Navigating through motherhood in pregnancy and postpartum periods during the COVID‐19 pandemic: A systematic review and qualitative meta‐synthesis

Abstract

Aim

The aim of this work is to critically appraise and synthesize the qualitative studies on the experiences, perspectives, and consequences of pregnant women experiencing motherhood during the COVID‐19 pandemic.

Background

The COVID‐19 pandemic has posed a threat to the health of pregnant women. Such a pandemic disrupted their routine care, as well as normal daily life. However, little is known about their coping strategies to the changes brought by COVID‐19.

Evaluation

A qualitative systematic review was conducted according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist. A meta‐aggregative approach rooted in pragmatism and Husserlian transcendental phenomenology was used to synthesize the findings. Dependability and credibility of both study findings and synthesized findings were appraised by Joanna Briggs Institute (JBI) ConQual process.

Key issues

Key issues include (a) pregnant women experienced changes in routine care, (b) pregnant women used a range of strategies to cope with the consequence of the pandemic, (c) pregnant women struggled to embrace motherhood, and (d) pregnant women received different levels of social support.

Conclusion

Facing challenges caused by the pandemic, pregnant women used a variety of strategies to cope with and adapt to the changes, but sometimes the adaption is limited. Emotional, instrumental, and informational support should be provided to them in an accessible way.

Implications for Nursing Management

As an essential part of policymakers, nursing managers should consider the balance between restriction and the accessibility of maternity care. It is also crucial for them to consider how to provide necessary support in an accessible way.

1. INTRODUCTION

In December 2019, a highly infectious novel coronavirus (SARS‐CoV‐2) hit Wuhan, China, and rapidly spread to the World, leading to a public health crisis worldwide. On 11 March 2020, the World Health Organization (WHO) declared a global pandemic. The Corona Virus Disease 2019 (COVID‐2019) has caused more than 6 million cumulative death as of writing (World Health Organization, 2021).

Pregnancy is a critical time that is full of pleasant experiences and uncertainty simultaneously in the life of most women (Biaggi et al., 2016). In the era of the COVID‐19 pandemic, the tension has intensified. Maternity care has been changed to limit virus transmission (Bradfield et al., 2021; Jardine et al., 2021; Lalor et al., 2021). Much nonessential maternity care was cancelled. Face‐to‐face services programs were substituted with the form of telehealth such as antenatal assessment or antenatal education. Besides, the relatives accompanying labour or birth were strictly limited (Chivers et al., 2020), making the pregnant women have to do medical tests or give birth alone. As a result, some women reported low satisfaction with the decreased quality of care.

The COVID‐19 pandemic has also posed a challenge to the motherhood of pregnant women. Strict restrictions were imposed on maternity care. Limited face‐to‐face engagement with women and the insufficiency of care provided may increase the risk of postpartum depression (Oskovi‐Kaplan et al., 2021; Viaux et al., 2020). Some behaviour that used to bond with babies, such as breastfeeding and accompanying their babies, were disrupted to a different degree due to the restriction policy. The separation or failure of bonding with babies may harm the early parent–child relationship (Bystrova et al., 2009).

Previous studies show that pregnant women have been among the most susceptible groups of people to coronavirus‐related diseases (Robinson & Klein, 2012; Shorey & Chan, 2020). The pandemic caused poor maternal and perinatal outcomes (Chmielewska et al., 2021). Experiencing transition to motherhood during the pandemic may cause an extra mental burden for pregnant women (Matvienko‐Sikar et al., 2020). Pregnant women were reported with a higher level of depression or anxiety compared with the general population during the pandemic (Preis et al., 2020; Saccone et al., 2020; Tomfohr‐Madsen et al., 2021). Many studies proved that emotions such as anxiety or stress could have negative consequences for both pregnant women and the growing foetus, such as preterm delivery, preeclampsia, and low birth weight of babies (Cook et al., 2018; Gentile, 2017; Waters et al., 2014). Thereby, pregnant women also used a variety of coping strategies to tackle the changes brought by the COVID‐19 pandemic correspondingly.

Compared with quantitative studies, qualitative studies can provide richness of evidence to address clinical practice or policy‐related questions (Hannes & Lockwood, 2011). To figure out the lived experience of pregnant women and their coping strategies can help us deepen our understanding of the impacts of the pandemic on pregnant women and their experience of motherhood. Meta‐aggregation allows to generalize synthesized findings to form clinical recommendations for practitioners and policymakers, which is regarded as a process to generate evidence‐based knowledge by the Joanna Briggs Institute (Lockwood et al., 2015). Thus, we used the method of qualitative systematic review from the Joanna Briggs Institute to aggregate qualitative studies focusing on the experience of pregnant women amidst the pandemic to provide evidence‐based knowledge for the midwives and other staff to respond to the pandemic. This qualitative systematic review will also give implications to the policy‐makers or guideline development groups.

1.1. Aim

The aims of this work are to review, critically appraise, and synthesize the qualitative studies on the experiences, perspectives, and consequences of pregnant women experiencing motherhood during the COVID‐19 pandemic.

2. METHODS

2.1. Protocol registration & reporting guidelines

This systematic review protocol was registered with PROSPERO (registering number: CRD42022313590). The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist (Supporting Information S1) was used to report the process and result of synthesis and enhance transparency (Tong et al., 2012).

2.2. Searching strategy

Two researchers and a medical librarian devised a search strategy to identify studies reporting on the relevant experiences of pregnant women in the pandemic. Searches were executed in seven electronic databases: Embase, JBI evidence‐based database, APA PsycINFO (three databases above were searched via OVID), PubMed, CINAHL, Web of Science, and ProQuest databases. The query used both subject headings and keywords for each concept. A separate searching strategy was designed and optimized for each database. Searching terms that we used in databases are as follows: “COVID‐19,” “2019 Novel Coronavirus*,” “2019‐nCoV,” “coronavirus disease 2019,” “SARS‐CoV2,” “novel coronavirus,” “childbearing,” “motherhood,” “maternity,” “maternal,” “pregnanc*,” “birth*,” “labor,” “intrapartum,” “delivery,” “postpartum,” and “puerperal.” Results were limited to journal articles, dissertations, theses written in English, and published before 1 March 2022. Conference proceedings, editorials, commentaries, abstracts only, newsletters, addresses, and research protocols were excluded manually. Reference lists of all selected articles were independently screened to identify additional studies left out in the initial search. Searching strategies in each database are detailed in Supporting Information S2.

2.3. Eligibility criteria

Studies were included if they met all of the following criteria: (1) Used a qualitative research design (e.g., phenomenology, grounded theory, ethnography, or just none‐specific qualitative design) and had qualitative data to support the themes that emerged; (2) focused on the experiences of pregnant women (both primiparous and multiparous pregnant women over the age of 18; focus on the beginning of pregnancy, perinatal period or postpartum period) during any time of the outbreak of the COVID‐19 pandemic; (3) provided synthesized themes or statements with exemplar quotes on pregnant women perceptions, experiences, and self‐reported consequences related to the pregnancy during the pandemic; and (4) were full‐text, peer‐reviewed articles or dissertations or theses published in English.

Studies were excluded if they met one of the following points: (1) Used mixed methods designs whereby qualitative data could not be extracted or the qualitative data is rare; (2) mainly focused on or combined responses from women diagnosed with COVID‐19, making it difficult to elucidate the experience; (3) combined responses of informal caregivers or medical staffs; (4) women with a terminal illness, cancer treatment, congenital intellectual disability, severe mental disorder, as these conditions have different physiologic mechanisms of a normal pregnancy; (5) those studies whose participants were pregnant women but the theme of study have little to do with pregnancy, labor, or taking care of babies in the postpartum period such as injection of COVID‐19 vaccination among pregnant women; (6) studies mainly focused on minority groups (i.e., ethnic minority) because minority groups may be the disadvantaged groups facing social inequity which will generate a unique experience.

2.4. Study selection

Study selection was performed by applying the eligibility criteria in stages following established guidelines for systematic reviews (Lefebvre et al., 2019). Results of database searches were first imported into the reference management software program Endnote X9.3.3. After the removal of duplicates, titles and abstracts were read for the assessment of eligibility. Then full‐text documents were screened to identify the studies that best fulfilled the selection criteria. At each stage of study screening, a minimum of two trained reviewers (JY, XY, ZZ, DF) independently read and evaluated the eligibility. Any discrepancies were discussed to reach a consensus by the research team. All references to the included articles were searched for additional potentially relevant studies (see Figure 1).

FIGURE 1.

Flow diagram for study selection

2.5. Quality appraisal of eligible studies

A minimum of two trained reviewers (XT, JY, XY) independently evaluated the methodological rigour of the included literature following the Checklist for Qualitative Research (Critical Appraisal tools for use in JBI Systematic Reviews) (Lockwood et al., 2015). This checklist consists of 10 items, and each item was evaluated with “yes,” “no,” or “unclear.” When the evaluation results conflicted, the third researcher (CJ), with expertise in qualitative research, decided finally. A study was included if the item of it achieved a minimum of 60% “yes” to guarantee the study showed acceptable quality. Studies were considered to possess acceptable quality if 60% of items were answered “yes,” to possess good quality if 70–90% of items were answered “yes,” and to maintain high quality if 100% of items were answered “yes” (Talley et al., 2021).

2.6. Data extraction and synthesis

The JBI meta‐aggregation approach was used to extract and synthesize the data (Lockwood et al., 2015). Meta‐aggregation was grounded in the philosophical traditions of pragmatism and Husserlian transcendental phenomenology. Transcendental phenomenology aimed to develop unbiased knowledge rather than being influenced by other factors. This approach accurately and reliably presented the findings by the original authors instead of re‐interpreting studies. Of all the methodologies available for qualitative study synthesis, meta‐aggregation is the most transparent and widely accepted for constructing high‐quality systematic reviews of qualitative studies (Lockwood et al., 2015).

This approach entailed extracting findings from each study and then categorizing them through their similarity in meaning. Then, we subjected these categories to further synthesis to generate more comprehensive findings called synthesized findings. A finding is defined as a verbatim extract of the author's analytical interpretation of the results or data. As a finding was extracted, the level of “plausibility” should be allocated based on the reviewers' assessment of the degree of fit, or congruency between the data and the accompanying exemplar quote. There are three levels of plausibility. A finding was rated as “unequivocal” if the congruence of the finding and the illustration accompanied was beyond a reasonable doubt; as “credible” if a clear association between them was lacking; as “unsupported” if the data did not support the findings. Only unequivocal and credible findings were included. Not supported findings were not presented in the synthesis or the results (Lockwood et al., 2015).

2.7. Quality appraisal of each synthesized finding

The JBI ConQual process was used to appraise the dependability and credibility of each synthesized finding (Munn et al., 2014). Dependability was appraised by the five items from JBI critical appraisal checklist: Items 2, 3, 4, 6, and 7. Dependability was rated high if 4–5 dependability items were responded with “yes,” moderate if two to three items were responded with “yes,” and low if 0–1 items were answered with “yes.” Credibility was appraised based on the result of the overall findings' levels of plausibility. The ConQual Score would be rated as high, moderate, low, or very low, depending on the downgrading factors of both dependability and credibility dimensions (Munn et al., 2014).

3. RESULTS

3.1. Searching results

After adjusting for duplicates, 8105 unique references were retrieved. A total of 7927 references were excluded by reading the title and abstract. One hundred seventy‐eight documents were screened by reading the full text, and 24 articles finally met the eligibility criteria. The detailed process of different phases of searching and screening is presented in Figure 1. The complete reference list of included studies can be found in Supporting Information S3.

3.2. Study characteristics

The characteristics of included studies are presented in Table 1. A variety of qualitative designs were used, including phenomenology (n = 9, 37.5%), qualitative design without a specific approach (n = 9, 37.5%), descriptive qualitative design (n = 5, 20.83%), and qualitative design with a theory (n = 1, 4.17%). All studies collected data using interviews or extraction from online forms. The included studies were conducted in 14 different countries: United States (n = 5), United Kingdom (n = 3), Turkey (n = 3), Canada (n = 2), Australia (n = 2), South Africa (n = 1), Columbia (n = 1), Bosnia and Herzegovina (n = 1), India (n = 1), Sweden (n = 1), Iran (n = 1), Ireland (n = 1), Pakistan (n = 1), and Spain (n = 1). The sample size ranged from 5 to 57 in those interview studies.

TABLE 1.

Characteristics of studies included

Study ID	Country	Aim	Characteristic of participants (sample size, age)	Methodological & sampling approach	Method of data collection and analysis
Anokwuru & Mulaudzi (2022)	South Africa	To present the lived experience of utilization of antenatal services among pregnant women during the covid‐19 pandemic.	12 women 25–36 years	Descriptive phenomenological design; Purposive and snowballing sampling.	In‐depth interviews; Descriptive phenomenology analysis
Aydin & Aktaş (2021)	Turkey	To examine women's pregnancy experiences during the COVID‐19 pandemic.	14 women; 24–39 years;	Descriptive qualitative design; Purposive sampling	Individual interviews; Thematic analysis
Charvat et al. (2021)	Columbia	To explore how women who were pregnant during the COVID‐19 pandemic communicatively made sense of their experience in light of their received social support.	21 women 29.14 ± 3.20 years	Qualitative study; Sample was from online platforms and personal networks	Semistructured interviews; Thematic analysis
Chivers et al. (2020)	Australia	To examine the public discourse of a perinatal cohort to understand unmet health information and support needs, and the impacts on mothering identity and social dynamics in the context of COVID‐19	831 posts	Qualitative design; Sample was from Australian online parenting forum	Online discussion posts; Thematic analysis, sentiment analysis, and word frequency calculations of stemmed words
Critchlow et al. (2022)	USA	To describe postpartum experiences of women who gave birth during the coronavirus disease 2019 (COVID‐19) pandemic, to identify short‐term and long‐term opportunities to address maternal–child health during this pandemic	30 women 30.6 ± 4.79 years	Qualitative design; Purposive sampling and snowball sampling;	Online interview; Content analysis
DeJoy et al. (2021)	USA	To understand childbearing persons' decision‐making during the pandemic and to illuminate their experiences giving birth in community settings	17 women 30.4 ± 3.6 years	Interpretive phenomenology design; Convenience sampling	Semistructured interview. Interpretive phenomenological approach
Draganović et al. (2021)	Bosnia and Herzegovina	To explore the lived experiences of pregnant women and mothers living in Bosnia and Herzegovina during the COVID‐19 outbreak.	30 women 21–41 years	Interpretive phenomenology design; Convenience sampling	Semistructured in‐depth interviews; Interpretative phenomenological analysis
Goyal et al. (2022)	USA	To explore the wellbeing, pregnancy, childbirth, and postpartum experiences of Asian American women who gave birth during the COVID‐19 pandemic	38 women 34 ± 3.5 years	Qualitative exploratory design; Convenience and snowball sampling	Semistructured interview; Content analysis
Güner & Öztürk (2022)	Turkey	To examine the challenges faced by pregnant women and their daily life activities during the COVID‐19 pandemic, to assess the psychological impacts of the pandemic and their expectations to improve women's mental health, thereby increasing the awareness of health care professionals of the subject.	30 women 20–38 years	Descriptive phenomenological design; Purposive sampling	Semistructured in‐depth qualitative interviews. Thematic analyses
Jackson et al. (2021)	UK	To explores the postpartum psychological experiences of UK women during different phases of the COVID‐19 pandemic and associated “lockdowns”	12 women 28–41 years	Qualitative research design. Convenience sampling	Semistructured interviews; Thematic analysis
Javaid et al. (2021)	USA	To explore if and how women perceived their prenatal care to have changed as a result of COVID‐19 and the impact of those changes on pregnant women.	2519 women 32.7 ± 4.5 years	Qualitative design; Snowball sampling	Online survey; Thematic analysis
Kolker et al. (2021)	Canada	To provide useful strategies from the patient's perspective	12 women 30–43 years	Qualitative descriptive approach; Purposive sampling	Semistructured interview; Thematic analysis
Kumari et al. (2021)	India	To address the psychosocial and behavioural impact of COVID‐19 on peripartum women's lives	25 women 28.5 ± 4.6 years	Qualitative design; Purposive sampling	Group discussions and in‐depth interviews; Thematic analysis
Linden et al. (2021)	Sweden	To figure out how women not infected by SARS‐CoV‐2 experienced pregnancy during the COVID‐19 pandemic	14 women 27–37 years	Phenomenology; Purposive sampling	Interviews through digital meetings; phenomenological approach
Mizrak Sahin & Kabakci (2021)	Turkey	To determine problems and attitudes of pregnant women related to diseases in the pandemic process	15 women 20–33 years	Qualitative design; snowball sampling	Semistructured questionnaire and interviews; Content analysis
Mortazavi & Ghardashi (2021)	Iran	To understand the lived experience of pregnant women in the COVID‐19 pandemic	19 women 29.3 ± 4.0 years	Descriptive phenomenological approach; Purposive sampling	In‐depth semistructured interviews; content analysis;
Panda et al. (2021)	Ireland	To gain insight and understanding of women's views and experiences of maternity care during the COVID‐19 pandemic	19 women 30–39 years	Qualitative descriptive study； Purposive sampling	Semistructured interviews; Thematic analysis
Rauf et al. (2021)	Pakistan	To explore the consequences of the pandemic on women of lower socioeconomic status with prenatal anxiety symptoms	27 women 18–36 years	Qualitative approach; purposive sampling	In‐depth interviews; Framework analysis
Rice & Williams (2021)	Canada	To examine how people in Canada who gave birth during the pandemic were affected by policies aimed at limiting interpersonal contact to reduce SARS‐CoV‐2 transmission in hospitals and during the early weeks postpartum	57 women 22–43 years	Qualitative descriptive methodology; Convenience and snowball sampling	Semistructured interviews; Thematic analysis
Riley et al. (2021)	UK	To understand the impact of COVID‐19 restrictions on women's pregnancy and postpartum experience	28 women 26–42 years	Phenomenology; Convenience and snowball sampling	Semistructured interviews; Thematic analysis
Rodríguez‐Gallego et al. (2022)	Spain	To explore the impact of the pandemic and of the measures adopted on breastfeeding initiation and maintenance	42 women 19–43 years	Qualitative descriptive study; Snowball sampling	Semistructured interviews; Thematic analysis
Snyder & Worlton (2021)	USA	To explore perceptions of social support among breastfeeding mothers during the COVID‐19 pandemic	29 women 19–42 years	Phenomenological approach; Purposive sampling	Semistructured interviews; a process of immersion and crystallization
Stumpfögger & Panagiotopoulou (2021)	UK	To get an in‐depth understanding of new mothers' experiences of bodily connectedness with their babies and the fluidity of their body boundaries	5 women 31–43 years	Phenomenology; Purposive sampling	Semistructured interviews; IPA method
Sweet et al. (2022)	Australia	To explore and describe childbearing women's experiences of receiving maternity care during the COVID‐19 pandemic	27 women 18–40 years	Qualitative exploratory design; Maximum variation sampling	Semistructured interviews; Thematic analysis

3.3. Methodological quality and level of dependability

All studies had good to high methodological quality (Table 2). Seventeen studies had good quality, and seven studies had high quality. All the studies were rated positively in research methodology (criteria 1, 2, 3). Meanwhile, all the studies were also rated positively in the representativeness of participants (item 8). All studies clearly stated the research ethics (item 9). All studies drawn conclusions in the research report flow from the analysis, or interpretation, of the data (item 10). Five studies had moderate dependability and 19 studies had high dependability.

TABLE 2.

Summary of the methodological quality and dependability of eligible studies

Study ID	1 a	2	3	4	5	6	7	8	9	10	Overall	Total percent of “yes” response	Dependability rating
Anokwuru & Mulaudzi (2022)	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	B	90%	High
Aydin & Aktaş (2021)	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	B	90%	High
Charvat et al. (2021)	Y	Y	Y	Y	Y	N	N	Y	Y	Y	B	80%	Moderate
Chivers et al. (2020)	Y	Y	Y	N	Y	N	N	Y	Y	Y	B	70%	Moderate
Critchlow et al. (2022)	Y	Y	Y	Y	Y	N	N	Y	Y	Y	B	80%	Moderate
DeJoy et al. (2021)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	A	100%	High
Draganović et al. (2021)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	A	100%	High
Goyal et al. (2022)	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	B	90%	High
Güner & Öztürk (2022)	Y	Y	Y	Y	Y	N	N	Y	Y	Y	B	80%	Moderate
Jackson et al. (2021)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	A	100%	High
Javaid et al. (2021)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	A	100%	High
Kolker et al. (2021)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	A	100%	High
Kumari et al. (2021)	Y	Y	Y	Y	Y	N	Y	Y	Y	Y	A	90%	High
Linden et al. (2021)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	A	100%	High
Mizrak Sahin & Kabakci (2021)	Y	Y	Y	Y	Y	N	N	Y	Y	Y	B	80%	Moderate
Mortazavi & Ghardashi (2021)	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	B	90%	High
Panda et al. (2021)	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	B	90%	High
Rauf et al. (2021)	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	A	100%	High
Rice & Williams (2021)	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	B	90%	High
Riley et al. (2021)	Y	Y	Y	N	Y	Y	Y	Y	Y	Y	B	90%	High
Rodríguez‐Gallego et al. (2022)	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	B	90%	High
Snyder & Worlton (2021)	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	B	90%	High
Stumpfögger & Panagiotopoulou (2021)	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	B	90%	High
Sweet et al. (2022)	Y	Y	Y	Y	Y	Y	N	Y	Y	Y	B	90%	High

^a The item of Critical Appraisal tools for use in JBI Systematic Reviews: 1. Is there congruity between the stated philosophical perspective and the research method? 2. Is there congruity between the research methodology and the research question or objectives? 3. Is there congruity between the research methodology and the methods used to collect data? 4. Is there congruity between the research methodology and the representation and analysis of data? 5. Is there congruity between the research methodology and the interpretation of results? 6. Is there a statement locating the researcher culturally or theoretically? 7. Is the influence of the researcher on the research, and vice‐ versa, addressed? 8. Are participants, and their voices, adequately represented? 9. Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body? 10. Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data?

Note: “Y” means “Yes”, “N” means “No”.

3.4. Meta‐aggregation

A total of 180 findings rated as either “credible” or “unequivocal” were extracted from the 24 studies included in the synthesis. The 180 findings were aggregated into 10 categories, which were subsequently synthesized into four synthesized findings. Summary of study findings, categories, and synthesized categories generating synthesized findings on the motherhood of pregnant women during the pandemic can be found in Supporting Information S4.

3.4.1. Synthesized finding 1: Pregnant women experienced changes in routine care

The epidemic has caused many changes in routine care. Pregnant women complained about the health care response consequence of the epidemic. Two categories illustrate these consequences: Altered access to care and disruption of routine care; changed conceiving plan.

Altered access to care and disruption of routine care

Many pregnant women desired to get medical help, and they showed much to worry about the unavailability of pregnancy services. They complained that they had missed out or partly missed out on several key aspects and moments of typical perinatal experiences, such as decreased pregnancy follow‐ups or the cancellation of appointments. The routine perinatal care was also disrupted. Some pregnant women were willing to choose safer health centres to give birth. Some complained the medical resources provided were limited. The disruption of usual maternity care caused navigational challenges to the pregnant when accessing services. The lack of perinatal support resulted in suffering, anxiety, and fear. However, the women's trust and satisfaction with care varied—some showed great trust while others thought it was far from satisfactory. Two exemplar quotes follow:

I cannot go [to the hospital] right now, but I contact my doctor by phone, and s/he asked me not to come unless I had a problem. (Mizrak Sahin & Kabakci, 2021)

The rules kept changing kind of minute by minute as they got more information, and it was really unsettling. (Sweet et al., 2022)

Changed conceiving plan

As the coronavirus continued to spread, the official confirmation and mortality rates increased, making pregnant women feel anxious and fearful. They expressed fear and concern about the high infectivity and the potential consequences caused by the COVID‐19 virus to them and their babies. So, they had to change their conceiving plan correspondingly to minimize the risk of infection. They finally postponed or changed their plan or reduced the number of antenatal visits. Two exemplar quotes follow:

… let us imagine I did not get sick and the birth took place and there was a … health worker with COVID‐19 helping my delivery and my baby caught COVID‐19 at the delivery, what would happen. I have no idea. (Güner & Öztürk, 2022)

[is anyone] temporarily pausing trying to conceive whilst our world is being rattled by corona? Has it changed your timeline in terms of when you want baby to born? Have you decided to wait or maybe not even have anymore? (Chivers et al., 2020)

3.4.2. Synthesized finding 2: Pregnant women used a range of strategies to cope with the consequence of the pandemic

Pregnant women complained that they had to stay at home due to the pandemic process. Pregnant women's emotional responses to coping with isolation were both positive and negative. Besides, they used both adaptive and maladaptive behaviours to manage the consequence brought by the pandemic. This can be illustrated by three categories: restriction and its consequence, strategies for coping with negative psychological consequences, and maladaptive behaviours.

Restriction and its consequence

Many pregnant women maintained health‐protective behaviours such as adhering to sanitarian protocols and changing their dietary structure to improve immunity. Some of them praised the benefit of restriction. They thought the isolation provided them with a quieter and more comfortable environment to give birth to and fewer social obligations to meet. However, it also contributed to many negative pregnancy experiences, such as poor physical health, restricted daily activities, and psychological stress in the family process. The isolation, which was used to reduce the spread of infection, also led to feelings of loneliness and depression. Two exemplar quotes follow:

We can literally adapt our lives around the baby's schedule. So erm without worrying about “Oh I'm getting up for work, I have not got enough sleep. I'm not going to be able to actually function at work with like only two hours sleep” so yeah, do not have to worry about that. (Jackson et al., 2021)

Being imprisoned in the house and not being able to visit my family and friends for a month made me feel depressed and agitated. (Mortazavi & Ghardashi, 2021)

Strategies for coping with negative psychological consequences

Although the level of stress decreased as time passed, many pregnant women still adapted and prepared for uncertain times. They mainly focused on their hobbies, their babies, or family members. They also turn to their faith and spirituality for strength and hope. Some women thought that balancing exposure risks for the benefit of mental health should help mitigate anxiety. Two exemplar quotes follow:

I am enjoying my hobbies like painting and reading many old books that I have. (Kumari et al., 2021)

When the number of deaths increased, it quite impressed me … I stopped watching television, I was not watching the news. (Güner & Öztürk, 2022)

Maladaptive behaviours

Maladaptive behaviours included the ignorant and oversensitive response to the pandemic. Some pregnant women did not regard COVID‐19 as a threat, and they did not understand its seriousness of it. On the contrary, some other pregnant women heightened their sensitivity towards adhering to sanitation protocols. The obsessions manifested in repeatedly washing hands, fearing leaving home, and so on. Two exemplar quotes follow:

I would say contracting the virus was honestly at the bottom of our list …. (DeJoy et al., 2021)

Wipe down the stroller and wash my hands, take of all his clothes. I do not understand why I do that part, but I take of all his clothes, change him into a different set of clothes. … it makes me feel obsessed … Every minute you are cleaning, because you just do not know. (Kolker et al., 2021)

3.4.3. Synthesized finding 3: Pregnant women struggled to embrace motherhood

Despite the challenges posed by the COVID‐19 pandemic, pregnant women tried their best to embrace their motherhood. This can be illustrated by two categories: bonding with babies and breastfeeding journal:

Bonding with babies

Many pregnant women could build a bond with their children smoothly. They were willing to experience their baby's distress as if it was their own. Some women faced challenges in bonding with their babies due to the anxiety caused by the pandemic. Besides, some women felt ambivalent in two aspects: When dealing with dependence on a baby; the emotions of having a baby during the pandemic. They thought spending almost all their time accompanied by a baby made them lose independence and self‐identity. Having a baby during the pandemic, quite different from that in the nonpandemic phase, may generate a sense of guilt—the contrast between happiness and a problematic situation. Two exemplar quotes follow:

I've felt a stronger bond among the four of us for being all the time together, it's been gratifying. (Rodríguez‐Gallego et al., 2022)

I feel like I'm getting to a stage where that sort of … amazing sort of period of just being completely attached to her [baby] is getting a little bit withered now and it's becoming a tired feeling as well. […] I'd quite like to be able to have a little bit of something else in my life as well. (Stumpfögger & Panagiotopoulou, 2021)

Breastfeeding journal

The pandemic caused an increase in the duration of maternity leave and more time confined at home. Pregnant women thought it was easier to establish breastfeeding with their infants. Besides, they regarded previous knowledge, support from breastfeeding groups, and support from family as the facilitators of the establishment and maintenance of breastfeeding. Therefore, the lack of support from the hospital and home may hinder the initiation or continuation of breastfeeding. Two exemplar quotes follow:

I believe that social isolation has favoured breastfeeding, in the first week, it gained 500 g instead of losing weight. (Rodríguez‐Gallego et al., 2022)

I had a couple of virtual appointments [with lactation consultants], which I found totally useless. I was so desperate to make it work because I had such a wonderful experience nursing my first kid and I was…devastated that it wasn't working with [the new baby] because it was something I was really looking forward to. (Rice & Williams, 2021)

3.4.4. Synthesized finding 4: Pregnant women received different levels of social support

Social support, which can mitigate the negative psychological consequences caused by the pandemic, was insufficient in most circumstances. Pregnant women desired more social support. However, in some cases, the support they received made them unsatisfactory. This can be illustrated by three categories: informational support; instrumental, emotional, and appraisal support; support from health personnel.

Informational support

The changing and conflicting nature of pandemic information made pregnant women feel anxious. Pregnant women tried to seek accurate and up‐to‐date information from different sources such as social media and midwives. They complained that the source and the accuracy of information related to the pandemic they acquired were insufficient. Additionally, a lack of clarity of information from health care staff might reduce the perceived quality of care. Although the multiple sources of information could increase pregnant women's knowledge of the pandemic and make them take precautionary measures, some other women stressed the rationality of balancing the state of “ignorance” and “overload of information.” They thought too much useless information would lead to anxiety and stress. Two exemplar quotes follow:

So the unknown was really, really challenging. […] like no children have passed away from it but it's really – I do not know, it's that unknown. It's that fear of not understanding – like it has not been around for so long that you understand and you can quantify what it is. (Kolker et al., 2021)

Yes, my daughter and I are healthy due to the recommendations we used to hear from the television. I might have caught this virus if I had not followed those guidelines. (Rauf et al., 2021)

Instrumental, emotional, and appraisal support

Support from husbands, family members, and other pregnant women can mitigate the stress or protect women from getting infected by COVID‐19 to some degree. However, instrumental, emotional, and appraisal support was often insufficient. The unemployment state of pregnant women or their family members, combined with the extra fees caused by the medication or medical tests may increase financial burdens and the level of anxiety for the pregnant women and their families. This may cause mental stress or modification of the conceiving plan. Due to the separation mandated by public health, support and encouragement from family and social networks were often disrupted. Pregnant women often felt frustrated and isolated about it. Two exemplar quotes follow:

We are going through a tough time because of it. My husband has no job and our savings are not going to last long. They will run out soon, and then what? We have a humble background. We cannot tell anyone that we do not have anything to eat at home. We cannot save anything [like food or money]. I think people will not die of coronavirus, but they will die of starvation if this lockdown continues. (Rauf et al., 2021).

It bothers me that my partner cannot come to my appointments with me anymore and (it) makes the appointments less relaxing and more stressful. (Javaid et al., 2021)

Support from health personnel

The degree of satisfaction with health care services was variable. Some pregnant women appraised the high level and good quality of maternity care they received. They regarded the communication with health personnel as supportive, whether face‐to‐face or online. Other pregnant women expressed dissatisfaction and distrust with the health care. They complained that they lacked the perceived support from the providers. The social distance and masks made the pregnant women feel the coldness of the staff. The poor communication between them and the staff left them feeling uncertain and ignorant about the disease. Two exemplar quotes follow:

… I did not see any deficiencies … they were taken to the ultrasound rooms one by one and they were disinfected one by one at that time … I was pleased … the employees were understanding this by communicating with us … being polite. (Güner & Öztürk, 2022)

there was utter confusion and chaos generally at the hospital, like I could never count on anything being the truth. (Sweet et al., 2022)

3.5. Quality appraisal of synthesized findings

The quality appraisal of the synthesized findings is presented in Table 3. The overall ConQual score for each synthesized finding ranged from low to moderate. The quality of the third synthesized finding is moderate and the other three are low.

TABLE 3.

Quality appraisal of synthesized findings using the ConQual approach

Synthesized finding	Dependability	Credibility	ConQualScore
Pregnant women experienced changes in routine care	Downgrade 1 level a	Downgrade 1 level b	Low
Pregnant women used a range of strategies to cope with the consequence of the pandemic	Downgrade 1 level	Downgrade 1 level	Low
Pregnant women struggled to embrace motherhood	Not downgraded	Downgrade 1 level	Moderate
Pregnant women received different levels of social support	Downgrade 1 level	Downgrade 1 level	Low

^a Downgraded 1 level for each synthesized finding including findings from studies with moderate dependability ratings.

^b Downgraded 1 level for each synthesized finding including a mix of unequivocal and credible findings.

4. DISCUSSIONS

This review may be the first qualitative systematic review and meta‐synthesis to comprehensively retrieve the literature for identifying publications reporting the impact of the COVID‐19 pandemic on pregnant women. The aggregation of 24 articles showed that during the coronavirus pandemic, pregnant women experienced changes in routine care. Moreover, they tried their best to cope with the changes and embrace motherhood, as well as received different levels of social support. The quality of synthesized findings was low to moderate. As a next step, this evidence could be used as a reference for future research.

The study found that maternal and foetal outcomes had worsened, primarily attributed to the disrupted routine care for pregnant women impacted by the COVID‐19 pandemic (Chmielewska et al., 2021). The accessibility and quality of maternal care played a decisive role in maternal and foetal outcomes. Our review revealed that some pregnant women had to change their conceiving plan correspondingly to adapt to the change in the health care system. Although the government's initial purpose of setting restrictions was to protect all citizens and ensure the safety of pregnant women and their babies. The restrictions and access to maternity care should be balanced (Lalor et al., 2021). Pregnant women should be guaranteed the right to have a companion during labor (World Health Organization, 2018). Health care providers must consider establishing robust maternity care for those vulnerable groups in response to the pandemic (Chmielewska et al., 2021). On the micro‐level, this may need the effort of midwives, nurses, and other health personnel. The review revealed that poor communication and social distance made pregnant women feel the coldness. Although face masks and distance are a necessity in protecting the medical staff, communication via eye contact or spoken words can still be an essential source of support. Considering the high level of compassion fatigue and burnout of health care personnel amidst the pandemic (Ruiz‐Fernández et al., 2020), cognitive or mindfulness‐based interventions were needed to train staff to improve their ability to empathy (Delaney, 2018; Duarte & Pinto‐Gouveia, 2016; Partlak Günüşen et al., 2021).

Many previous studies found that the restriction and isolation at home had caused many negative impacts on pregnant women, such as increased all‐cause mortality, increased risk of domestic violence, and increased anxiety (Chivers et al., 2020; Jackson et al., 2021; Jago et al., 2020; Leigh‐Hunt et al., 2017; Milne et al., 2020). However, in our systematic review, the benefit of restriction was also reported by the participants in the original study, which was different from the results of many quantitative studies. Pregnant women regarded the restriction at home as an excellent opportunity to be exempt from obligation and give birth. Studies in the future should not overestimate the negative psychological effect brought by the pandemic because the impact of the pandemic on women is both positive and negative. Adapting to the impact of the COVID‐19 pandemic voluntarily such as adhering to the sanitarian protocols was an important part of coping strategies (Meaney et al., 2022). However, the self‐adaption was sometimes limited. The ignorant attitude may cause the spread of the virus. The oversensitive attitude may elevate the level of anxiety. Face‐to‐face or online psychological counselling was needed with the careful assessment of the mental stress of pregnant women considering the limited capacity for self‐adaption (Zuo et al., 2022).

Social support was complained to be insufficient by most of the women amidst the pandemic, which was consistent with previous studies (Davenport et al., 2020; Zhou et al., 2021). The policy of pandemic prevention and control made pregnant women separate from their relatives and friends, which may cut down the primary source of emotional and appraisal support (Chivers et al., 2020). The increased financial burden caused by the extra fees of pregnancy and the decreased source of income resulting from the disruption of work subsequently led to the lack of instrumental support. As Tedros Adhanom Ghebreyesus, WHO's director‐general said “We're not just fighting a pandemic, we are fighting an infodemic” (The Lancet Infectious Diseases, 2020). Consistent with many previous studies, pregnant women had limited sources of reliable and accurate information during the pandemic (Meaney et al., 2022; Wang et al., 2022; Yuksel & Cakmak, 2020). However, uninfected and infected pregnant women all presented the desire of acquiring up‐to‐date information (Freitas‐Jesus et al., 2021). Considering that the authoritative information from official channels led to a low level of depression or anxiety (Jiang et al., 2021; Lee et al., 2021), ensuring the credibility of information was of critical importance. However, in our review, some participants regarded the amount of information should be balanced. Too little or too much information would cause anxiety. This highlighted the importance of selective information to prevent overload of information. To conclude, the accuracy and the appropriate amount of information related to the pandemic was of equal importance. Specific information targeted at pregnant women should be considered (Jackson et al., 2021; Jiang et al., 2021).

Although much effort is needed, pregnant women struggled to embrace motherhood. Our review revealed that due to the restriction of the pandemic, breastfeeding time was prolonged. This verified the conclusion drawn by Davidson and Ollerton (2020) that appropriately timed breastfeeding support has a positive impact on breastfeeding practice. Besides, previous knowledge and support from breastfeeding groups and families were detected as facilitators of breastfeeding. However, consistent with previous studies (Kuehn, 2021; Latorre et al., 2021; Milani et al., 2022), a lack of informal and formal sources of support may hurt the establishment or maintenance of breastfeeding. Current evidence (Chowdhury et al., 2015; Lubbe et al., 2020; Milani et al., 2022) showed that the benefits of breastfeeding during the pandemic outweighed possible risks and could protect both mothers and babies. As a result, adequate breastfeeding support should be provided (van Dellen et al., 2019; Witt et al., 2021). Due to the restriction imposed by the government, lack of support is universal. Virtual support both in web‐based forms or app‐based forms may be helpful to elevate the rates of breastfeeding both in the short‐term and long‐term (Gavine et al., 2022; Lewkowitz & Cahill, 2021). It may be reasonable to promote the virtual forms of breastfeeding when the support is hard to acquire.

This review revealed the lived experience of pregnant women and their coping strategies during the COVID‐19 pandemic through meta‐synthesis, which is relatively innovative. Besides, we included studies from multiple countries, which can more comprehensively reflect pregnant women all over the world and draw meaningful conclusions. However, limitations also existed in this review. First, we restricted the language of studies to English which may miss some articles. Second, details of the influence of the researcher on the research description of many studies were unknown. Third, this study included pregnant women without regard to their family members. They could have different perspectives from one member to another.

5. CONCLUSIONS

The COVID‐19 pandemic has disrupted the conceiving plan and the routine care of pregnant women. The government or health care providers should balance the restrictions and access to maternity care. Many women used a range of coping strategies to cope with the negative psychological consequences. Though they tried their best to cope with the changes and embrace motherhood, their ability to self‐adaption was limited. Psychological and maternity care counselling should be provided when needed. Considering that the support provided to the women was universally insufficient, more formal and informal support should be provided in an accessible way such as through virtual means.

6. IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers should balance the restriction and the accessibility of maternity care. The policy of pandemic prevention and control should be adapted flexibly according to the requirement of pregnant women under the circumstance of not violating the public health of society. Making sure at least one person's company should be considered. Additionally, breastfeeding support or prenatal counselling should be provided in virtual means if the routine service provided is disrupted. So, the deployment of equipment for telemedicine and the training for virtual techniques should be put on the agenda of nurse managers.

CONFLICT OF INTEREST

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

ETHICS STATEMENT

No ethical approval was necessary because this is a review article.

Supporting information

Supporting Information S1. ENTREQ checklist (Enhancing transparency in reporting the synthesis of qualitative research) ^†

Supporting Information S2 Searching strategies

Supporting Information S3. Full_included_studies

Supporting Information S4. Summary of study finding, categories, and synthesized categories to generate synthesized findings on the motherhood of pregnant women during the pandemic

Zheng, X. , Zhang, J. , Ye, X. , Lin, X. , Liu, H. , Qin, Z. , Chen, D. , & Zhan, C. (2022). Navigating through motherhood in pregnancy and postpartum periods during the COVID‐19 pandemic: A systematic review and qualitative meta‐synthesis. Journal of Nursing Management, 30(8), 3958–3971. 10.1111/jonm.13846

DATA AVAILABILITY STATEMENT

Data sharing is not applicable—No new data are generated.