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Abstract

Background: Pregnant healthcare workers often face unique and complex experiences of stigma, bias, and communication challenges in the workplace that can have significant negative impacts on their well-being, job satisfaction, and career trajectories. However, a comprehensive understanding of these lived experiences and the strategies used to navigate them is lacking. This systematic review aims to synthesize qualitative evidence on the stigma, bias, and communication challenges faced by pregnant healthcare workers, as well as the ways in which they cope with and resist these challenges. Methods: A systematic search will be conducted in PubMed, Web of Science, Embase, CINAHL, MEDLINE, The Cochrane Library, PsycINFO, and Scopus databases from inception to June 2025. Qualitative studies that explore the experiences of stigma, bias, and communication challenges among pregnant healthcare workers will be included. Two reviewers will independently screen studies for eligibility, extract data, and assess methodological quality using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist. Thematic synthesis will be used to inductively analyze and integrate findings across studies, with a focus on generating new interpretive constructs and explanations. Confidence in the review findings will be assessed using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. Discussion: This review will provide an in-depth, nuanced understanding of the qualitative experiences of stigma, bias, and communication challenges faced by pregnant healthcare workers, grounded in their own voices and perspectives. The findings will offer valuable insights to inform the development of interventions, policies, and support strategies that are responsive to the unique needs and challenges of this essential workforce. Implications for promoting more inclusive, equitable, and supportive healthcare work environments will be discussed, with attention to structural and cultural barriers that need to be addressed. Prospero registration number: CRD42024617361.

Keywords

communication discrimination gender healthcare personnel pregnancy stigma

Introduction

Pregnancy is a significant life event that poses unique challenges for healthcare workers, who often face high-pressure, demanding work environments while also managing the physical, emotional, and social changes associated with pregnancy. Pregnant healthcare workers may encounter experiences of stigma, bias, and communication difficulties in the workplace that can have profound negative impacts on their well-being, job satisfaction, and career trajectories (Gatrell, 2011a; Halpert et al., 1993).

Stigma involves the labeling, stereotyping, separation, status loss, and discrimination of individuals based on a discredited attribute, such as pregnancy (Goffman, 2009). Pregnant healthcare workers may face stigmatizing attitudes and assumptions from colleagues, supervisors, and patients that call into question their competence, commitment, and fitness for work (Davis, 2020). They may be viewed as a liability or burden, and face negative comments or judgment about their changing bodies and abilities (Kutcher et al., 2002).

Bias, both explicit and implicit, can also shape the experiences of pregnant healthcare workers. They may encounter overt discrimination or disparate treatment based on their pregnancy status, such as being passed over for promotions, excluded from important meetings or decisions, or pressured to take leave or resign (Hebl et al., 2007). They may also face more subtle forms of bias, such as microaggressions, social exclusion, or lack of accommodation for their physical needs (Jones et al., 2016).

Communication challenges are particularly salient for pregnant healthcare workers, who may feel reluctant to disclose their pregnancy or advocate for their needs due to fear of negative repercussions (Little et al., 2015). They may struggle to navigate difficult conversations with unsupportive or hostile colleagues, or to set boundaries around their workload and responsibilities (Greenberg et al., 2009). At the same time, they may face challenges in maintaining open and empathetic communication with patients while managing the physical and emotional demands of pregnancy (Ladge & Greenberg, 2015).

Despite the significance of these experiences, there is a lack of comprehensive, synthesized evidence on the qualitative experiences of stigma, bias, and communication challenges among pregnant healthcare workers. Previous reviews have examined the general workplace experiences of pregnant women (Gatrell, 2011b), or specific issues such as pregnancy discrimination (Williams & Segal, 2003) or work-family conflict (Collie et al., 2022), but have not focused on the unique challenges within healthcare settings or the strategies used to navigate these challenges.

Existing qualitative studies offer rich insights into the lived experiences and perspectives of pregnant healthcare workers, but are dispersed across different contexts, populations, and timeframes (Cech & Blair-Loy, 2014; Freeney et al., 2024; Gatrell, 2008). A systematic review is needed to integrate these findings and identify overarching themes, patterns, and gaps in the evidence. Qualitative research is particularly valuable for understanding the complex, context-dependent, and subjective nature of experiences of stigma, bias, and communication challenges, and for giving voice to marginalized or underrepresented groups (Braun & Clarke, 2019).

A synthesis of qualitative evidence on this topic will complement existing quantitative research by providing a more in-depth, nuanced understanding of the range and impact of challenges faced by pregnant healthcare workers, as well as the meanings they ascribe to these experiences. It will also highlight the agency, resilience, and resistance of pregnant healthcare workers in navigating and challenging stigma, bias, and communication barriers.

The aim of this systematic review is to synthesize qualitative evidence on the experiences of stigma, bias, and communication challenges among pregnant healthcare workers, as well as the strategies they use to cope with and resist these challenges. The review will address the following research questions:

(1) How do pregnant healthcare workers describe and make sense of experiences of stigma, bias, and communication challenges in their work environments?

(2) What are the impacts of these experiences on pregnant healthcare workers’ well-being, job satisfaction, professional identities, and career trajectories?

(3) How do pregnant healthcare workers navigate, cope with, and resist experiences of stigma, bias, and communication challenges, both individually and collectively?

(4) What are the structural, cultural, and interpersonal factors that shape pregnant healthcare workers’ experiences of stigma, bias, and communication challenges across different healthcare contexts?

By addressing these questions, the review aims to generate new insights and interpretations that can inform the development of interventions, policies, and support strategies to improve the experiences and retention of pregnant healthcare workers. The review will also identify gaps and priorities for future research on this important topic.

Methods

This systematic review protocol follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines (Moher et al., 2015) and the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement (Tong et al., 2012). The protocol will be registered with the International Prospective Register of Systematic Reviews (PROSPERO).

Eligibility Criteria

Studies will be selected for inclusion based on the following criteria, defined using the PICO (Population, Interest, Context, Study Design) framework:

• Population: Pregnant healthcare workers, including but not limited to physicians, nurses, midwives, physician assistants, technicians, and other clinical roles. Postpartum healthcare workers will be included if they report retrospectively on their experiences during pregnancy. Studies of healthcare students or trainees who become pregnant will also be considered.

• Interest: Experiences of stigma, bias, and communication challenges related to pregnancy in the workplace, as well as strategies used to navigate these challenges. Studies must explore at least one of these issues from the perspective of pregnant healthcare workers themselves. Studies that focus solely on the attitudes or behaviors of colleagues, supervisors, or institutions towards pregnant healthcare workers will be excluded.

• Context: Healthcare workplace settings, including hospitals, clinics, private practices, and other healthcare facilities across all geographic locations and time periods. Studies in non-healthcare workplace settings (e.g., business, education, government) will be excluded.

• Study Design: Primary qualitative studies that use descriptive or interpretive approaches to collect and analyze data, such as phenomenology, grounded theory, ethnography, narrative inquiry, case study, or qualitative description. Studies must report first-hand accounts from pregnant healthcare workers in the form of interviews, focus groups, observations, diaries, or other qualitative data sources. Mixed-methods studies will be included if they report qualitative findings separately. Editorials, commentaries, reviews, and purely quantitative studies will be excluded.

No restrictions will be placed on the date of publication, geographic location, or cultural context of the studies. Only studies published in English will be included due to resource constraints for translation.

Search Strategy

A comprehensive search strategy will be developed in consultation with a health sciences librarian to identify potentially relevant studies. The electronic databases that will be searched from inception to June 2025 include PubMed, Web of Science, Embase, CINAHL, MEDLINE, The Cochrane Library, PsycINFO, and Scopus. The search strategy will combine concepts related to the population (pregnant healthcare workers), interest (stigma, bias, communication challenges), and study design (qualitative research). Both free-text keywords and controlled vocabulary terms (e.g., MeSH) will be used to capture relevant studies. The search terms will be adapted from the following template:

(“pregnant healthcare workers” OR “pregnant health personnel” OR “pregnant physicians” OR “pregnant nurses” OR “pregnant midwives”) AND (“pregnancy discrimination” OR stigma OR bias OR prejudice OR stereotype OR “communication challenges” OR “communication barriers” OR “difficult conversations” OR “workplace challenges” OR “workplace accommodations” OR “workplace support” OR “maternity leave” OR “social support” OR “coping strategies” OR “resilience strategies”) AND (qualitative OR “qualitative research” OR “qualitative study” OR “qualitative methods” OR interviews OR “focus groups” OR phenomenology OR “grounded theory” OR ethnography OR “narrative inquiry” OR “case study” OR “qualitative description” OR “thematic analysis” OR “content analysis” OR “discourse analysis” OR “interpretive analysis”)

The search strategy will be peer-reviewed by a second librarian using the Peer Review of Electronic Search Strategies (PRESS) checklist (McGowan et al., 2016). No date or language limits will be applied to the search. The reference lists of included studies and relevant reviews will also be hand-searched to identify additional eligible studies.

Study Selection

The results of the database searches will be exported into Covidence systematic review software for screening and data management. After removing duplicates, two reviewers will independently screen the titles and abstracts of all records against the eligibility criteria. Records that clearly do not meet the inclusion criteria will be excluded at this stage. Full texts of potentially eligible studies will then be retrieved and reviewed independently by two reviewers. Discrepancies at either stage will be resolved through discussion or adjudication by a third reviewer. Reasons for exclusion at the full-text stage will be documented in a PRISMA flow diagram.

Data Extraction

A standardized data extraction form will be developed in Covidence and piloted on a sample of included studies. Two reviewers will independently extract data from each study, with disagreements resolved through discussion or adjudication by a third reviewer. Key data elements to be extracted include study characteristics (authors, year, country, aims), participant demographics (sample size, professions, demographics), methodological details (design, data collection, analysis), primary findings related to experiences of stigma and bias, and implications for practice and policy (details in Appendix: 1). Where necessary, study authors will be contacted to obtain missing or unclear data.

Quality Appraisal

The methodological quality of included studies will be critically appraised using the Critical Appraisal Skills Programme (CASP) Qualitative Checklist (CASP, 2018). This checklist includes 10 questions that assess the appropriateness of qualitative methodology, the validity and relevance of recruitment, data collection and analysis, the clarity of findings, and the value of the research. Two reviewers will independently appraise each study, with disagreements resolved through discussion. Studies will not be excluded based on quality scores, as this may overlook valuable insights from studies with methodological limitations (Dixon-Woods et al., 2004). However, the quality appraisal will be used to inform the interpretation and credibility of the review findings.

Data Synthesis

Thematic synthesis (Thomas & Harden, 2008) will be used to analyze and integrate the findings of included studies. This approach involves three stages: (1) line-by-line coding of the results or findings sections of primary studies; (2) organization of codes into descriptive themes; and (3) development of analytical themes that go beyond the primary studies to generate new interpretive constructs, explanations, or hypotheses.

In the first stage, two reviewers will independently read and re-read the results or findings sections of each study and apply initial codes to capture salient concepts, emotions, values, and experiences related to stigma, bias, communication challenges, and coping strategies. The reviewers will then meet to compare their codes, resolve discrepancies, and agree on a preliminary coding framework.

In the second stage, the reviewers will work collaboratively to organize the initial codes into descriptive themes that capture patterns of meaning across studies. This will involve constant comparison of codes within and between studies to identify similarities, differences, and relationships. The descriptive themes will be refined through discussion and consensus among the reviewers.

In the third stage, the reviewers will develop higher-order analytical themes that provide new interpretive constructs or explanations for the descriptive themes. This will involve moving beyond the original findings of the primary studies to generate new insights, theories, or hypotheses about the experiences of pregnant healthcare workers. The analytical themes will be reviewed and refined through discussion with the full review team, with attention to negative or disconfirming cases.

Throughout the synthesis process, the reviewers will maintain a reflexive and transparent approach, documenting their preconceptions, decisions, and interpretations in memos and a reflexive journal (Toye et al., 2014). The synthesis findings will be presented narratively, with illustrative quotes from the primary studies to support the descriptive and analytical themes. Diagrams or conceptual models may also be used to visually represent the relationships between themes.

Confidence in the Evidence

The Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach (Lewin et al., 2018) will be used to assess the confidence in each review finding. This approach assesses four components:

(1) Methodological limitations of the primary studies contributing to the review finding, based on the quality appraisal

(2) Coherence of the review finding, or the extent to which the data from primary studies support the finding

(3) Adequacy of data supporting the review finding, in terms of number and richness of data sources

(4) Relevance of the data to the review question, in terms of context, perspective, or phenomenon of interest

Two reviewers will independently assess each component for each review finding using the GRADE-CERQual guidelines. Based on the assessments, each finding will be assigned a level of confidence (high, moderate, low, or very low) that reflects the extent to which the finding is a reasonable representation of the phenomenon of interest. The GRADE-CERQual assessments will be presented in a Summary of Qualitative Findings table, along with an explanation of the judgments for each finding.

Discussion

This systematic review protocol outlines a rigorous and comprehensive approach to synthesizing qualitative evidence on the experiences of stigma, bias, and communication challenges among pregnant healthcare workers. Despite growing recognition of the unique challenges faced by this population, there is a lack of comprehensive, synthesized evidence on their lived experiences and the strategies they use to navigate and resist these challenges.

Existing studies have explored various aspects of the experiences of pregnant healthcare workers, such as pregnancy discrimination (Hebl et al., 2007), work-family conflict (Collie et al., 2022), and postpartum return to work (Cech & Blair-Loy, 2014; Freeney et al., 2024). However, these studies have not employed a systematic approach to synthesizing qualitative evidence specifically on stigma, bias, and communication challenges. Furthermore, previous reviews have focused on the general experiences of pregnant women in the workplace (Gatrell, 2011a) or on specific subpopulations of pregnant healthcare workers, such as physicians or nurses. To address these gaps, our systematic review will adopt a rigorous methodology to focus specifically on the experiences of stigma, bias, and communication challenges among pregnant healthcare workers across all healthcare professions and settings.

The qualitative focus of this review is particularly important for understanding the complex, nuanced, and context-dependent nature of these experiences. Qualitative research allows for an in-depth exploration of the perspectives, meanings, and interpretations that pregnant healthcare workers ascribe to their experiences, as well as the strategies they use to cope with and resist stigma, bias, and communication challenges. By synthesizing qualitative evidence from diverse healthcare contexts and populations, this review will provide a comprehensive and rich understanding of the range and depth of these experiences.

The use of a thematic synthesis approach in this review will enable the generation of new interpretive constructs and explanations that go beyond the findings of the primary studies. This approach is well-suited to the aims of the review, as it allows for the identification of overarching themes and patterns across studies, as well as the development of new theoretical insights and hypotheses. The use of the GRADE-CERQual approach to assess the confidence in the review findings will also strengthen the credibility and trustworthiness of the synthesis.

The findings of this review will have important implications for policy, practice, and research. By identifying the structural, cultural, and interpersonal factors that contribute to stigma, bias, and communication challenges, the review will inform the development of interventions and policies to support pregnant healthcare workers and create more inclusive and equitable work environments. The review will also highlight the strategies and forms of resistance used by pregnant healthcare workers themselves, which can inform the design of training programs, support services, and advocacy efforts.

In terms of research, this review will identify gaps and priorities for future studies on the experiences of pregnant healthcare workers. The synthesis may reveal underexplored contexts, populations, or dimensions of these experiences that warrant further investigation. The review may also generate new research questions or hypotheses based on the emergent themes and patterns identified in the synthesis.

The strengths of this review include the comprehensive search strategy, rigorous screening and quality appraisal procedures, and transparent reporting of methods and findings. The involvement of multiple reviewers and adherence to established reporting guidelines will enhance the reliability and replicability of the review process. The use of a qualitative synthesis approach and confidence assessment will also strengthen the credibility and relevance of the review findings for informing policy, practice, and research.

However, this review also has some limitations that should be considered. The focus on qualitative evidence may not capture the full range of experiences or outcomes associated with stigma, bias, and communication challenges among pregnant healthcare workers. The exclusion of studies published in languages other than English may also limit the generalizability of the findings to different cultural contexts. Furthermore, the review findings will be based on the subjective interpretations of the reviewers, which may introduce some bias or inconsistency in the analysis and synthesis of the data.

Despite these limitations, this systematic review will make a valuable contribution to the evidence base on the experiences of pregnant healthcare workers. By providing a comprehensive and rigorous synthesis of qualitative evidence on stigma, bias, and communication challenges, the review will advance our understanding of the complex realities and needs of this essential workforce. The findings will inform the development of strategies and interventions to support pregnant healthcare workers and promote more inclusive and equitable work environments in healthcare settings.

The findings of this review will be disseminated through multiple channels to reach a wide audience of researchers, practitioners, policymakers, and the public, with the ultimate goal of promoting more inclusive, equitable, and supportive work environments for all healthcare workers.

Supplemental Material

Supplemental Material - Experiences of Stigma, Bias, and Communication Challenges Among Pregnant Healthcare Workers: A Protocol for a Systematic Review of Qualitative Evidence

Supplemental Material for Experiences of Stigma, Bias, and Communication Challenges Among Pregnant Healthcare Workers: A Protocol for a Systematic Review of Qualitative Evidence by Ravi Shankar, Fiona Devi, and Jaminah Ali in International Journal of Qualitative Methods

Footnotes

ORCID iDs

Ravi Shankar

Fiona Devi

Ethical Considerations

This protocol has been registered with PROSPERO (CRD42024617361). As this is a systematic review protocol, ethical approval was not required. However, the review itself will only include studies that have received appropriate ethical approval, and this will be assessed during the quality appraisal process using the CASP checklist.

Author Contributions

R.S. conceptualized the review protocol, developed the methodology, and designed the search strategy. R.S. and F.D. collaboratively designed the data extraction and quality appraisal procedures. J.A. contributed expertise on stigma in healthcare settings and its impact on care delivery. R.S. drafted the introduction and methods sections. All authors contributed to refining the inclusion criteria and thematic analysis approach. All authors reviewed and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The systematic review protocol has been registered on PROSPERO (CRD42024617361). The search strategy, data extraction forms, and quality assessment tools will be made available as supplementary materials with the published protocol. Following completion of the review, the extracted data and analysis files will be made available in a suitable repository, subject to copyright restrictions for the included papers.*

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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Experiences of Stigma,Bias,and Communication Challenges Among Pregnant Healthcare Workers: A Protocol for a Systematic Review of Qualitative Evidence

Abstract

Keywords

Introduction

Methods

Eligibility Criteria

Search Strategy

Study Selection

Data Extraction

Quality Appraisal

Data Synthesis

Confidence in the Evidence

Discussion

Supplemental Material

Supplemental Material - Experiences of Stigma, Bias, and Communication Challenges Among Pregnant Healthcare Workers: A Protocol for a Systematic Review of Qualitative Evidence

Footnotes

ORCID iDs

Ethical Considerations

Author Contributions

Funding

Declaration of Conflicting Interests

Data Availability Statement

Supplemental Material

References

Supplementary Material