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American Journal of  Medical 
Science and Innovation (AJMSI) 

Influence of  Covid-19 Pandemic on Prenatal Care Utilization and Birth outcome:
Qualitative Systematic Review Protocol

Khulud Alhussain1*, Fatimah Alhussain2, Jasmine Mirasol2, Najla Alotaibi3

Volume 2 Issue 2, Year 2023
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v2i2.2226
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: November 05, 2023
Accepted: December 02, 2023
Published: December 05, 2023

The COVID pandemic disrupted routine prenatal care, yet little is known about expectant 
mothers’ experiences during this time.  This qualitative systematic review aims to synthesize 
evidence on the experiences, views and impact of  COVID on prenatal care utilization and 
birth outcomes. A systematic search is conducted in 5 databases and Google Scholar. Studies 
providing qualitative data on pregnant women’s experiences accessing prenatal care during 
COVID are included. Methodological quality is assessed using CASP and thematic synthesis 
is used to analyse the data. Even among these patients from affluent backgrounds, those who 
responded to the survey stated that the pandemic had significantly disrupted many parts 
of  their daily lives and medical care, especially regarding social activities and postpartum 
support. Our findings make it clear that, in addition to increased support from healthcare 
systems, counseling on coping mechanisms and stressor adaptation techniques should be a 
part of  perinatal care during public health emergencies for everyone. Results have provided 
an in-depth understanding of  pregnant women’s experiences with barriers and facilitators 
to prenatal care during COVID, and the impact on maternal and neonatal outcomes. This 
review has identified recommendations to improve prenatal care access and quality during 
future health crises, contributing to more resilient and equitable maternity care systems. 

Keywords
COVID, Prenatal, Pregnancy, 
Postnatal, Healthcare

1 School of  Health Sciences, University of  Dundee 11 Airlie Pl, Dundee DD1 4HJ, United Kingdom
2 Badayah General Hospital. Jubail P.O.Box: 10566, Postal Code: 31951, Jeddah, Saudi Arabia
3 King Salman Hospital. P.O. Box 66833. Riyadh 11586. Kingdom of  Saudi Arabia
* Corresponding author’s e-mail: kh4tah@hotmail.com

INTRODUCTION
The COVID pandemic has caused changes in the 
countries, even developed or developing countries, and 
these changes disrupted the health system, particularly 
routine care across the world. Little is known about the 
expectant mother’s perception and experience of  prenatal 
care during COVID-19. 
The COVID-19 virus was discovered for the first time 
in China in 2019 and rapidly spread to the rest of  the 
world. The pandemic had a huge influence on the world, 
affecting nearly every business and mode of  life as people 
were obliged to adapt new ways of  living in order to curb 
the disease’s spread (Zhu et al., 2020). The pandemic has 
had an impact on people’s lives, not only via COVID-19 
infections but also through government efforts to restrict 
mobility and social interaction in order to reduce the 
virus’s spread (Hale et al., 2021).  
According to Akowuah et al. (2018), the WHO defines 
antenatal healthcare as “care a pregnant mother receives 
before birth” and includes education, screening, 
counseling, minor ailment treatment, and immunization 
services.  Moreover, antenatal care reduces mother 
morbidity and mortality by giving knowledge about risk 
indicators, health promotion, birthing preparation, and 
postpartum care (Ayalew & Nigatu, 2018). Pregnant 
women are a different demographic that needs specialized 
mental and physical health care. Pregnancy and delivery 
are among the leading causes of  women’s hospitalisation, 
and birth-related procedures are used in evaluating global 
health quality (Kozhimannil et al., 2013).  In accordance 
with official regulations, maternity care facilities have 
also implemented sanitary measures to control the 

spread of  the virus and protect health workers, expecting 
mothers, and their new-borns (Montagnoli et al., 2021). 
These measures include the exclusion of  partners from 
face-to-face antenatal and postnatal appointments, the 
instauration of  telehealth consultations, the prohibition 
of  visitors, sometimes giving birth without the presence 
of  a partner, and the cancellation of  parent education 
classes or birth afterthoughts sessions (Węgrzynowska et 
al., 2020). 
It is critical for pregnant women to have high-quality 
prenatal care in order for their unborn children to grow 
normally and for them to be healthy. Prenatal care and 
antenatal outcomes have both directly and indirectly 
been affected by the epidemic. According to recent 
research carried out by in the United States, a decline in 
antenatal care (ANC) coverage ranging from 39.3% to 
51.9% owing to the pandemic might possibly result in a 
further 56,700 maternal fatalities (Ephi, 2019). Notably, 
the COVID-19 pandemic has had an indirect influence 
on pregnancy outcomes, with a considerable drop in 
institutional deliveries occurring during strict lockdown 
times. This reduction is linked to issues such as the lack 
of  transportation, concern about contagion and disturbed 
healthcare systems. Furthermore, economic problems 
during the pandemic  have slowed access to healthcare 
services (Goyal et al., 2021). 
Moreover, a reduction in prenatal visits and hospital 
births may lead to greater issues during pregnancy, 
increasing the need for intensive care and increasing 
maternal death rates. As a result, the pandemic might 
hinder worldwide attempts to achieve maternal health-
related sustainable development targets(Goyal et al., 



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2021; Khalil et al., 2020). Furthermore (Chmielewska et 
al., 2021) claimed that, gaps in care exposed expecting 
mothers to great risk during the COVID-19 pandemic, 
possibly leading to undesirable delivery outcomes and 
increased mortality. This qualitative systematic review 
protocol aims to synthesis qualitative evidence on the 
experience and perception of  the expectant mothers on 
accessing prenatal care service during the COVID-19 
pandemic and how care changes may have impacted on 
their birth outcome. In order to learn more about how 
affluent obstetric patients adjusted to the COVID-19 
pandemic’s effects on perinatal care and postpartum 
support, we polled a group of  these patients. Our 
objective was to comprehend how COVID-19 affected 
their perinatal care experiences, general wellbeing, and 
coping mechanisms. By reviewing the qualitative studies 
from various countries to obtain in depth understanding 
of  the expectant mother’s care experiences in this health 
crisis. It also assesses to synthesize qualitative evidence on 
pregnant women experience with prenatal care disturbed 
during pandemic and how these disruptions have 
influence on maternal and child health outcome. This 
systematic qualitative review protocol could contribute 
to shape recommendations for improving prenatal care 
access during health-care system disruptions.
This Qualitative systematic review protocol aims to 
synthesise the qualitative systematic review and will 
provide answer for the following research question:

Research Questions
1. What are the experiences, views and perceptions of  

the expectant mothers in accessing perinatal care during 
the COVID-19 pandemic?

2. What are challenges and barriers faced by the mothers 
in accessing the perinatal care during the pandemic, 
including disruption of  the routine care and changes in 
the health care system?

3. How have these changes in perinatal care services 
system during COVID-19 influences on maternal and 
neonatal outcome, and overall well-beings?

4. What potential strategies and recommendations can 
be identifies from the qualitative evidence can enhance 
the perinatal care access and quality in the context of  the 
global health crisis?

LITERATURE REVIEW 
The global economy, society at large, and healthcare 
systems have all suffered as a result of  the COVID-19 
pandemic. One of  the most fragile health systems in the 
world is still the one in Liberia.  The current Covid-19 
epidemic and the Ebola outbreaks that occurred in 
2014–2016 are the main causes of  Liberia’s health 
system’s instability (Kezelee et al., 2023) .The pandemic-
related lockdowns, fear of  seeking medical attention, 
and disruptions in healthcare services have probably had 
an impact on women’s and their children’s health. The 
COVID-19 pandemic is posing challenges for maternal 
and child health services(Lalor et al., 2023). A study 

carried out in low- and middle-income nations predicted 
that 28,000 maternal deaths could occur from a 10% drop 
in the coverage of  critical healthcare services for expectant 
mothers and new-borns(Wall & Dempsey, 2023).
In low- and middle-income countries, the pandemic has 
caused disruptions to healthcare services, which has 
resulted in a decrease in critical interventions related to 
maternal and child health. Worsening maternal health 
outcomes have been linked to changes in healthcare-
seeking behaviour and a decrease in maternity 
services(Senkyire et al., 2023). Maternal mortality, ectopic 
pregnancies, maternal depression, ruptured pregnancies, 
and stillbirths have all increased, according to a systematic 
review and meta-analysis. The literature claims that 
pregnant women infected with COVID-19 have a more 
severe form of  the illness, increasing their risk of  death 
by up to 35.0 percent and leading to almost a quarter 
of  them developing pneumonia (El Debek, 2023). 
Additionally, there is evidence indicating a worsening 
of  fetal outcomes, with higher rates of  stillbirth and 
preterm birth(Geleto et al., 2023). The COVID-19 
pandemic presents a serious obstacle to the provision of  
necessary maternity, new-born, and child health services 
in many nations. Because of  limitations, anxiety, fear 
of  contracting the virus, and transportation concerns, 
women may have trouble getting access to maternity 
healthcare(Septianingrum et al., 2023). The use of  crucial 
maternity healthcare services has significantly decreased, 
according to a systematic review and meta-analysis.
Maternal health services have been disrupted and the risk 
of  maternal illness and death has increased as a result 
of  the resources being diverted toward the pandemic 
response. This makes managing COVID-19 while 
providing necessary services across the maternity care 
continuum even more difficult(Tungwarara & Godfrey 
Musuka, 2023). Recent data indicates that maternity 
care given to mothers during pregnancy, childbirth, and 
the postpartum period may have been influenced by 
government initiatives such as stay-at-home directives, 
women’s healthcare-seeking behaviour, community 
perception, perceived low quality of  care during the 
pandemic, and fear of  contracting COVID-19.On 
March 13, 2020, Ethiopia announced the country’s first 
COVID-19 case that was confirmed(Chua et al., 2023). 
As a result, people were told not to travel around much, 
were not allowed to get together, and anyone who thought 
they might have the virus had to notify the local health 
authorities. In addition, upon arrival, foreign visitors had 
to self-isolate for 14 days and show a negative COVID-19 
test result(Lee & Singh, 2023). There is a dearth of  
national data regarding the effect of  COVID-19 on the 
use of  critical maternity healthcare services in Ethiopia. 
Furthermore, not enough information has been provided 
about the obstacles pertaining to the government and 
healthcare facilities, as well as the ways in which individual 
and community perceptions affect the use of  maternal 
healthcare services during the pandemic(Cruz-Ramos 
et al., 2023). Thus, by estimating the overall decline and 



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difficulties in the use of  crucial maternal healthcare 
services in Ethiopia, this systematic review and meta-
analysis sought to close this gap.

METHODOLOGY
The systematic review is done in accordance with the 
Centre of  Research and Dissemination Guidelines (CRD, 
2021). The CRD focuses on gathering, synthesizing, 
and evaluating research evidence from a wide range of  
studies to generate evidence that can be used to enhance 
healthcare practice and policymaking.  The enhancing 
transparency in reporting qualitative research synthesis 
(ENTREQ) (See Appendix A) checklist is used in this 
systematic review, as it was developed to encourage 
explicit and comprehensive reporting of  qualitative 
studies synthesis (Tong et al., 2012). The report is also 
done following the Preferred Reporting Items for 
Systematic Reviews and Meta-Analyses Protocols 
(PRISMA-P) 2015. PRISMA-P guideline (See Appendix 
B) is an internationally recognized protocol that helps in 
improving accuracy, completeness, and transparency in 
systematic reviews. and meta-analyses(Moher et al., 2015). 
Thus, ENTREQ and PRISMAP-P 2015 is used to cover 
all the necessary process of  making systematic review of  
qualitative evidence.

Eligibility Criteria 
Inclusion and Exclusion Criteria
The inclusion criteria set boundaries for the review, 
indicating which studies are possibly relevant to the study 
and which are not (Stern et al., 2014). 
Inclusion Studies were considered if  they met the 
following criteria:

• Qualitative studies, such as but not limited to 
interviews, focus groups, and observations, as well as 
mixed-method studies having a significant qualitative 
component.

• Studies focusing on pregnant women’ experiences 
and views of  obtaining prenatal care services during the 
COVID-19 epidemic.

• Studies that investigate the obstacles and restrictions 
that pregnant women had in getting prenatal care during 
the pandemic, including as interruptions in routine care 
and changes in the healthcare system.

• Studies that examine the influence of  care changes on 
birth outcomes include mother and neonatal health and 
over all well beings. 

• Studies that have been published in English or have 
an English translation accessible.

• Studies conducted and published during the 
COVID-19 pandemic, perhaps beginning in 2020.

Exclusion Criteria
• Studies that are solely quantitative based and do not 

include any qualitative components.
• Studies that tend to focus on pregnant women’ 

experiences and views of  obtaining prenatal care during 
the COVID-19 epidemic.

• Research that focuses only on the experiences of  
healthcare professionals or other stakeholders without 
taking into account the views of  pregnant mothers.

• Studies that do not investigate the challenges and 
barriers that pregnant women had in getting prenatal care 
during the pandemic, as well as the possible influence of  
service alterations on birth outcomes.

• Studies published in languages other than English 
without English translation available.

• Studies that were done and published before to the 
COVID-19 pandemic or after the epidemic were declared 
over by relevant health authorities.

Information Sources 
The search is done on five key electronic databases. 
The first one will be the Cumulative Index to Nursing 
and Allied Health Literature (CINAHL) database. 
When performing a review of  qualitative evidence, the 
CINAHL database is generally thought as reliable source 
to search (Wright et al., 2015). The second electronic 
database is Excerpta Medica Database (EMBASE) which 
is contains published information. The third source is 
Medical Literature Analysis and Retrieval System Online 
(MEDLINE) which is a bibliographic database on issues 
related to biomedical and life sciences. The fourth source 
is the (PsycINFO), an electronic database with studies 
on psychology. The final data base is the (SCOPUS) and 
finally Search engines like Goggle and Google Scholar is 
utilised to search for additional studies. The information 
obtained through the six sources is used to answer the 
formulated research question.

METHODOLOGY
The five electronic databases are used in the current 
review contain a wide range of  information on healthcare 
challenges Therefore, the need to select and identify 
specific articles related to the topic of  discussion. The main 
search terms for this study include ‘Covid-19’ ‘Pandemic’ 
‘prenatal care’ ‘perinatal care’ ‘antenatal care’ ‘Expectant 
mothers’ ‘pregnant women’ ‘maternal health’ ‘neonatal 
health’ ‘experiences’ ‘perceptions’ ‘access to health care’ 
‘barrier’ ‘challenge’ ‘health care system’ ‘disruptions’ 
Search terms are matched with the appropriate Boolean 
operators (‘OR’ ‘AND’ ) to connect the search as well as 
medical subject headings (MESH) terms. Titles, abstracts, 
and themes are searched for terms. To find additional 
articles, the reference lists of  the included studies and 
studies that quote the listed research are searched.

Selection Process
Titles, abstracts, and complete texts are reviewed for 
eligibility by the PI (KH) and 40 % are randomly 
checked by the screeners in this study. Full-text articles 
are retrieved once it meets the inclusion criteria. If  the 
title and abstract are insufficient to determine inclusion, 
the complete text was requested. Then, if  complete texts 
were not available, the relevant authors of  the research 
was contacted. Screeners discussed eligibility until an 



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agreement is achieved if  it is unclear at the title, abstract, 
or full-text stage. If  no agreement is achieved, a third 
independent screener was served as an adjudicator. 
Exclusion reasons were documented at each level, and 
the inclusion and exclusion process were documented 
with a flow diagram, as recommended by the PRISMA 
guidelines (Moher et al., 2009). The endnote software 
version x20 was used to encode.

Data Extraction and Management 
The data extraction process was performed by the PI and 
three reviewers. The first reviewer re-examined the articles 
and gather the relevant information about the topic from 
the PI, while the second reviewer validated the gathered 
information by the first reviewer.  The data extraction was 
based on a predetermined form incorporating important 
components of  the studies. The main concepts addressed 
in the forms included in bibliographic details, a summary 
of  the study design, study participants (pregnant mothers 
faced the challenges on accessing the perinatal care 
during COVID-19 pandemic regardless of  age, ethnicity, 
occupation status, economic status, and educational 
level), and aim of  the study, evidence appraisal, results, 
and conclusion. Any concerns that occur throughout the 
process were handled by a consensus discussion between 
the reviewers. The reviewers used systematic approach 
to ensure that the comprehensiveness of  information 
(Campbell, 2010). In cases where further information is 
required, the reviewers contacted the authors to collect 
missing data or insights into the articles before proceeding 
to the next step of  the project. Data extraction, analysis, 
and duplicate removal will be used by Microsoft excel.

Critical Appraisal
The included papers will be evaluated using the Critical 
Appraisal Skills Programme Qualitative Research 
Checklist (CASP). The CASP tool is a commonly 
used checklist/criteria-based tool for quality appraisal 
in health and social care-related qualitative evidence 
syntheses (Long et al., 2020). The checklist contains 
ten items that address the following: the study aims, 
methodology, design of  the studies, recruitment, data 
collection method, participant-researcher relationship, 
ethical considerations, data analysis, findings, and the 
study value(Coates et al., 2019). In addition, the Critical 
Appraisal Skills Programme (CASP) is a checklist for 
qualitative studies that provides as a quality assessment 
tool and recommended by Cochrane to use. Thus, this 
tool was chosen because it provides for rapid review 
through the use of  a 10-item checklist which can easily 
be used by the researcher. Moreover, the checklist can be 
applied to several types of  qualitative designs to assess 
the studies’ credibility, transferability, dependability, and 
conformability(Aziz et al., 2016).

RESULTS
The data was extracted for all studies included in the 
review, and qualitative summaries were generated. The 

generated data is analysed by using thematic analysis. A 
theme is described as a consistent combination of  various 
pieces of  data that create the findings (Sandelowski, 
2000). Thematic analysis includes searching for and 
finding common themes throughout given data 
(DeSantis & Ugarriza, 2000). According to Braun and 
Clarke, (2006), thematic analysis is a comprehensive and 
useful research approach that provides a full, detailed, 
and nuanced explanation of  data. The importance of  a 
theme is determined not by quantifiable measures, but 
rather by whether it captures everything vital in relation 
to the research aim (Braun & Clarke, 2006). The six 
analytical phases defined by Braun and Clarke (2006) are 
the following: (a) becoming acquainted with the data, (b) 
developing initial codes, (c) searching for themes among 
codes, (d) reviewing themes, (e) defining and naming 
themes and (f) completing the final report. The included 
studies will be read several times and classified by using 
preliminary codes to identify sub-themes among the 
articles. The sub-themes were formed from descriptive 
information within the data and can be considered as an 
expression of  the text’s manifest sub-themes (Graneheim 
& Lundman, 2004). Following the familiarisation process, 
it will produce the initial codes for sub-themes of  interest 
across all articles in a systematic way. Despite the fact 
that the main goal will guide the research, the initial sub-
themes were data-driven without trying to integrate the 
sub-themes into a previous thematic framework. Then 
carefully discussing subthemes that emerged from the 
data to arrange the overall theme. All the themes that 
were examined were part of  a recursive process in which 
they were moved back and forth between the studies and 
the identified themes (Braun & Clarke, 2006). The themes 
will then be reviewed several times to ensure that they 
accurately and completely represent the coded semantic 
extraction of  the data. Each sub-theme within the topics 
is described as closely to the source studies as possible, 
with direct quotations included if  available (see figure 3).

DISCUSSION
Pregnant women reported feeling more fear, uncertainty, 
and anxiety during the COVID-19 pandemic, according 
to research(Cox et al., 2023). One of  the main 
causes of  these symptoms has been found to be the 
absence of  information given during prenatal care as 
a result of  cancelled or remote appointments. It has 
become challenging to deliver consistent and accurate 
information due to the ever-changing health restrictions 
and protocols(Tikouk et al., 2023). Women have felt less 
prepared and informed as a result, which is consistent 
with earlier research that links a lack of  information 
to unfavourable childbirth experiences and elevated 
anxiety and fear in mothers. Promoting healthy practices 
during pregnancy on the basis of  reliable information is 
crucial(Septianingrum et al., 2023).
Because of  the protective measures that were put in place, 
the women in this study felt secure during their hospital 
stays, even in spite of  any potential misinformation 



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during pregnancy. This result is in line with earlier 
studies showing that in less congested hospitals, these 
measures offered patients privacy and peace of  mind. 
Healthcare providers concentrated on giving women a 
normal birth experience even though prenatal care may 
have been compromised during the pandemic(Alabi et 
al., 2023). The mothers’ perception of  their experience 
as safe and positive was probably greatly aided by the 
close support these professionals offered. Despite the 
workload, physical and mental exhaustion, and fear of  
contagion experienced by healthcare workers during the 
pandemic, emotional and practical support is a crucial 
component in boosting confidence during labour and can 
be maintained(De Genna et al., 2023).
The fact that women voluntarily choose to isolate 
themselves out of  a fear of  spreading infection is another 
finding that is consistent with earlier research. Despite the 
fact that lack of  social support and worries about infection 
have been linked to postpartum depression, the mothers 
in this study said they appreciated the closeness and peace 
that the COVID-19 health restrictions provided(Jahromi 
et al., 2023). This pandemic-era postpartum way of  life is 
reminiscent of  customs from other cultures. For instance, 
in order to avoid infections, strengthen their bond with 
their infants, and accept their new role as mothers, new 
mothers customarily spend up to sixty days at home 
alone. Perhaps there are unacknowledged advantages to 
postpartum isolation in Western societies. As a result, 
cultural expectations surrounding early motherhood 
ought to be modified to accommodate each individual’s 
physical and psychological needs(Thapaliya et al., 2023).
In addition to the findings discussed in this review, it is 
crucial to emphasize the promotion of  emotional well-
being and self-care among healthcare professionals. This 
becomes especially important during times of  crisis, such 
as the COVID-19 pandemic, which has placed immense 
pressure on the healthcare sector(Toh & Shorey, 2023). 
Healthcare professionals who are calm, composed, and 
well-informed can enhance communication with patients 
and foster trust, ultimately leading to the provision of  
better overall healthcare services(Tungwarara & Godfrey 
Musuka, 2023).

Future Implications 
This review study has future implications for the 
researches to identify the relevant qualitative studies 
that explore the experience, view and perceptions of  the 
expectant mothers in accessing perinatal care during the 
COVID-19 pandemic.
It will help to investigate the challenges and barriers faced 
by the mothers in accessing the perinatal care during the 
pandemic, including disruption of  the routine care and 
changes in the health care system. Furthermore, it will also 
evaluate the influences of  these changes on maternal and 
neonatal outcome, and overall well-beings. Identification 
of  the potential strategies and recommendations to 
enhance the perinatal care access and quality in the 
context of  the global health crisis will be beneficial for 
the coming years. 

CONCLUSION 
This qualitative systematic review protocol aims to 
synthesise and deeply understand the experiences, views, 
and perceptions of  expectant mothers when accessing 
perinatal care during the COVID-19 pandemic. Further, 
the review will explore the potential impact of  care access 
changes on maternal and birth outcomes and identify the 
strategies and recommendations that guide policymakers 
to enhance care access and quality in the context of  
the global health crisis. By including the diverse and 
enormous range of  evidence from multiple countries, this 
will contribute to a better understanding of  the mothers’ 
experiences and views during an unprecedented period. 
In addition to the findings of  this study, it will highlight 
potential areas for improvement in service provision and 
policy changes to support expectant mothers, their new-
borns, and their families during the future health crisis. 
Eventually, this study will add to the evidence foundation 
for the establishment of  more resilient, patient-centred, 
and equitable prenatal care systems.
This Qualitative systematic review protocol registered 
with the International Prospective Register of  Systematic

Acknowledgements
We are grateful to the journal editors for recognizing 
the value of  this systematic review in understanding and 
improving prenatal care services during health crises. 
Your support is helping shape woman-centred maternity 
care for the future. We are indebted to our colleagues 
and research assistants for their contributions at various 
stages of  developing this protocol. Your time, expertise 
and feedback have helped refine and strengthen our 
methodology.
 
Contribution
KH is the PI leading protocol development and the 
systematic review. In addition, the co-authors FA, JM, 
NO typically actively help search papers, extract data, 
evaluate bias risk, analyse data, write sections, and edit or 
revise the review throughout the process. Co-authors are 
accountable for ensuring the final review’s overall rigour, 
openness, and trustworthiness will be contributed by all 
the authors.

Registration
Reviews in compliance with the standards (PROSPERO), 
registration number (CRD42023428034). The registration 
of  systematic review protocol details is now considered 
as vital to promote and maintain transparency in the 
systematic review process, contributing in the reduction 
of  biases and the removal of  consequently study 
duplication (Stewart et al., 2012).

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APPENDIX

Table 1: The enhancing transparency in reporting qualitative research synthesis (ENTREQ) (Tong et al. 2015).
No Item Guide and description
1 Aim State the research question the synthesis addresses.
2 Synthesis methodology Identify the synthesis methodology or theoretical framework which underpins 

the synthesis, and describe the rationale for choice of  methodology (e.g. meta-
ethnography, thematic synthesis, critical interpretive synthesis, grounded theory 
synthesis, realist synthesis, meta-aggregation, meta-study, framework synthesis).

3 Approach to searching Indicate whether the search was pre-planned (comprehensive search strategies 
to seek all available studies) or iterative (to seek all available concepts until they 
theoretical saturation is achieved).

4 Inclusion criteria Specify the inclusion/exclusion criteria (e.g. in terms of  population, language, 
year limits, type of  publication, study type).

5 Data sources Describe the information sources used (e.g. electronic databases (MEDLINE, 
EMBASE, CINAHL, psycINFO, Econlit), grey literature databases (digital thesis, 
policy reports), relevant organisational websites, experts, information specialists, 
generic web searches (Google Scholar) hand searching, reference lists) and when 
the searches conducted; provide the rationale for using the data sources.

6 Electronic Search strategy Describe the literature search (e.g. provide electronic search strategies with 
population terms, clinical or health topic terms, experiential or social phenomena 
related terms, filters for qualitative research, and search limits).

7 Study screening methods Describe the process of  study screening and sifting (e.g. title, abstract and full text 
review, number of  independent reviewers who screened studies).



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8 Study characteristics Present the characteristics of  the included studies (e.g. year of  publication, 
country, population, number of  participants, data collection, methodology, 
analysis, research questions).

9 Study selection results Identify the number of  studies screened and provide reasons for study exclusion 
(e,g, for comprehensive searching, provide numbers of  studies screened and 
reasons for exclusion indicated in a figure/flowchart; for iterative searching 
describe reasons for study exclusion and inclusion based on modifications t the 
research question and/or contribution to theory development).

10 Rationale for appraisal Describe the rationale and approach used to appraise the included studies or 
selected findings (e.g. assessment of  conduct (validity and robustness), assessment 
of  reporting (transparency), assessment of  content and utility of  the findings).

11 Appraisal items State the tools, frameworks and criteria used to appraise the studies or selected 
findings (e.g. Existing tools: CASP, QARI, COREQ, Mays and Pope [25]; reviewer 
developed tools; describe the domains assessed: research team, study design, data 
analysis and interpretations, reporting).

12 Appraisal process Indicate whether the appraisal was conducted independently by more than one 
reviewer and if  consensus was required.

13 Appraisal results Present results of  the quality assessment and indicate which articles, if  any, were 
weighted/excluded based on the assessment and give the rationale.

14 Data extraction Indicate which sections of  the primary studies were analysed and how were the 
data extracted from the primary studies? (e.g. all text under the headings “results /
conclusions” were extracted electronically and entered into a computer software).

15 Software State the computer software used, if  any.
16 Number of  reviewers Identify who was involved in coding and analysis.
17 Coding Describe the process for coding of  data (e.g. line by line coding to search for concepts).
18 Study comparison Describe how were comparisons made within and across studies (e.g. subsequent 

studies were coded into pre-existing concepts, and new concepts were created 
when deemed necessary).

19 Derivation of  themes Explain whether the process of  deriving the themes or constructs was inductive 
or deductive.

20 Quotations Provide quotations from the primary studies to illustrate themes/constructs 
and identify whether the quotations were participant quotations of  the author’s 
interpretation.

21 Synthesis output Present rich, compelling and useful results that go beyond a summary of  the 
primary studies (e.g. new interpretation, models of  evidence, conceptual models, 
analytical framework, development of  a new theory or construct).

Table 2: PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist: 
recommended items to address in a systematic review protocol Shamseer et al (2015).
Section and topic Item No Checklist item
Administrative Information
Title:
Identification 1a Identify the report as a protocol of  a systematic review
Update 1b If  the protocol is for an update of  a previous systematic review, identify 

as such
Registration 2 If  registered, provide the name of  the registry (such as PROSPERO) and 

registration number
Authors:
Contact 3a Provide name, institutional affiliation, e-mail address of  all protocol 

authors; provide physical mailing address of  corresponding author
Contributions 3b Describe contributions of  protocol authors and identify the guarantor of  

the review



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Amendments 4 If  the protocol represents an amendment of  a previously completed or 
published protocol, identify as such and list changes; otherwise, state plan 
for documenting important protocol amendments

Support:
Sources 5a Indicate sources of  financial or other support for the review
Sponsor 5b Provide name for the review funder and/or sponsor
Role of  sponsor or funder 5c Describe roles of  funder(s), sponsor(s), and/or institution(s), if  any, in 

developing the protocol
Introduction
Rationale 6 Describe the rationale for the review in the context of  what is already 

known
Objectives 7 Provide an explicit statement of  the question(s) the review will address 

with reference to participants, interventions, comparators, and outcomes 
(PICO)

Methodology
Eligibility criteria 8 Specify the study characteristics (such as PICO, study design, setting, time 

frame) and report characteristics (such as years considered, language, 
publication status) to be used as criteria for eligibility for the review

Information sources 9 Describe all intended information sources (such as electronic databases, 
contact with study authors, trial registers or other grey literature sources) 
with planned dates of  coverage

Search strategy 10 Present draft of  search strategy to be used for at least one electronic 
database, including planned limits, such that it could be repeated

Study records:
Data management 11a Describe the mechanism(s) that will be used to manage records and data 

throughout the review
Selection process 11b State the process that will be used for selecting studies (such as two 

independent reviewers) through each phase of  the review (that is, screening, 
eligibility and inclusion in meta-analysis)

Data collection process 11c Describe planned method of  extracting data from reports (such as piloting 
forms, done independently, in duplicate), any processes for obtaining and 
confirming data from investigators

Data items 12 List and define all variables for which data will be sought (such as 
PICO items, funding sources), any pre-planned data assumptions and 
simplifications

Outcomes and 
prioritization

13 List and define all outcomes for which data will be sought, including 
prioritization of  main and additional outcomes, with rationale

Risk of  bias in individual 
studies

14 Describe anticipated methods for assessing risk of  bias of  individual 
studies, including whether this will be done at the outcome or study level, 
or both; state how this information will be used in data synthesis

Data synthesis 15a Describe criteria under which study data will be quantitatively synthesised
15b If  data are appropriate for quantitative synthesis, describe planned 

summary measures, methods of  handling data and methods of  combining 
data from studies, including any planned exploration of  consistency (such 
as I2, Kendall’s τ)

15c Describe any proposed additional analyses (such as sensitivity or subgroup 
analyses, meta-regression)

15d If  quantitative synthesis is not appropriate, describe the type of  summary 
planned

Meta-bias(es) 16 Specify any planned assessment of  meta-bias(es) (such as publication bias 
across studies, selective reporting within studies)

Confidence in cumulative 
evidence

17 Describe how the strength of  the body of  evidence will be assessed (such 
as GRADE)



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Figure 1: Braun and Clarke thematic analysis approach (Braun & Clarke, 2006).


