Abstract
INTRODUCTION: Food insecurity, when individuals do not have sufficient access to food, has rapidly increased in high-income countries (HICs) since the 2008 global financial crisis. Women are particularly at risk of experiencing food insecurity, and during pregnancy, this can have detrimental physical and emotional health implications. OBJECTIVE: To synthesise qualitative research exploring pregnant women's experiences of food insecurity in HICs (PROSPERO 2023 CRD42023404774). METHODS: Systematic review of qualitative literature reporting data on women's experiences of food insecurity. Six databases (MEDLINE, Embase, Web of Science, CINAHL, ASSIA, Scopus) and grey literature sources were searched, followed by forwards and backwards citation chaining for all included studies. Screening of titles, abstracts and full-texts, data extractions and quality appraisals (using the Critical Appraisal Skills Programme (CASP) Qualitative Studies Checklist) were completed in duplicate. Certainty in the evidence was evaluated using GRADE-CERQual. PARTICIPANTS/SETTING: Food-insecure pregnant and postnatal women, in HICs, since the global financial crisis of 2008. MAIN OUTCOME MEASURES: Experiences of food insecurity during pregnancy. ANALYSES: Thematic synthesis using NVivo14 to code data. Hand-drawn thematic maps were used to group codes into sub-themes and overarching themes. Coding and hand-drawn thematic maps were combined to create a final visual summary of analytical themes. RESULTS: Searches resulted in 32,685 studies, and 32 were included (n = 20 North America, n = 10 Europe, n = 2 Australia). Findings identified three overarching themes: (1) barriers in access to food, (2) impact on physical and mental health, and (3) established individual, informal and statutory coping strategies. Women frequently discussed barriers to accessing fresh fruit and vegetables, resulting in poorer quality diets. Whilst qualitative data extracted precluded any direct pregnancy versus pre-pregnancy comparison, pregnancy appeared to exacerbate the experiences of food insecurity for women. The future arrival of a newborn created additional financial concerns along with worries over nutritional needs. Reliance on others was a recurrent strategy for pregnant women to mitigate the impact of food insecurity. The GRADE CERQual assessment showed moderate to high confidence in all findings. CONCLUSIONS: The findings of this qualitative review-the first to focus on experiences of food insecurity during pregnancy across HICs-show that women are experiencing substantial impacts from food insecurity during this critical life course stage. Review findings emphasise the need for co-ordinated screening and interventions that aim to support women to mitigate the impacts of food insecurity and its underlying causes to improve postpartum health and wellbeing.