Seeking digital maternity healthcare during the pandemic health system shock: a systematic review of women's experiences in low- and middle-income countries.

Background: The pandemic created global disruption acting as a health system shock not seen before in living memory. As a consequence, there were significant implications for healthcare delivery in low- and middle-income countries. Challenges such as lockdown restrictions created substantial modifications to the delivery of maternity care. This review aims to explore the experiences of maternity care by women, specifically in low- and middle-income countries, during the pandemic global health system shock. Methods: A systematic search was conducted for qualitative literature published about maternity healthcare experiences during the pandemic. Studies which provided qualitative data on women's experiences of digital healthcare, and other maternity care reconfigurations in low- and middle-income countries were included. The studies underwent quality assessment using twelve criteria adapted from the quality appraisal tool developed by the Evidence for Policy & Practice Information (EPPI) Centre. Thematic synthesis was employed. Results: Of the 21,860 records identified, 30 met the inclusion criteria for this review. Across the 4 key predetermined areas of study: (1) Care seeking and experience; (2) Digital health; (3) Vaccination; and (4) Ethical future of maternity services; 10 concepts were reported upon, namely: (1.1) Emotional challenges and uncertainty, (1.2) Disruption of services, (1.3) Stigma and discrimination, and (1.4) Changing support systems; (2.1) Safety and reassurance, (2.2) Locus of responsibility; (3.1) Vaccine understanding and acceptance; and (4.1) Improvements for maternity care delivery, (4.2) Implementation of virtual care, (4.3) Education and empowerment. Conclusion: Our findings suggest emotional challenges, isolation, and limited access to maternity services were prominent among pregnant individuals in low- and middle-income countries. This synthesis provides insights into how pandemic associated adaptations, which have been retained beyond, such as digital health solutions were experienced by women within constrained health systems, revealing both opportunities and persistent gaps in digital health access and equity. Although a review of low- and middle-income countries-there is learning to be taken from these settings which could easily be applied not only across low- and middle-income countries, but also in high-income settings, in the form of reverse (or "trickle-up") innovation to improve maternity care as we recover and re-build from the pandemic and offer more resilient ways of providing maternity care through future health system shocks.