Hope Aspects of the Women’s Experience after Confirmation of a High-Risk Pregnancy Condition: A Systematic Scoping Review

Background: Pregnancy is a period of transformation, hope, expectation, and worry for women and their families. A high-risk pregnancy refers to a pregnancy in which the mother and/or fetus are at greater-than-normal risk of complications, and it evokes a range of emotional and psychological experiences that largely depend on the care and support provided by health professionals. The purpose of this review is to summarize the existing literature on the lived experience of hope in women facing a high-risk pregnancy related to their own health and/or medical conditions related to the fetus. Methods: This review followed the Joanna Briggs Institute’s methodology. No limits on a date were applied to the search. Identified titles and abstracts were screened to select original reports and were cross-checked for any overlap of cases. We included studies that emphasized the experience of hope of pregnant women dealing with a pregnancy complication. Main Results: According to the results of the present scoping review, we found two main dimensions: women experiencing a high-risk pregnancy themselves and prenatal diagnosis. In both cases, the women were in a dilemma between hope and hopelessness. Conclusion: The findings demonstrate that women facing high-risk pregnancies struggle with multiple fears and concerns about their own health and the fetus’s health. Further research is needed to identify best practices for the care provided to the vulnerable populations.


Introduction
In 2017, approximately 810 women died from preventable causes related to pregnancy and childbirth [1]. Globally, more than 20 million women are at risk of high-risk pregnancies, which results in an estimated 830 deaths per day, more than 99% occurring in developing countries, and is more frequent among rural women and adolescents [2]. Nearly 22% of pregnant women develop a high-risk pregnancy [3]. As part of the sustainable development goals (SDG), countries have agreed on a new target to accelerate the decline of maternal mortality by 2030. The World Health Organization (WHO) considers high-risk pregnancies a major public health challenge, addressing the healthcare needs as a priority [1], and includes an ambitious target: decreasing the global maternal mortality rate to less than 70 per 100,000 births, with no country having a maternal mortality rate of more than twice that of the global average [1].
In most cases, the birth of a child is an experience filled with joy and happiness. However, when a mother is diagnosed with a medical condition or the child with a congenital anomaly, the parents' experience can take on a different meaning [4]. A high-risk pregnancy is defined as any pregnancy in which there is a medical factor, maternal or fetal, that may potentially adversely affect the outcome of the pregnancy [5]. The most common maternal complications are gestational diabetes, preeclampsia and eclampsia,

Materials and Methods
The protocol and proposed systematic review were drawn and conducted in accordance with the JBI methodology for systematic reviews [16]: define search strategy, study selection, assessment of methodological quality, data extraction, and data synthesis. The protocol was registered prospectively with the Open Science Framework on 26 May 2022 (https://osf.io/u9ns8 (accessed on 12 September 2022)). Registration DOI: 10.17605/OSF.IO/U9NS8.

Review Questions
The following question guided this scoping review: What are the hope aspects related to the women's lived experience of a pregnancy that continues after confirmation of a highrisk pregnancy diagnosis? This question was divided into the following sub-questions: What type of evidence or study design exists in the area of women's life experience of pregnancy research in relation to hope aspects after confirmation of a high-risk pregnancy diagnosis?; What aspects of hope in the life experience of pregnant women have been addressed during health care associated with a high-risk pregnancy?; What are the gaps in the nursing research in relation to hope interventions in the context of care for women with high-risk pregnancies?

Participants
Both the exploratory and textual components of this review considered qualitative and quantitative studies that include women's lived experiences of pregnancy with a high-risk condition that may affect their own health or their baby's health, including the prenatal diagnosis of a congenital anomaly, regardless of race, nationality, level of education, or religious affiliation. The study could also include any patient with an age above 18, primigravida and multigravida, and in the second or third trimester of their pregnancy. This review excluded any studies focusing on healthcare professionals and pregnant women who were healthy and did not have any risk factors for high-risk pregnancies.

Concept
This review considered studies that explore woman's hopeful experiences when proceeding with a high-risk pregnancy diagnosis, which may have included maternal and/or fetal complications. The included studies may or may not have directly addressed hope in their proposals having, however, addressed hope-related experiences and related concepts in their findings or women's expectations. The aspects related to women's experiences of hope included psychological well-being; uncertainty; finding a sense of normality; finding a new meaning to life experiences; setting realistic goals and objectives; imagining possibilities and seeking alternative solutions; an ability to share their pregnancies with other women and/or health care professionals; and expressing positive personal transformation and identifying positive psychological factors. The aspects related to women's expectations will include difficulties in thinking about the child's future; condition-related expectations (positive or negative outlook); and concerns about acceptance by family and social networks.

Context
Women with high-risk pregnancies are usually referred to larger health centers for better treatment. In this review, women were assisted in high-risk maternal-fetal health consultations, which included the literature from any country or sociocultural setting.

Types of Sources
This review considered quantitative, qualitative, and mixed study designs for inclusion. Systematic reviews and meta-analyses were also considered in this review.

Search Strategy
The search strategy aimed to find studies published in the Portuguese, English, or Spanish languages, with no date limit. As recommended in all JBI types of reviews, a three-step search strategy was carried out [16].
An initial limited search took place on the EBSCO platform, where the databases CINAHL and MEDLINE (PubMed) were selected, as well as the Google Scholar platform. The search was performed using the keywords included in the PCC question. A second search with all identified keywords and index terms was undertaken across all of the included databases, using Boolean descriptors such as "OR" and "AND". A search with all identified keywords and index terms was used to develop a full search strategy for PubMed (see Appendix A). In the third stage, reference lists of sources selected from the full text and/or included in the review were examined. The databases searched include CINAHL Complete (from EBSCO); Pubmed; Nursing and Allied Health Collection (from EBSCO); PsycINFO; Mediclatina (from EBSCO); and Scopus.

Study/Source of Evidence Selection
Following the search, all identified citations were compiled and uploaded to Mendeley version 2.71.0 (Mendeley Ltd., Elsevier, Amsterdam, Netherlands), and duplicates were removed. After a pilot test, the titles and abstracts were screened by two or more independent reviewers for assessment against the inclusion criteria for the review. The resulting reference list was then uploaded to Rayyan (Qatar Computing Research Institute, Doha, Qatar). In the second phase of screening, the references of the selected studies were reviewed, and relevant studies were identified for a full review. The studies were classified into one of three categories: included, excluded, and uncertain. Later, the full texts of the "included" and "uncertain" studies were retrieved to identify potentially relevant studies, and their full citation details were imported into Rayyan.
The full texts of the selected citations were assessed in detail according to the inclusion criteria by two independent reviewers. Reasons for the exclusion of sources of evidence in full text that did not meet the inclusion criteria were recorded and reported in the scoping review. Any disagreements that arose between the reviewers at each stage of the selection process were resolved through discussion, or with an additional reviewer/s. The results of the search and the study-inclusion process are reported and presented in a preferred reporting items for systematic reviews and meta-analyses extension for scoping review (PRISMA-ScR) flow diagram [17].

Assessment of Methodological Quality
In describing the quality of the selected articles (n = 15), the studies were appraised by all of the authors. Divergent views regarding the critical appraisal were reviewed until a consensus was achieved. The Hawker et al. [16] assessment tool, with a four-grade scale (1 = very poor; 2 = poor; 3 = fair; 4 = good) was used. The total scores ranged between 9 and 36, and higher scores indicated a higher quality. An article's quality appraisal was centered on the following items: 1-abstract and title; 2-introduction and aims; 3-method and data; 4-sampling; 5-data analysis; 6-ethics and bias; 7-results; 8-transferability or generalizability; and 9-implications and usefulness.

Data Extraction
After the analyses of the title and abstract, duplicates and articles that did not correspond to the topic were excluded. Primary studies published in Portuguese, English, and Spanish were included, with no time limit. The search was conducted on 16 March 2022, with an update on 16 September 2022. A total of 479 articles were excluded, and another 4 full-text articles were excluded, two of them with an unsuitable concept and for the other two we did not receive a response from the authors to access the full text, leaving 15 for analysis ( Figure 1). The titles and abstracts identified during the search were independently reviewed by the authors using the inclusion and exclusion criteria. The decision of whether to include or exclude studies was made by mutual agreement.
Healthcare 2022, 10, x 5 4 full-text articles were excluded, two of them with an unsuitable concept and for the two we did not receive a response from the authors to access the full text, leaving 1 analysis ( Figure 1). The titles and abstracts identified during the search were pendently reviewed by the authors using the inclusion and exclusion criteria. The dec of whether to include or exclude studies was made by mutual agreement.

Data Synthesis
The 15 studies eligible for SR are described in Appendix A2. The results are prese in narrative form. Considering the JBI guidelines [16], the synthesis of relevant dat lected from each article was composed of the following elements: the identification o article, hope and hopelessness experiences or expectations, aims, study design, study ulation/sample, context, population characteristics, typology, and main results.

Results
The generated demand resulted in 495 titles. After applying the inclusion/excl criteria and excluding duplicate studies, 15 studies were eligible. Of these, 14 were i English language and 1 was in the Portuguese language (Brazil).

Data Synthesis
The 15 studies eligible for SR are described in Appendix B. The results are presented in narrative form. Considering the JBI guidelines [16], the synthesis of relevant data collected from each article was composed of the following elements: the identification of the article, hope and hopelessness experiences or expectations, aims, study design, study population/sample, context, population characteristics, typology, and main results.

Results
The generated demand resulted in 495 titles. After applying the inclusion/exclusion criteria and excluding duplicate studies, 15 studies were eligible. Of these, 14 were in the English language and 1 was in the Portuguese language (Brazil).

Characteristics of Sources of Evidence
The main characteristics of the fifteen articles were as follows: fifteen primary studies, four of which were conducted in Iran, two in the United States of America, one in Brazil, one in the United Kingdom, one in Belgium and the United Kingdom, one in Sweden, one in Australia, one in Paris, one in Africa, one in Malaysia, and one in Thailand. Only one of the studies found was quantitative (descriptive, prospective, and longitudinal); the rest of the studies were qualitative. The selected studies were published between 2004 and 2021. The ages of the women ranged from 18 to 45 years. The sample sizes varied from nine to seventy-two women who used the services of specialized centers, hospitals, or clinics for the specific medical condition presented.
Few studies have addressed the aspects of hope during health care associated with highrisk pregnancies, and only one study was quantitative, while fourteen studies were qualitative.
The empirical studies described the lived experiences of women during pregnancy in the second and third trimesters with varied medical conditions. Authors such as Behboodi-Moghadam, Khalajinia, Nasrabadi, Mohraz and Gharacheh (2016), and Sanders (2008) explored the experiences of women diagnosed with HIV at each stage of pregnancy [18,20,23]. This same medical condition was the focus of other studies that examined these experiences in the prenatal period in South Africa [25], Thailand [24], and Brazil [27]. On the other hand, authors such as Tong, Brown, Winkelmayer, and Craig and Jesudason described the beliefs, values, and experiences of pregnancy in Australian women with CKD to inform on pre-pregnancy counseling and pregnancy care [21].
The experiences and perceptions of women with high-risk pregnancies are focused on topics regarding health and care practice issues/needs [22,30]. Tayeh, Jouannic, Mansour, and Kesrouani and Attieh explored patients' perceptions of the prenatal diagnosis of fetal cardiac pathology and their reasons for deciding to continue the pregnancy despite being eligible for the medical termination of their pregnancy [30]. Norhayati, Hazlina, Hussain, Asrenee and Sulaiman examined women's experiences of near-misses and their perceptions of quality of care in a retrospective study [26].
A theoretical framework for the process of adaptation following a fetal anomaly diagnosis was provided based on the proposal in the study of Lalor, Begley and Galavan [28]. In this study, data was collected from Irish women's experiences of carrying a baby with a fetal abnormality to the end and beyond birth [28,29]. Integrated into the fetal abnormality, other authors describe the women's reactions to the discovery of fetal hydronephrosis in the context of uncertainty about prognosis [19] and the women's experiences during pregnancy with a child with a known, nonlethal congenital abnormality [32].
The concepts and strategies that women in the UK and Belgium use when considering maternal-fetal surgery as an option for the management of spina bifida in their fetus, and how this determines the acceptability of the intervention, were researched in [31].

Critical Appraisal within Sources of Evidence
The study's quality was high. Methods, ethics, and bias, as well as transferability, were the studies' main limitations, and the critical appraisals ranged from 32 to 36 (see Appendix C).

Results of Sources of Evidence
According to the results of the present systematic review, women who experience a high-risk pregnancy or a prenatal diagnosis of fetal abnormality found themselves in a dilemma between hope and hopelessness and, in some cases, a second dilemma between terminating or continuing the pregnancy.
To answer the question: "What are the hope aspects related to the women's life experience of a pregnancy that continues after confirmation of a high-risk pregnancy diagnosis?", we were able to find two subcategories within the main category of "Hope experiences in women with a high-risk pregnancy." We can distinguish hopelessness and hope experiences. In nine studies it was possible to analyze that the risk involved was related to the women themselves in the context of their medical conditions (see Table 1). The studies we found related well to the hope and hopelessness women experience in the context of prenatal diagnoses that could endanger the fetus's health (see Table 2). Some studies have established a link between women's experiences of hope and the positive outcomes associated with this perception. The following results in women with medical conditions include the change from their experiences of uncertainty to new solutions and/or possibilities about a future uncertainty. These women focus their hope on the child and the privilege of experiencing pregnancy.
On the other hand, studies conducted with women with prenatal diagnoses are focused on outcomes that are associated with a positive future for the child and the realization that they made the right decision when they decided not to terminate the pregnancy.
The hope experiences related to women have more expression in the group of women who have the prenatal diagnosis without medical conditions in themselves. However, after a prenatal diagnosis of a fetal anomaly in the initial phase, some women hoped that they would hear that the diagnosis was a mistake [28].
Each person has different coping strategies when faced with stress [19]. Women should be clearly informed about the options and decisions they may need to make in cases of abnormal tests and prenatal screenings [29,32].

Discussion
In the study of high-risk pregnancies with different medical problems, hopelessness experiences are implicitly related to pregnancy worries, concerns about the child, future pregnancy, relationships and support with others, and higher costs [18].
When the risk was associated with the diagnosis of HIV during pregnancy, the attribute that emerged in all studies was fear of the cruelty of stigma, stereotyping, discrimination, and judgment [20,[23][24][25]27].
Studies also showed the existence of concerns about the transmission of the virus to the baby and possible effects on their health [20]; emotional distress, ambivalence about pregnancy and motherhood [23], an association with negative self-image, loneliness, feelings of isolation, fears of loved ones, blame, and that they avoided any romantic relationships, and fears of being sick, going to the hospital, or dying [25]. In the same population, Ross et al. found that women perceived their lives as a struggle [24], such as with shock, fear, anxiety, and depression; with sharing one's struggling with others and that they struggle to care for their baby, especially after birth; and that they struggle through ups and downs. The consciousness of fragility, noxious self, denied motherhood, social jealousy, and fear of genetic transmission have been described in the study of women with chronic kidney disease [21].
Studies focused on maternal near-miss experiences showed many fears and concerns [22,26]: fear of being unable to become pregnant again, fear of raising their child without siblings, fear of carrying about their child without a mother, fear of remarriage of a spouse if the spouse wanted more children, fear of becoming pregnant again and experiencing postpartum complications, fear of not being able to adjust to the complications and grieving for a long time, and guilt, intolerance of pain, irritability, and postpartum depression.
In the optical of mental health, other emotions have an expression in this analysis, such as anxiety, discouragement, and numbness, fear for their own life and the life of their baby, feelings of death, and feelings of an incomplete self because they are a woman without a uterus and a baby [26].
In a study that looked at the experiences of women with various pathologies during pregnancy, hope was found to be related to the adaptation to challenges, the belief that conditions will improve, and being hopeful about the future [18].
Children were seen as a "divine gift", a chance to correct past mistakes, and to be good, loving mothers [20,23,27].
Religiousness resurfaced with the wish for a child to give meaning to their life's and to help with the construction of a female identity, because to be a mother was stronger than any problem [27]. Hope was also identified in protecting children from contracting the disease and from stigma in the case of HIV disease [23][24][25].
In general, the studies reported that a positive pregnancy experiences was an important source of support and hope for women [27]. By participating in spiritual practices, women believed that God would respond to their needs and take care of their children [20,25,27]. Spirituality and resorting to God and Imams are the most common attributes of hope found in the found studies [18,22,[25][26][27].
Other forms of adaptations included the natural maternal disposition to focus on their child, which was a motivator to seek treatment and a source of strength to continue living [21,26].
When a prenatal diagnosis occurs, studies identified the following women's hopelessness attributes: the sense of disbelief, stress, doubting the struggle, shock, anger, and fear of developing a bond with the baby who may die [19,28,29,32]; anxiety and fears about the unknown [19]; guilt by the loss of the perfect baby [32].
Only one study analyzed the hopeless experience in the case of a woman who had maternal-fetal surgery [31]. Emotions such as uncertainty about their future child's quality of life, fear of potential complications of the surgery and the possibility of losing their unborn child, fear of not waking up after the operation, and post-traumatic stress and depression were related [31].
In the rebuilding phase after prenatal diagnosis, a positive vision of the future seems to develop (whatever that may be) as the woman processes her experiences in such a way as to reconstruct the future and adjust her earlier beliefs about pregnancy and the world in general [28]. For example, in the context of fetal surgery, women felt strong feelings of responsibility and determination to do anything to improve their future child's health outcomes [31].
The study conducted by Oscarsson et al. found that women's experiences of hope were based on going through a crisis and knowing that they were doing the right thing [19]. Irani et al. compared the emotional experiences of women that decided to continue or terminate the pregnancy after the prenatal diagnosis of fetal anomalies [29]. The results identified in this population include a dilemma between hope and worry maintained by a positive attitude toward childbirth to cope with the situation and/or a return to normality [29]. In another study that compared the experiences between continuing and terminating the pregnancy, the authors cited religious beliefs and convictions and the belief that the baby would survive after birth [30]. Other sources of hope were found when there were good sources of information, time to prepare, support from family and friends, spiritual beliefs, staying busy with work and other activities and empathizing with the baby [32].

Conclusions and Implications for Practice
This review demonstrated the meanings of the lived experiences of women with high-risk pregnancies due to maternal medical conditions or prenatal diagnoses.
The hope aspects related to the women's lived experiences of pregnancies that continued after the confirmation of a high-risk pregnancy diagnosis were addressed during health care and were analyzed with a personal woman's attributes.
The type of evidence or study design that exists in women's life experiences of pregnancy research in relation to hope aspects after the confirmation of a high-risk pregnancy diagnosis is mostly qualitative. In the studies analyzed, the qualitative design stood out in terms of methodology (14 of the 15 studies analyzed in this review). This aspect is related to the type of the main review question, as we intended to understand the experiences of hope and not measure them quantitatively.
In the studies that explored high-risk pregnancies, the main issues identified were women's fears for their own lives and the lives of their babies, the impossibility of getting pregnant again, postpartum complications, and an incomplete self. On the other hand, women facing a prenatal diagnosis of fetal anomalies faced the fear of developing an attachment to a baby who may die, the loss of the perfect baby, and the fear of possible complications of treatment. In both cases, women went through phases with feelings of emotional distress, ambivalence, disbelief, stress, struggle, anxiety, and depression.
Most women facing a high-risk pregnancy used religion, spirituality, and faith in God as coping mechanisms. Some others relied on good sources of information, time to prepare, support from family and friends, employment at work, and empathy with the baby. These women had a strong sense of responsibility for the treatment and saw it as an opportunity that they had been given. If they decided to continue with the pregnancy, they focused on the idea of doing the right thing. They hoped for the best possible outcome and that everything would be okay in the end.
In relation to hope interventions in the context of care for women with high-risk pregnancies, the gaps in the nursing research are about hope interventions. The results of different studies describe an implicit proposal to develop research about hope interventions in the context of care for women with high-risk pregnancies. However, we believe that women who are well informed about their situation and treatment are most likely to adapt and comply with treatment. In addition, recognizing the benefits of religious faith in situations of uncertainty is important and helps women to adjust to challenging situations. It is extremely important to monitor women's emotional and psychological reactions after a prenatal anomaly diagnosis, not only throughout the pregnancy but also in the postnatal stages. Nurses and midwives have a privileged position in relation to women and can help them overcome difficult challenges in the present and future.
To establish a comparison between women's responses in the different conditions (maternal medical situations and prenatal diagnoses), it is highly important to increase our understanding of the impacts of these experiences in this population.

Limitations
The present scoping review was based mainly on qualitative studies conducted on a limited number of mothers with high-risk pregnancies, so the results cannot be generalized to similar populations.    [28] Hopelessness implicit on sense of incredulity, stress, the dually of the fight. Fear of developing a bond with the baby that could die. Initially some women hoped they would hear that the initial diagnosis was a mistake. Finally, in the rebuilding phase it would appear that the emergence of a positive vision of the future (whatever that might be), as the woman works through her experience in ways that permit her to reconstruct the future and adapt her previously held beliefs about pregnancy in particular and the world in general.
To provide a theorical framework of the process of adaptation following fetal anomaly diagnosis based on women's experiences of carrying a baby with a fetal abnormality up to the end and beyond the birth Grounded theory study Pregnant women carrying a baby with fetal abnormality Fetal medicine unit of a major Dublin maternity hospital All Irish women. Forty-one women, eleven primigravidae and 30 multigravidae. Thirthy-one women continued the pregnancy and ten travelled to UK to access termination of pregnancy services not available within the state. Forty women were married or partnered and although not all pregnancies were planned, all were wanted.
Recasting Hope, the process of adaptation following diagnosis is represented temporally as four phases: 'Assume Normal', 'Shock', 'Gaining Meaning' and 'Rebuilding'. Some mothers expressed a sense of incredulity when informed of the anomaly and the 'Assume Normal' phase provides an improved understanding as to why women remain unprepared for an adverse diagnosis. Transition to phase 2, 'Shock,' is characterised by receiving the diagnosis and makes explicit women's initial reactions. Once the diagnosis is confirmed, a process of 'Gaining Meaning' commences, whereby an attempt to make sense of this ostensibly negative event begins. 'Rebuilding', the final stage in the process, is concerned with the extent to which women recover from the loss and resolve the inconsistency between their experience and their previous expectations.
When fetal hydronephrosis is suspected antenatally-a qualitative study Oscarsson, Gottvall & Swahnberg (2015) Sweden [19] Hopelessness experiences of anxiety and fears about the unknown, worry and stress. Experiences of hope are based on going through crisis by knowing that you are doing the right thing, told themselves that they would deal with it after delivery and that everything would be all right at the end To explore women's reactions to the discovery of fetal hydronephrosis in the context of uncertainty regarding the prognosis Qualitative study Pregnant women University clinic of Sweden Ten women with antenatal diagnosis were invited to the interview 6-12 months after delivery. Mean age were 30.6 years. Six nulliparous and four parous.
The core category, 'Going through crisis by knowing that you are doing the right thing' illustrates the meaning of women's reactions and feelings. It illuminates the four categories: 'When the unexpected happens'-on the one hand, women had positive views that the suspicious malformation could be discovered; however, on the other hand, women questioned the screening. 'To live in suspense during pregnancy'-the suspicious malformation caused anxiety and was a stressful situation. 'Difficulties in understanding information'-the women thought they had limited knowledge and had difficulties in understanding the information. 'Suppress feelings and hope for the best'-the women tried to postpone the problem and thought they should deal with it after delivery Iran [20] Hopelessness experiences implicit on the concerns about transmitting the virus to the baby, effects on their health. Becoming a mother after a HIV diagnosis was a source of hope, value and esteem, children seen as a "divine gift", a chance to correct past mistakes. By participating in spiritual practices, women believed that God would respond to their needs, God would take care of their children. Hopelessness implicit on fears and concerns. Unable to get pregnant again, fear of raising their child without siblings, concerns about their child without a mother, re-marriage of the spouse if the spouse wanted more children, fear of getting pregnant again and experiencing postpartum complications, failure to adjust to complications and prolonged mourning, feeling guilty, not tolerating pain, irritability, and postpartum depression. The only hope seemed to be believing in God's will and their survival and ability to support their children.
To understand experiences and perceptions of women with higher risk pregnancy relating to problems/needs of health and care practices.
Descriptive and qualitative

Pregnant women
The interviews were conducted at the office of the educational supervisor of Sabzevar Mobini Hospital or any other place that was conveni-ent to the mothers (e.g. their home).
The mothers were selected based on their ability to express their near-miss experience and willingness to be interviewed. The age range of the selected mothers was 19-36 years.
Five main categories were extracted, including fears and concerns, failure to accept and adapt, tolerating physical and psychological pain and hardships, death experience, and medical team mismanagement. Regret and fear of raising the child with siblings, fear of the remarriage of the spouse, and fear of complications and costs were among the subcategories of fears and concerns. Lack of adaptation to the complications and prolonged mourning were the subcategories of failure to accept and adapt, and the subcategories of tolerating physical and psychological pain and hardships were a sense of guilt, tolerating physical pain, hopelessness, irritability, hatred toward the medical team, and postpartum depression. In addition, returning to normal life, and seeing/actually feeling death were the subcategories of the death experience. The subcategories of the medical team mismanagement included medical errors, lack of sup-port/negligence,

Hope and Hopeless Experiences or/and Expectations Aims Study Design Study Population/Sample Context Population Characteristics and Typology Main Results
Emotional and cognitive experiences of pregnant women following prenatal diagnosis of fetal anomalies: A qualitative study in Iran Irani, Khadivzadeh, Nekah, Ebrahimipour & Tara (2019) Iran [29] Hopelessness is defined by disbelief, distress, panic and shock during the time of diagnosis. When their pregnancy was terminated, women experienced perinatal loss such as guilt and shame during pregnancy termination, loss of their expected child, suffering and emotional distress process, and fear of recurrence in future pregnancies. Women that decided to continue their pregnancy had a dilemma between hope and worries. In general, women carrying babies tried to keep a positive attitude towards the birth, as a way to cope with the situation. They were hopeful about the best possible outcome or return of normality. Some women hope that the problem for the health of their unborn child in the case of abnormal findings will be resolved or is miner anomaly.
To explore the emotional and cognitive experiences of pregnant women following prenatal diagnosis of fetal anomalies in Mashhad, Iran.

Qualitative study Pregnant women
Two tertiary referral centers for fetal anomaly at Mashhad University Hospitals, Omolbanin Hospital and Imam Reza Hospital in Mashhad, Iran.
The sample studied consisted of Persian speaking parents with prenatal diagnosis of fetal anomalies at the gestational week of 12-27. All the pregnant women with a suspected or definitive diagnosis of fetal anomaly as per the ultrasound or the combined test (NT, free β-hCG and PAPP-A) were eligible for participation.
Four categories and 10 subcategories emerged. Category one, grief reactions during the time of diagnosis, contained two subcategories: shocked and panicked, and distressed and disbelieved.
Category two, perinatal loss through a pregnancy termination, contained four subcategories: guilt and shame during pregnancy termination, loss of their expected child, suffering and emotional distress process, and unmet needs by health professionals. Category three, fears of recurrence in future pregnancies, had two subcategories: worried about inadequate prenatal care in the future pregnancies and worried about abnormal fetus in next pregnancies. Finally, Category four, a dilemma between hope and worries contained two subcategories: hope for normality and worried about future.
Complexity of consenting for medical termination of pregnancy: Prospective and longitudinal study in Paris Tayeh, Jouannic, Mansour, Kesrouani &Attieh (2018) Paris [30] Hope implicit in religious beliefs and convictions and believed that their child could exceptionally survive after birth.
To analyze the patients' perception of prenatal diagnosis of fetal cardiac pathology, and the reasons for choosing to continue with pregnancy despite being eligible to receive a medical termination of pregnancy.
Descriptive, prospective and longitudinal study Pregnant women Hôpital Necker-Enfants Malades in Paris, France Eligible participants were pregnant women who decided to continue their pregnancy despite an unfavorable medical advice because they were carrying fetuses with incurable cardiac pathologies. Age between 23 and 44 years old.
Patient informed consent should be sought before any decision in neonatology, even if conflicting with the medical team's knowledge and the pregnant mother's benefits. Decisions to accept or decline pregnancy termination depend on the patients' psychological character, ideologies, convictions, and mistrust in the diagnosis/prognosis, or hope in the fetus survival.
Women's Voices: The Lived Experience of Pregnancy and Motherhood After Diagnosis With HIV Sanders (2008) New York (USA) [23] Hopelessness characterized by periods of emotional distress, ambivalence in relation to pregnancy and mother-hood, and stigma. Hope in protecting children from contracting HIV and from HIV related stigma and hoped to rectify mistakes made with children born previously and to be a good, loving mother.
The study aimed to explore the meaning of pregnancy after diagnosis with HIV

Qualitative study Pregnant women
Interviews conducted in two academic health centers in metropolitan New York.
Participants were a purposive sampling of 9 women, 34 to 53 years old, who had been diagnosed with HIV and were currently pregnant or who had become mothers postdiagnosis.
The result of the study included themes of extreme emotional distress after HIV diagnosis, feeling stigmatized, emotions related to the pregnancy and baby, experiences with health care providers, and as positive and supporting.  [25] Hopelessness implicit in a negative self-image, loneliness, feelings of isolation, fear from loved ones, women experienced blame, fear, the cruelties of stigma, stereotyping and judging an avoided any romantic relationship. Fear of being ill, being in a hospital or dying. Women felt hope to live and see the future of their children, hope on their spiritual beliefs. The initiation of ART gave them hope as they were confident that the treatment would improve their health, extend their life, protect their unborn children and even cure HIV. The most important hope that they had for the future was that their unborn child would be HIV free

Author(s) Year
To explore the lived experiences of women diagnosed with HIV in the antenatal period in a rural area in the Eastern Cape province of South Africa.

Phenomenological study Pregnant women
Pregnant women residing in the Maluti local service area in the Eastern Cape who attended one the local clinics.
Ten women over the age of 18, diagnosed with HIV for the first time in the antenatal period of pregnancy.
Women diagnosed with HIV during pregnancy are ultimately concerned with the wellbeing of their unborn children, and this concern motivates their adherence to ART. Women's lived experiences are situated in their unique sociocultural context, and although some known challenges remain, counselling and support strategies need to be informed by exploring context-specific issues and involving the local community. All participants in these study decided not to end their pregnancies. This might be explained in the fact that all women were Buddhist, with Buddhists usually believing that terminating one's life or ending a pregnancy is a big sin. From a health care perspective, identifying helpful resources such as a peer/support group can be critical for a woman when she is ready to share her struggle with others. Peer support was found to be helpful for 7 women in our study and has been found to be effective across cultures and countries in reducing seropositive women's fears, depression, and attempts at suicide. In general, support from health care professionals to assist the HIV-positive mother's efforts to promote her baby's health will be of great value, regardless of the ultimate diagnosis of the baby's HIV status. Hopelessness: several forms of negative emotions such as fear, anxiety, alarm, incomplete self, discouragement and numbness. Fear on their own lives and lives of their babies, fear for the prenatal outcomes and of undergoing surgery, fear of recurrence similar incidents and inability to conceive in the future, sense of death; incomplete self, because being a woman without a uterus and without a baby; sadness for not being able to have more children Hope: The women adapted to most of negative emotions and to difficult life events, like traumatic childbirth by anchoring their reasoning to religiosity and faith and appeared to have accepted the situation calmly. They responded to their situations positively, delegating the resolution to God and regarding what had happened as what God had planned for them. They were very grateful that God gave them a second chance. Other forms of adaptation included natural maternal disposition in which their attention were distracted and focused on their children and that was a motivator to seek treatment and as a source of strength to continue living. The competency of the healthcare providers in the form of adequate knowledge and skills in providing optimal care had gained trust from the women. Emotion and social support and improved relationship quality were associated with better mental health and well-being, reduced stress and protection from postpartum depression. In the current study, social support appeared to play a role in protecting the women from ill health. Despite their experiences, the women were relieved at having survived their acute, severe complications and looked forward to resuming their lives normally. In appraising the maternal near miss events, the study found that the women viewed their experiences as frightening and that they experienced other negative emotions and a sense of imminent death. Their perceptions of the quality of their care were influenced by the competency and promptness in the provision of care, interpersonal communication, information-sharing and the quality of physical resources. These factors should be of concern to those seeking to improve services at healthcare facilities. The predisposition to seek healthcare was influenced by costs, self-attitude and beliefs.

Hope and Hopeless Experiences or/and
The lived experience of pregnancy while carrying a child with a known, nonlethal congenital abnormality Hedrick (2004) USA [32] Hopelessness is define by the loss of the perfect baby with feelings of grief, shock, anger and guilt. Hope defined with good sources of information, time to prepare, support from family and friends, spiritual beliefs and staying busy with work and other activities and empathizing with the baby -Motherhood has such a strong meaning to these women that not even the possibility of transmitting the virus to the foetus can change their mind. The wish to be a mother is stronger than the problems faced throughout life. -Mothers with HIV focus their life on the uninfected child, which symbolizes the continuity and the hope to overcome their fears. The child can be the motivator that helps them to face the challenges imposed by the disease. -For them, positive pregnancy experiences were an important source of support and hope to carry on living and taking care of their own health. The participants accepted their pregnancy and asked for a healthy baby. Even if it is an unplanned pregnancy, the child becomes a motivating force, giving them reason to fight the disease. -A mother living with HIV will adhere more easily to treatment if she has been informed about the seriousness of the disease and about the possibilities of the child being infected. -Pregnant women make adjustments to deal with their seropositivity through religion, seeking in God's figure love, care, help, strength, forgiveness, and well-being. The support of religion brings hope conveying a feeling of comfort and has an impact on coping with HIV/AIDS -For these women, the unborn child is the motivation for them to rethink their life and to withstand the bad times. Religiousness resurfaced by the wish for a child gives meaning to their life and helps the construction of a female identity -Faith is a life support that helps these women to withstand the uncertainties of being pregnant and HIV positive. Their faith in God gave them the confidence to face the difficulties imposed by the disease and hope for better days for them and their children -Spirituality is a comfort that helps them to bear the pain of being HIV positive; it makes them believe in quality of life due to treatment and, in the hope of a miracle, that God may transform their lives completely Five pregnant women diagnosed with HIV monitored in SAE of Foz do Iguaçu, in the state of Paraná, participated in the study. They were married, aged between 20 and 35 years old, and had been diagnosed from one month to ten years before research began The interviews conveyed the experiences of the women with HIV, their acceptance of the limitations imposed by the disease and showed how they dealt with the stigma surrounding HIV. Despite the prejudice, such pregnant women did not lose faith and hope. Pregnant women believe in the treatment and the possibility of their children being born healthy. The desire of motherhood increases their expectations about the care, which prevents complications from the infection. The study participants accepted the pregnancy, mainly because the desire to become a mother was stronger than anything else they could feel. The treatment was then accepted, as the only way to protect their children from a HIV infection. The researchers identified feelings of strength, will, and determination to overcome the problems which transcend the difficulties encountered throughout pregnancy. The fear of harming the child-symbol of perseverance, wishes and hopes-is faced and reignites their desire to carry on living in order to care for their children and to protect them. Communication and education for the construction of new concepts and ideas related to the phenomenon can indicate new ways to learn about change processes. Social movements, cultural changes, as well as social equality and inequality; action and intervention based on fair policies can also be one of the responses to the problem. Parents whose fetuses with SB were eligible for MFS, Age above 18 years old.

Author(s) Year
MFS for SB remains highly acceptable from diagnosis until 3-6 months postnatally. For those opting for MFS, expectations seemed to be realistic yet were driven by hope and expectation of the best outcome. For parents opting for termination of pregnancy, the potential benefit of MFS seems to play a minimal role in their final decision