Background
Methods
Design
Database and search strategy
Selection: Inclusion and exclusion criteria:
Inclusion | Exclusion | |
---|---|---|
Participants | ● > 50% study participants had personally experienced depression in the perinatal period, whether new episode or continuing episode of pre-existing diagnosis ● Discussing current episode or recalling details retrospectively ● Perinatal depression either diagnosed by clinicians, detected through screening questionnaires (such as the Edinburgh Postnatal Depression scale) or self-identified ● Participants who had experienced a pregnancy of any duration and a live birth or a miscarriage or a stillbirth. ● Perinatal period defined as pregnancy up to 2 years post birth ● No age restrictions ● No restrictions on other physical or mental health co-morbidities (apart from substance misuse) | ● Participants with a co-morbid diagnosis of substance misuse disorder. ● Participants who have experienced distress, bereavement, loss, grief or trauma during the perinatal period but without a diagnosis of perinatal depression ● Studies including qualitative data collected from health care professionals, partners or other people with close experience of and interactions with women with perinatal depression. ● Participants discussing experience of depression outside the perinatal period |
Concept | ● Any primary research study with a qualitative research design to explore a participant’s experience, including any data collection method (such as interviews, focus groups, diaries or online data collection) and any method of qualitative analysis of primary data (such as grounded theory, ethnography, thematic analysis, interpretive phenomenological analysis (IPA), framework approach, or narrative analysis). ● Majority (> 50%) of the results section concerned with participants discussing their subjective experiences of loneliness or closely-related themes (such as perceived social isolation, lack of connection or lack of social support) associated with their perinatal depression. | ● Existing qualitative meta-syntheses or reviews ● Mixed methods studies (the qualitative element of these studies did not tend to be of high enough quality). ● Case studies or ethnographic exploration with only one participant ● Conference abstracts, PhD theses, dissertations or other types of grey literature. ● Studies evaluating an intervention. |
Context | ● Studies in any geographical or cultural setting. | |
Language | ● English only | ● Non-English |
Data screening
Quality appraisal
Data extraction and analysis
Author & ref | Year | Participants | Study setting | Data collection & analysis | Quality assessment (score out of 10) | ||||
---|---|---|---|---|---|---|---|---|---|
Sample size | Diagnosis | Country | Clinical setting recruited | Data collection | Data analysis | ||||
Beck [27] | 1992 | 7 | Postpartum depression | Self report | USA | Postpartum depression support group | One-to-one interviews | Colaizzi’s phenomenological 6-step data analysis method | 6 |
Blanchard [51] | 2009 | 7 | Antenatal depresssion | EPDS> = 10 | USA | Family health centre - primary care & counselling | Semi-structured interviews | Colaizzi’s phenomenological data analysis method | 9 |
Boath [52] | 2013 | 15 | Postpartum depression | EPDS> 12 | England | Health visitors in the community | Semi-structured interviews | Thematic framework analysis | 9 |
Edhborg [53]** | 2005 | 22 | Postpartum depression | EPDS> = 10 | Sweden | Maternity ward | Unstructured interviews | Grounded theory | 9 |
Evans [54] | 2012 | 512 online postings (unknown number of participants) | Postpartum depression | Self report | Study based in Canada (unknown location of participants) | Online postpartum depression support group | Unit of analysis was individual online messages | Directed content analysis | 7 |
Gardner [55] | 2014 | 6 | Postpartum depression | EPDS> = 10 | England | NHS commissioned parenting groups. | Semi-structured interviews | Interpretative Phenomenological Analysis | 8 |
Hanley [56] | 2006 | 10 | Postnatal depression | EPDS> = 12 & clinical diagnosis | Wales | General Practice/ primary care. | Semi-structured interviews | Content analysis using Colaizzi’s method | 6 |
Highet [28] | 2014 | 28 | Postnatal depression | Self report | Australia | Website of 3rd sector organisation | 24 Face to face and 4 telephone interviews | Grounded theory | 8 |
Jackson [57] | 2020 | 21 | Antenatal or postnatal depression. | Self report | England | Flyers, health visitors, midwives, support groups and local press. | Semi-structured interviews (18 face-to-face & 3 telephone) | Thematic analysis | 10 |
Keefe [58] | 2016 | 30 | Postpartum depression | Self report | USA | Flyers in an urban health centre serving low-income residents. | Semi-structured face-to-face interviews | Constant comparative analysis | 4 |
Keefe [59] | 2019 | 30 | Postpartum depression | Self report | USA | Flyers in an urban health centre serving low-income residents | Semi-structured face-to-face interviews | Constant comparative analysis | 5 |
Letourneau [60] | 2007 | 41 | Postpartum depression | Self report | Canada | Newspapers and community health care clinics | 41 Semi-structured interviews & 11 focus group interviews | Thematic content analysis | 9 |
Mauthner [61] | 1995 | 18 | Postpartum depression | Self report | England | Details not available | Semi-structured interviews | Voice centred relational method | 5 |
Mauthner [62]** | 1998 | 18 | Postpartum depression | Self report | England | Local and national organisations, support groups, health clinics & ‘network sampling’ | Semi-structured in-depth interviews | Voice centred relational method | 6 |
Montgomery [63]** | 2009 | 27 | Perinatal depression | Self report | Canada | Peer support groups, community mental health agency, public health agency & family play centres | Unstructured interviews | Narrative analysis | 7 |
Morrow [64] | 2008 | 18 | Postnatal depression | Self-report | Canada | General and family practitioners, community-based organisations, | Semi-structured interviews | Ethnographic narrative approach | 8 |
Nahas [65] | 1999 | 45 | Postpartum depression | Self report | Australia | Arabic community centres | Unstructured interviews | Phenomenological study | 9 |
O’Mahony [66] | 2012 | 30 | Postpartum depression | EPDS> = 10 | Canada | Health care providers & organisations that provide mental health services | Semi-structured interviews | Critical ethnographic method | 10 |
Raymond [67] | 2009 | 9 | Antenatal depression | Self report | England | GPs, nurseries, health visitors | Semi-structured interviews | Thematic analysis | 9 |
Recto [68] | 2020 | 20 | Perinatal depression | Self report | USA | Parenting classes - school nurses and social workers helped recruit | Interviews | Deductive content analysis | 7 |
Roseth [69] | 2011 | 4 | Postpartum depression | EPDS> = 13 or clinical diagnosis | Norway | Local healthcare clinic nurses or psych outpatient dept | Interviews | Descriptive-phenomenological method | 6 |
Scrandis [70] | 2005 | 10 | Postpartum depression | Self report | Unknown | Community sites - churches, postpartum support groups, home visiting programs | Semi-structured interviews | Grounded theory | 5 |
Shafiei [71] | 2015 | 39 | Postnatal depression | EPDS or self report | Australia | Antenatal clinics or postnatal wards | 39 Semi-structured telephone interviews then 10 face-to-face in depth interviews | Thematic analysis | 9 |
Tang [72] | 2016 | 38 | Postpartum depression | Self report | China | Convenience sample from community | Semi-structured interviews online | Grounded theory approach and constant comparison method | 6 |
Taylor [18] | 2021 | 14 | Perinatal depression | Self report | England | NHS health providers from primary care to acute and secondary mental health care | Semi-structured interviews | Social constructionist theory. Thematic analysis. | 10 |
Templeton [73] | 2003 | 20 | Postnatal depression | EPDS> = 12 | England | Local community known to health viitors | 6 Semi-structured interviews + 14 from focus groups | Descriptive thematic analysis | 6 |
Wittkowski [74]** | 2012 | 10 | Postnatal depression | EPDS> = 12 | England | Health visitors and midwives. | Face to face interviews | Constant comparison and grounded theory approach | 8 |
Patient involvement
Reflexivity
Results
Description of included studies
Study name & date | CASP Quality Assessment Score Categories | Total score | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Validity | Results | Value of research | |||||||||
Clear aims | Appropriate qual methodology | Appropriate research design | Appropriate recruitment | Appropriate data collection | Considered reflexivity | Ethics addressed | Rigor data analysis | Clear findings | |||
Beck 1992 [27] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 6 | ||||
Blanchard 2009 [51] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 9 | |
Boath 2013 [52] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 9 | |
Edhborg 2005 [53] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 9 | |
Evans 2012 [54] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 7 | |||
Gardner 2014 [55] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 8 | ||
Hanley 2006 [56] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 6 | ||||
Highet 2014 [28] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 8 | ||
Jackson 2020 [57] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 10 |
Keefe 2016 [58] | ✓ | ✓ | ✓ | ✓ | 4 | ||||||
Keefe 2019 [59] | ✓ | ✓ | ✓ | ✓ | ✓ | 5 | |||||
Letourneau 2007 [60] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 9 | |
Mauthner 1995 [61] | ✓ | ✓ | ✓ | ✓ | ✓ | 5 | |||||
Mauthner 1998 [62] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 6 | ||||
Montgomery 2009 [63] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 7 | |||
Morrow 2008 [64] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 8 | ||
Nahas 1999 [65] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 9 | |
O’Mahony 2012 [66] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 10 |
Raymond 2009 [67] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 9 | |
Recto 2020 [68] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 7 | |||
Roseth 2011 [69] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 6 | ||||
Scrandis 2005 [70] | ✓ | ✓ | ✓ | ✓ | ✓ | 5 | |||||
Shafiei 2015 [71] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 9 | |
Tang 2016 [72] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 6 | ||||
Taylor 2021 [18] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 10 |
Templeton 2003 [73] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 6 | ||||
Wittkowski 2012 [74] | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | 8 |
Thematic synthesis
Research question | Meta-theme | Sub-theme | Primary data |
---|---|---|---|
Experiences of loneliness and perinatal depression | 1. Self-isolation, hiding depressive symptoms and loneliness due societal stigma | 1.1 ‘Just snap out of it’ – Societal stigma about perinatal depression and fear of judgement as a ‘bad mother’ makes women feel lonely | ‘It was clear from women’s narratives that many experienced a sense of failure or inadequacy that could prevent them from connecting to others. The mothers described feeling under pressure—from themselves, partners, family members, other mothers, and wider societal narratives—to take on the role of a primary caregiver and to be, as Lottie put it, “a perfect mum”’ [18] |
1.2 Self-isolation & hiding depressive symptoms compounds loneliness | ‘The participants described a withdrawal from others by hiding their true thoughts and feelings by isolating themselves. One mother described vividly how her strong feelings of shame made her actively conceal her real feeling and thoughts. Another mother described how she exhausted herself by putting on a happy mask and doing her best to keep up appearances’ [69] ‘There was also a tendency in depressed women to isolate themselves. Women described a strong desire to not have to leave the house but rather be alone and for others to go away: “I didn’t want to see anyone – even though I needed support I just wanted everyone to leave me alone” [28] | ||
2. Sense of emotional disconnection associated with perinatal depression fuels loneliness | 2.1 ‘Inauthentic relationships’ with other mothers and feeling misunderstood | “This girl I knew. .. I said “Oh, do you feel like that, do you?” and she’d say “Oh, no, no, no” and I said “Oh-oh, pull yourself together dummy. .. you’re alright.” and then I’d get home and think “She doesn’t feel like that, perhaps it isn’t normal”. ... That was the one thing that really got to me through it all, that I couldn’t find anyone who felt like I did, and I felt like I was going through it on my own. ... I couldn’t find anyone who said “Oh yes, I felt like that, don’t worry, you’ll get better”. ... I felt really isolated and lonely through it.’ (Pam)’ [61] | |
2.2 Disconnection from baby | “Several women also described difficulties bonding with their babies, for example feeling “nothing”, “numb”, “terrified of them” or like their baby “wasn’t a part of me”. For some mothers, a baby’s need to be close to them could feel uncomfortable, even threatening, yet a lack of closeness also resulted in high levels of distress. As Emma explained: “[My baby] used to have to sleep on my chest and, because I didn’t want him near me, it was really hard having him on my chest. So he used to just lay there and scream in pain and I used to just sit in another part of the room and just cry.”’ [18] | ||
2.3 ‘Dislocation’ in sense of self after birth | ‘….feelings of dislocated identity clearly included a strong sense of loneliness and desolation, as the mothers described themselves becoming confined to their homes with their babies, isolated from the wider world, and disconnected from their past lives and social networks. A dislocated self was particularly evident in the narratives of first-time mothers who had stopped working or taken maternity leave to have a baby.’ [18] | ||
3. Mismatch between expected and actual support associated with loneliness | 3.1 Subjective lack of emotional and practical support from the wider family and community | ‘Anna left a safe, secure social network back home to find a very precarious situation in her new country: The biggest problem that I faced was arriving late in my pregnancy and didn’t have a specialist. So when it’s time for delivery they said go to the ER. .. I was so stressed the words were gone and was unable to speak. Everything is new. .. you are alone and not with your family and don’t know their system, so this is scary.. .’ [66] | |
3.2 Lack of support and gender imbalance in partner relationship | ‘Women spoke about feeling isolated and alone and overwhelmed with anxiety by being the sole caregiver for their infants while their partner was at work.’ [60] | ||
What made loneliness better for women with perinatal depression? | 4. Validation from trusted healthcare professionals | I recognise she can only come to the house once a week and then only for 2 hours but they are the two most important hours in my week. My volunteer is more like a friend than a person in a ‘working relationship’ [56] | |
5. Peer support from other mothers with perinatal depression | ‘Groups are a safe place to say ‘This isn’t the greatest time of my life’, and getting some support that you are a good mom, and that your baby does feel loved, even though you’re not, like, jumping up and down for joy, and that it will get better.’ [60] ‘All participants within this study were recruited from mother and baby groups. For those mothers who were feeling particularly isolated, these groups provided not only a source of support and knowledge but also gave women a sense of community, which is embedded within collectivist West African culture: ……… [when you start going to the group] you know that you are not alone. So many mothers are going through what you are going through. And some are even MORE than yourself…….. [I think] there should be a gathering for mothers……. So you can chat with another mother.…. it does help. – Participant 1’ [55] | ||
6. Practical and emotional support from family | ‘Health services often did not accommodate women’s children during treatment sessions, and therefore some women relied on informal childcare to enable them to access this formal support. I’ve been having counselling every week and I’ve come on in leaps and bounds… my Mum and Dad kept these two (children) and it’s so helpful. (Tina, postnatal depression and post-traumatic stress disorder, rural village)’ [57] | ||
What made loneliness worse for women with perinatal depression? | 7. Lack of professional support, groups and facilities | “There’s nothing really in this area for mothers. I found it very difficult to meet up locally. ... I would have liked to have known. .. other mothers around, and if there was sort of a central meeting place in this area’ [61] | |
8. Conflict and separation from partner, family & community | ‘Most participants expressed that being a newly immigrated mother without the familiar, preexisting support networks could predispose women to PPD. Women felt that they were vulnerable because of the lack of family support after childbirth. For Anna, being connected was the norm back home: “The families are so big and so supportive. We’re always in touch. .. always gathering around someone.” Kate maintained that PPD is more commonly found here because of the lack of familial support and the stress of being alone. She felt that isolation and solitude are the biggest problems in developed countries.’ [66] |