], [55], [58], [59]	High	‘My mum knows what my favourite foods are and what I need for doing the month. She cooks meals at home and brings them to me. She reminds me to pay more attention to food now because this is vital for women who have given birth. [58]	It takes a community to raise a mother
Value practical advice, information and support from health professionals–Women value support, reassurance and information from health professionals especially around baby development, hygiene, vaccinations, breastfeeding, nutrition, and practical caregiving tips. Some women would like to be given more information in the early postnatal phase (prior to discharge), whilst others would prefer to be given information during the antenatal phase.	16 studies–[26], [27], [30], [31], [34], [35], [37], [39], [41], [44], [46], [48], [49], [53], [54], [57]	High	“I think the nurses were really helpful, taking the time to stay with you and showing you how, or trying to find different techniques” [31]
Value, information, support and reassurance from peers and peer groups–Women value the emotional support, reassurance and informational resources they acquire from meeting with other mothers (especially first-time mothers) in formal or informal peer support groups. They appreciate the non-hierarchical nature of these groups and the normalization of perceived insecurities about being a "good mother". In some contexts, women want peer support but are unable to attend regular meetings (costs) whilst others advocate a "peer support DVD" in which first-time parents would recount their experiences in an informal, authentic manner.	15 studies–[26], [27], [28], [32], [33], [38], [41], [43], [44], [45], [46], [52], [53], [57], [59]	High	‘Yeah, we all get together and sort of lash things out and talk, babies . . .and you know everybody learns from their own experiences and if we all can sort of contribute, that's really good.’ [27]
Importance of online sources of support and information–Some women (especially first-time mums) find benefit in online support groups and web-based sources of information and some wanted an online guide to address common postnatal concerns. However, others found too much online searching added to their levels of stress and anxiety.	4 studies–[38], [44], [45], [53]	Low	‘Reading and looking for advice online was good in that it was on my own time, often in the middle of night while nursing and I could take what I wanted and leave what I didn’t in terms of advice, I wasn’t going to offend anyone’. [45]
Coping with labour and birth induced trauma–Women feel unprepared for the physical and psychological effects of labour & birth induced trauma and the impact this has on their ability to provide appropriate care for their baby (and other children). Women experience feelings of fear and anxiety associated with the long-term management of caesarean section wounds, perineal damage, bladder problems, vaginal bleeding and general discomfort. Some women would like more information from health professionals about how to soothe/treat physical injuries and some would welcome the opportunity to discuss their labour and birth with a healthcare provider.	15 studies–[28], [31], [32], [38], [39], [40], [43], [47], [48], [49], [50], [52], [56], [59], [60]	High	‘Was this expected? Bizarrely no! Thinking about it now I cannot understand what I thought it would feel like. Obviously I was under no misapprehension that actually giving birth would be painful although how much I had no idea. I had never given it any thought to how I would feel afterwards.’ [56]	Re-forming the birthing body
Coming to terms with changes in body image–Some women struggle with feelings of shame, embarrassment and insecurity about their post-birth body image. Unrealistic expectations of how quickly they can get 'back into shape' sometimes leads to frustration and changes in their sexual identity, e.g. viewing their breasts in a non-sexual way or experiencing a reduction in their sex drive, may also cause concerns.	6 studies—[25], [29], [40], [50], [52], [56]	Low	‘Now I look at my stomach and think ‘well, now she’s not in there it’s not so good’ … you have a baby and then you’re left with a big stomach and then you’ve got to try to get rid of it.’ [25]
Value continuity of care–Women want to build a relationship with health professionals during the postnatal period and may become frustrated if continuity of care isn't available	5 studies–[27], [30], [37], [39], [42]	Low	‘ . . .in those two weeks you've built up such a relationship. I felt comfortable and . . . a few weeks is not long enough for breastfeeding and all that . . .When she left I felt very alone. . . . Because she takes all my notes and I didn't have any contact numbers for the health visitor. What do I do in the next week?. . . . A relationship with someone, it's trust isn't it?’ [27]	Putting the mother into postnatal care
Need for consistent information–Women want consistent information from health professionals (e.g. around breastfeeding, care practices, nutrition and clinical or informal observations) and express frustration when information is conflicting or inconsistent	7 studies–[26], [30], [37], [45], [46], [48], [54]	Moderate	‘one person will tell you give your baby a certain type of food…another one will tell you not that one…another one will tell you apply something to your baby…now all this information…which one do you follow?’ [48]
Value woman-centred care–Women want to feel 'cared for' during the immediate postnatal period and would like personal preferences to be acknowledged by health professionals. These may include not feeling pressure to breastfeed, recognizing and acting on maternal intuition, involving partners in caregiving practices and being more flexible in meeting women's needs. More tailored support for mothers of pre-term babies and more information on how to cope after a caesarean section are also important considerations for some women.	10 studies–[26], [27], [30], [32], [35], [37], [39], [45], [48], [58]	Moderate	“I was always so grateful when she was ringing the bell. Even if she was just observing and then telling me how good my child and I were doing. Or giving me some advice or helping me understand my child who did cry a lot. This was so important to me and I still benefit from this now." [37]
Need for greater emphasis on mothers' wellbeing–Although women recognize and appreciate the attention on the postnatal care needs of their baby they sometimes feel their own emotional and psychosocial needs are overlooked or neglected by health professionals.	10 studies–[28], [31], [32], [38], [39], [42], [46], [53], [54], [60]	High	‘When I went to see [the doctor] at the six weeks check-up, it seemed to be almost more about her than me!’ [38]
Organizational systems hinder effective care–Women may experience poor or inadequate care in the immediate post-partum period which may be exacerbated by organizational limitations (shared rooms, lack of privacy, poor hospital condition) and disruptive hospital routines (ward rounds, visiting hours). Perceived staff shortages leads to delays in calls for support and assistance and some women feel they are discharged from hospital too early. Women value postnatal home visits but occasionally feel they don't receive enough and find health professionals difficult to access when they are needed.	9 studies–[26], [30], [31], [35], [38], [39], [41], [47], [60]	Moderate	‘I was uncomfortable, I didn't sleep, the girl next me had a baby that was crying all night.’ [30]