What are antenatal maternity care needs of women who conceived through fertility treatment?: a mixed methods systematic review

Figures & data

Table 1. PICO and matching PubMed search items for a mixed methods literature review on antenatal care needs of women who conceived through fertility treatment.

PICO^a	Research question	Specification
Population	Women who conceived	Pregnant women.	Pregnancy [MeSH]^b, Pregnant women [MeSH], Pregnan* [tiab], Gravidity [tiab]^c
Intervention group	Fertility treatment	Conception with the use of hormone treatments and all types of ART.	Reproductive techniques, assisted [MeSH]^d, Fertility treatment [tiab], In vitro fertilization [tiab], Ivf [tiab], Assisted conception [tiab], Assisted reproduct* [tiab], Intracytoplasmic Sperm Injections [tiab], Icsi [tiab], Artificial insemination* [tiab]
Comparison group	Spontaneously	Conception without the use of hormone treatments or ART.	Spontaneous pregnancy [tiab]^e, Spontaneous conception [tiab]^e
Outcome	Antenatal care needs	The (additional) care or support that women who conceived through fertility treatment want to receive from maternity caregivers.	Prenatal care [MeSH], Needs assessment [MeSH], Care [tiab], Need* [tiab], Needs [tiab], Support [tiab], Patient need* [tiab], Qualitative research [MeSH], Interviews as topic [MeSH], Surveys and questionnaires [MeSH], Qualitative [tiab], Interview* [tiab], Midwifery [MeSH], Maternity care [tiab], Midwi* [tiab]

^aPopulation, intervention group, comparison group, outcome.

^bMedical Subject Heading (MeSH): search item is the subject of articles.

^cTitle abstract (tiab): search item can be found in title or abstract of articles.

^d“Reproductive techniques, assisted [MeSH] contains all individual fertility treatments.

^eRemoved from the final search while this led to too many articles concerning spontaneous pregnancy.

Figure 1. PRISMA flowchart.

Table 2. Background characteristics and relevant findings of 15 studies included in a mixed methods literature review on antenatal care needs of women who conceived through fertility treatment.

First author, year country of publication	Design	Objective	Research population	Research method	Relevant findings
Chen, 2011 Taiwan	Quantitative study, survey design	To describe the differences in Maternal-Fetal Attachment (MFA) and Maternal-Infant Attachment (MIA) among women who conceived spontaneously (SC-women) and women who conceived through fertility treatment (Artificial Reproductive Techniques (ART) women).	60 Pregnant ART-women and 65 pregnant SC -women.	Self-reported measures: Taiwanese MFA Scale during pregnancy and Taiwanese Maternal Attachment Inventory at one or two months postpartum.	Pregnant ART-women had higher perinatal MFA and MIA than SC-women.
Chen, 2019 China	Quantitative study cross‐sectional design	To investigate the prevalence of depression in the third trimester of pregnancy and identify the related demographic risk factors.	29 ART & 744 SC (total 773) women in third trimester of pregnancy from three hospitals	Edinburgh Postnatal Depression Scale	ART was considered as a negative life event by that made them anxious by 90% of women who received it. ART (OR = 5.631) and adverse life events strongly predict antenatal depression.
Crespo, 2016 Spain	Qualitative study, grounded theory design	To assess the experiences of Spanish couples who conceived through fertility treatment (ART-couples) with a focus on their psychosocial needs after successful ART using the research question: ‘What are the psychosocial needs of women and their partners following assisted reproductive treatment in the Spanish context?’.	30 Women and 21 of their partners pregnant after ART.	Repeated rounds of individual, semi-structured, in-depth interviews at no specific time.	Participants revealed a complexity of reasons for anxiety, including concerns related to the risk of medical conditions. They also revealed that the ART process resulted in the narrowing of experiences related to feelings and practice of healthcare. They felt like they had ‘no right’ to complain.
De Pascalis, 2012 Italy	Quantitative study, cross-sectional analytic design	To investigate quality of life (QoL) among ART-couples compared to couples who conceived spontaneously (SC-couples).	57 Pregnant ART –couples and 58 pregnant SC-couples.	Short Form 36 (SF-36) to measure QoL at 22 and 32 weeks gestation.	ART-women had lower physical functioning scores than SC-women. ART-couples reported lower scores on role limitations tied to physical health, vitality, social functioning and physical well-being. ART-couples showed a decrease in social functioning, SC couples reported stable scores. ART-couples reported stability in mental well-being scales, whereas SC-couples showed an increase.
Dornelles, 2014 Brazil	Qualitative study, descriptive design	To explore women’s fears during pregnancy following ART and to relate these fears to existing literature in order to examine how they compare with the fears expressed by SC-women.	19 Pregnant ART–women.	Semi-structured interviews during the third trimester of pregnancy.	As well as experiencing fears reported by SC-women, ART-women also experienced more context-specific fears. The most common fear was that of fetal death. Moreover, ART-women focused primarily on maintaining the pregnancy, which may affect their engagement with mothering.
French, 2015 Great Britain	Qualitative study, exploratory design	To explore the antenatal experiences of ART-women and their partners in order to assess if they have specific antenatal care needs that are not met.	12 pregnant ART-women and 8 male partners.	Individual, in-depth interviews at 28 weeks gestation.	Participants experienced early pregnancy following ART as an anxious time in which they fear pregnancy loss. They also experienced a ‘care gap’ between going to the ART clinic and having their first ultrasound, which caused more anxiety, and reported difficulty adjusting to pregnancy and planning for parenthood. Female participants were struggling to express their ambivalent feelings regarding pregnancy toward others.
Gourounti, 2013 Greece	Quantitative study, cross-sectional design	To examine the relationship between coping strategies, antenatal anxiety, pregnancy worries and depressive symptomatology.	163 Pregnant women, with gestational ages between 11 and 26 weeks.	Self-reported measures: Brief COPE, Cambridge Worry Scale, State-Trait Anxiety Inventory (STAI), and Center for Epidemiologic Studies-Depression Scale.	Women who conceived through In Vitro Fertilization (IVF-women) had higher levels of state anxiety and pregnancy worries than SC-women.
Hjelmstedt, 2003 Sweden	Quantitative study, prospective longitudinal design	To compare IVF and SC women and men regarding psychological variables and to study whether the IVF-couples’ recalled infertility distress and the way they responded emotionally to the pregnancy are associated.	57 Pregnant IVF-women and 55 male partners and 43 pregnant SC women and 39 male partners.	Self-reported measures: Infertility Reaction Scale, Barnett scale, Karolinska Scales of Personality (KSP), STAI, Emotional Responses to Pregnancy Scale (ERPS) around 13 weeks gestation.	During early pregnancy, IVF-couples are more anxious about losing the pregnancy compared to SC-couples.
Hjelmstedt, 2006 Sweden	Quantitative study, longitudinal cohort design	To compare prenatal attachment among IVF-women and SC-women and to study relationships between attachment and psychosocial variables.	56 Pregnant IVF-women and 41 pregnant SC-women.	Self-reported measures: Prenatal Attachment Inventory (PAI), STAI, KSP, EPDS, Barnett Scale (marital relationship), ERPS at 26 and 36 weeks gestation.	Method of conception was not related to prenatal attachment, indicating that IVF-mothers are attached to their unborn children equally as SC-mothers.
Huang, 2019a Taiwan	Qualitative study, phenomenological design	To explore the experiences of pregnancy and transition to parenthood of first-time mothers following successful ART treatment.	12 Women who experienced pregnancy and gave live birth after ART.	Individual, in-depth semi-structured interviews at 8 to 18 weeks postpartum.	Participants felt different from SC-women. Pregnancy gave mixed feelings: excitement, joy, uncertainty, anxiety. As pregnancy progressed, intense anxieties increased and they felt under constant psychological pressure. Relying on their family’s assistance and support worked well. They worried about the impact of ART on their baby and own health. Participants ensured the health and safety of the fetus by quitting their jobs, reducing psychical activity and monitoring fetal movement constantly to maintain peace of mind.
Huang, 2019b Taiwan	Quantitative study, longitudinal design	To investigate changes over time in psychological health of ART-women during the trimesters of pregnancy and during the postpartum period.	158 pregnant ART-women	Web-based questionnaires- Edinburgh Postnatal Depression Scale, State Anxiety Inventory, Modified Maternal Fetal Attachment Scale, Maternity Social Support Scale, Pregnancy Stress Rating Scale, Intimate Bond Measure, and Parenting Stress Index. Data collection in trimesters of pregnancy and at 7–10 weeks postpartum.	Psychological health (Anxiety and depression) was found to be poorest during the first trimester and at two-months postpartum. The most important predictors of change in psychological health during pregnancy and the postpartum period were antenatal stress and social support.
Lehto, 2019 Finland	Narrative qualitative study	To explore how women who experienced infertility and underwent fertility treatments constructed maternal identities after they successfully gave birth.	Twenty-six previously infertile Finnish women who later conceived after fertility treatment		Four different identity stories emerged from the data: Fractured Maternity, Pursuing Maternity, Learning Maternity, and Discovering Maternity. Infertility, its treatment, and childbirth were narrated as turning points in the participants’ life courses, but the significance of these turning points for maternal identity varied across the four stories. Infertility and its treatment clearly left marks on our participants. Becoming a mother after years of infertility is not a straightforward process and does not follow the same pattern for everybody.
Ranjbar, 2015 Iran	Qualitative study, phenomenological design	To explore how women make sense of assisted pregnancy in Iranian culture and context and to describe the meaning of pregnancy through ART.	12 Women who experienced pregnancy through ART.	Semi-structured, in-depth interviews at no specific time.	Participants experienced paradoxical feelings: joy, fear, hope, uncertainty. They had doubts about being pregnant, were concerned about miscarriage and the health of the fetus. The uncertainties made that some women did not allow to start to feel attachment to their fetus. They also demonstrated a variety of adjusting behaviors and felt uncomfortable talking about their pregnancies.
Sahin, 2020 Turkey	Qualitative study; descriptive design	To gain a more in‐ depth understanding of the processes in which infertility affected the kinds of psychological and social consequences they experienced.	11 Pregnant ART-women in the first or second trimester of pregnancy	Semistructured, in-depth interview	The social experiences of women when they got pregnant were defined under the sub‐themes “the meaning of motherhood and being a family,” “feeling comfortable and valuable in society,” and “facing difficulties during pregnancy.” The women stated that they envied pregnant women during the treatment and that they wanted to get pregnant and experience these feelings. However, some participants stated that the pregnancy process was not as they thought or as they were told.
Warmelink, 2016 The Netherlands	Qualitative study, descriptive design	To explore the care needs of ART-women, using the research question: “What are the midwifery care needs during pregnancy of couples of women who have conceived as a result of fertility treatment?”.	2 ART-couples and 7 individual ART-women.	Semi-structured, in-depth interviews at no specific time.	ART-couples had paradoxical feelings concerning their antenatal care needs because of the normalcy/non-normalcy of their pregnancies. Some couples said that midwives could have paid more attention to the impact of their ART history. Participants indicated the need for more psychosocial support as they were often anxious about the course of the pregnancy and found it difficult to communicate these feelings. They also wanted more frequent checkups and ultrasounds.

Assisted Reproduction Technology (ART).

women who conceived through Assisted Reproduction Technology (ART-women).

In Vitro Fertilization (IVF).

Maternal-fetal attachment (MFA).

Maternal-Infant Attachment (MIA).

Women who conceived spontaneously (SC-women).

Table 3. Themes and subthemes derived from 15 studies included in a mixed methods literature review on antenatal care needs of women who conceived through fertility treatment.

Theme	Subtheme	Related articles^a
Behavioral needs	Lifestyle behavior, exercise, nutrition and compliance	De Pascalis 2012, Huang 2019a, Ranjbar 2015
Relational/social needs	Relationship with fetus (Maternal Fetal Attachment)	Chen 2011, Hjelmstedt 2006, Ranjbar 2015
	Relationship with partner, family, friends and larger social network	Crespo 2016, De Pascalis 2012, French 2015
Emotional needs	Adjustment to pregnancy, general well-being	De Pascalis 2012, French 2015, Huang 2019ab, Letho 2019, Ranjbar 2015, Sahin 2020, Warmelink 2016
	Anxiety, depression	Chen 2019, Crespo 2016, Dornelles 2014, French V, Gourounti 2013, Hjelmstedt 2003, Huang 2019ab, Ranjbar 2015, Warmelink 2016
Cognitive needs	Knowledge and concerns	Dornelles 2014, French 2014
Women’s preferences about maternity care		Crespo 2016, French 2014, Ranjbar 2015, Warmelink 2016

^aOnly the first authors are listed.