Over the past few decades, climate change has increased the scale of disasters,1 which have altered the lives of millions of people and will continue to do so.2 In this context, supporting pregnant people is essential because the prenatal development and birth of children do not stop during natural disasters. However, it is difficult for support to reach pregnant people for various reasons, including that they do not speak up because they feel that other people are experiencing a more complicated situation or they cannot tell others that they are pregnant.3 The number of professionals who have experience supporting pregnant people in natural disasters is limited, and it is unclear what kind of experience pregnant people have. For this reason, this review focuses on pregnant people. People who have already experienced childbirth will be excluded because the experiences of people before and after childbirth may differ.
Pregnancy is an important developmental stage4 and a period of psychological and social preparation for mothers to accept the child into their self-system and living space.5 As the starting point of the mother-child relationship, it is necessary to prepare for childbirth and childcare during pregnancy. Pregnant people experience physical and psychosocial changes as their pregnancy progresses, and most of these physical changes result from hormonal influences caused by the growth of the fetus inside the uterus, as well as the mother's physical adaptation to the changes.6 Therefore, it is necessary to understand and support people experiencing this complex process during pregnancy.
High impact events, such as natural disasters, significantly affect pregnant people's cognitive processes and behaviors.5 These effects must be investigated and understood to support pregnant victims of natural disasters. Qualitative studies on pregnant people affected by natural disasters have focused on their needs, problems, concerns, and the means of addressing these problems.3,7-10 These studies demonstrated that pregnant people's needs increase during disasters due to the consequent physical and mental changes. However, it is difficult for support to reach all pregnant people. Some people may experience abnormal pregnancy symptoms during the evacuation, which may cause worry and concern9; however, most prioritize survival in the immediate aftermath of a disaster, rather than focusing on their symptoms.9,10 Further, they may have trouble accessing social infrastructure, including networks and government and medical institutions.3 Maternity experiences vary in the first, second, and third trimesters of pregnancy.5 For instance, it may be challenging to ascertain if someone is pregnant by just looking at them in the first trimester, while an enlarged abdomen may be evident in the third trimester, interfering with evacuation activities. A person's stage of pregnancy can affect their decisions and how they act during evacuation from a disaster.7 Therefore, to understand the experiences of pregnant people throughout pregnancy, the target population of this review includes people in all trimesters of pregnancy.
When a disaster occurs, the medical needs of pregnant people increase.11 Quantitative studies indicate that disasters have physical, mental, and social effects on pregnant people. The physical and mental effects include changes in the child's birth weight,12,13 deterioration of nutritional status,14 depression and post-traumatic stress disorder (PTSD),15-17 and lack of confidence in parenting.18 Among demographic factors and social services, impacts such as poor functioning of perinatal health care services,19 and changes in neonatal and infant mortality rates20 have been reported. Pregnant people's health is affected by biological, natural environmental, and socioeconomic factors; moreover, disasters affect pregnant people as well as their fetuses.12,13
A quantitative systematic review by Harville et al.21 revealed the effects of disasters on perinatal health. The review discovered that experiencing a disaster may reduce fetal growth for some, although no effect was found on gestational age at birth. While some studies have found little evidence that earthquakes cause premature births,12,18 others have reported an increase in premature births due to dam rupture accidents22 and earthquakes.13 Methodological limitations, including cross-sectional designs, different numbers of subjects, geographical characteristics, and confounding factors, may explain the inconsistencies in previous findings.
Another quantitative systematic review by Khatri et al.23 explored the prevalence and determinants of clinically significant symptoms of antenatal common mental disorders among women who had recently experienced an earthquake. The review summarized the following risks: negative coping styles have been demonstrated as higher marital conflict, poor social support, multiparity, and stresses of pregnancy. Positive coping styles have been identified as protective against antenatal common mental disorders. Further, a quantitative systematic review by Ren et al.24 explored the potential psychological impact of earthquakes on peripartum women. In this review, depression and PTSD were the most commonly reported mental disorders. Several factors, including family relationships and social support, were associated with mental disorders in perinatal women who had experienced an earthquake.
However, the 2 systematic reviews presented above only included quantitative studies. To adequately support pregnant people during disasters, their critical medical resources (namely nurses, midwives, and other professionals) need to develop and provide support services based on complex factors, such as family relationships, social support, and stress. It is essential to know the situations and conditions experienced by pregnant people during a disaster to accomplish this, which requires qualitative analyses.
A search of the Cochrane Library, JBI Evidence Synthesis, PROSPERO, MEDLINE, and PubMed databases did not reveal any previous or planned systematic reviews of qualitative evidence on pregnant people's experiences of natural disasters. The absence of such systematic reviews was identified as a gap in the existing literature. A review of the relevant studies reporting the experiences of pregnant people during disasters will increase and improve our understanding of the difficulties they face and the way they cope, which may provide health care workers with valuable information for developing supportive measures for pregnant people.
This qualitative systematic review aims to identify, appraise, and synthesize existing qualitative evidence regarding the experiences of pregnant people during a natural disaster. It will also provide a deeper understanding of the complex factors that influence their experiences.
What are the experiences of pregnant people during a natural disaster?
The review will consider qualitative studies that include pregnant people living in disaster areas during natural disasters. People in all trimesters of pregnancy will be considered regardless of their age or marital status. Pregnant people may change their residence after marriage or temporarily move to their parents’ homes, therefore, no minimum duration of living in the affected area will be considered; however, those in the affected area temporarily will be excluded (eg, just visiting or there for work). We will not consider people with high-risk pregnancies, including those with maternal and/or fetal morbidities, such as previous placenta pravia or pregnancy-specific hypertensive disease, as they are not the focus of our study.
Phenomena of interest
This review will include descriptions of experiences, including perceptions, meanings, cognitive processes, and behaviors, focusing on pregnant people's experiences of living through a geophysical, meteorological, hydrological, or climatological disaster. There are 6 types of natural disasters: i) geophysical disasters, such as earthquakes or volcanic activity; ii) meteorological disasters, such as storms or extreme temperatures; iii) hydrological disasters, such as floods or landslides; iv) climatological disasters, such as droughts or wildfires; v) biological disasters, such as epidemics or insect infestations; vi) and extra-terrestrial disasters, such as astronomical impacts or space weather.25 The natural disasters considered in this study are geophysical, meteorological, hydrological, and climatological. Geophysical disasters are less predictable than meteorological and hydrological disasters, and as a result, are more likely to cause fear and anxiety due to the suddenness of the event. In meteorological and hydrological disasters, evacuation may be disrupted and delayed. Climatological disasters refer to hazards caused by long-lived, meso- to macro-scale atmospheric processes, which differ in the duration and diffusion of their effects. Biological and extra-terrestrial disasters are markedly different in terms of their origins, the meaning of spread, type, and severity of impact; hence, they are excluded from the study. Furthermore, the review will exclude social or communal disputes, acts of terrorism, and wars since they are anthropogenic disasters. Data will include information collected during pregnancy and after childbirth. Any time duration between the disaster experience and the interview will be acceptable. In addition, due to the limited availability of qualitative data, the gender and occupation of the individuals who collected the interview data will not be considered.
This review will include all primary studies with data collected through interviews and observations, independent of the location (eg, health care facilities, home, temporary shelters) where these data were collected. Additionally, all health care system and financing types (eg, private systems, universal and free access to health care, mixed health care systems) will be considered.
Types of studies
The review will include studies focused on qualitative data, including, but not limited to, phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research. Qualitative data from mixed methods studies will also be included. Studies that use statistical reports of results, clinical case reports, historical analysis, review articles, meta-analyses or meta-syntheses, editorials, commentaries, letters, conference abstracts, and studies with the full text not available will be excluded.
The proposed systematic review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence.27 This protocol is registered in PROSPERO (CRD42021265326).
The search strategy was developed with the aid of a librarian and aims to find both published and unpublished studies with data collected through interviews and observations. A 3-step search strategy will be utilized in this review. The population, phenomena of interest, and context (PICo) framework will be used to extract search terms for the review question. An initial limited search of MEDLINE (English) and Ichushi-Web (Japanese) will be conducted, followed by textual analysis of the title, abstract, and index terms of the obtained article. A second search using all identified keywords and index terms will be performed across all included databases. Finally, the references of all identified reports and articles will be used to search for additional studies.
The databases and other sources to be used for our research include MEDLINE (EBSCO), CINAHL with full text (EBSCO), PsycINFO (EBSCO), CiNii, and Ichushi-Web (Japanese medical literature database). References from the included studies will also be cross-checked with search outcomes to identify any additional studies. The search for gray literature will be performed using Google Scholar and ProQuest. Almost 20 years have passed since natural disaster classification was developed in 200226; therefore, this systematic review will consider studies published from 2002 to 2021 in English or Japanese.
Following the search, all identified citations will be collated and uploaded into EndNote Basic (Clarivate Analytics, PA, USA), and duplicates will be removed. Two independent reviewers will screen the titles and abstracts to assess the inclusion criteria for the review. Potentially relevant studies will be retrieved in full, and their citation details will be imported into the JBI System for the Unified Management, Assessment, and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of the selected studies will be retrieved and assessed in detail against the inclusion criteria by 2 independent reviewers. Full-text studies that do not meet the inclusion criteria will be excluded. The reasons for exclusion will be provided in an appendix of the final systematic review. The results of the search will be fully reported in the final review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram.28 Any disagreements that arise between the reviewers will be resolved through discussion or by a third reviewer.
Assessment of methodological quality
Each paper selected for retrieval will be assessed independently by 2 reviewers for methodological quality using the JBI critical appraisal checklist for qualitative research27 prior to inclusion in the review. Where required, authors will be contacted to request missing or additional data for clarification. Any disagreements about the quality of studies between the 2 reviewers will be resolved through discussion or consultation with a third reviewer. The results of the critical appraisal will be reported in narrative format and in a table. All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (when empirical study findings are available).
Qualitative data will be extracted from papers included in the review by 2 independent reviewers using the standardized data extraction tool from JBI SUMARI.27 The data extracted will include specific details about the populations, contexts, cultures, geographical locations, study methods, and phenomena of interest relevant to the experiences of pregnant people affected by natural disasters. The level of congruency between the findings and the supporting data will be graded for credibility on 1 of 3 levels: unequivocal, credible, or unsupported. Any disagreements arising between the reviewers will be resolved through discussion or by a third reviewer. When required, authors of specific papers will be contacted to request missing or additional data.
Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.29 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings on the basis of similarity in meaning. These categories will then be subjected to a synthesis in order to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative format.
Assessing confidence in the findings
The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.30 The Summary of Findings will include the major elements of the review and details on how the ConQual score was developed. The title, population, phenomena of interest, and context for the specific reviews will be included in the Summary of Findings. Each synthesized finding from the review will then be presented, along with the type of research informing it, scores for dependability and credibility, and the overall ConQual score.
The Graduate School of Nursing, Chiba University, for providing JBI Comprehensive Systematic Review training.
SS participated in relief activities for pregnant people during disasters in Japan, the Nepal earthquake, and the Mozambique cyclone. SS, NS, and MM authored a recently published paper on pregnant people affected by the 2016 Kumamoto earthquake for Health Emergency and Disaster Nursing.
SS was responsible for the study conception and design, and drafting of the manuscript. NS and MM critically reviewed the manuscript and supervised the overall review process.
Appendix I: Search strategy
Search conducted: January 7, 2022
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