Table 4 Meta-themes, sub-themes and primary supporting data

Experiences of loneliness and perinatal depression

1. Self-isolation, hiding depressive symptoms and loneliness due societal stigma

1.1 ‘Just snap out of it’ – Societal stigma about perinatal depression and fear of judgement as a ‘bad mother’ makes women feel lonely

‘It was clear from women’s narratives that many experienced a sense of failure or inadequacy that could prevent them from connecting to others. The mothers described feeling under pressure—from themselves, partners, family members, other mothers, and wider societal narratives—to take on the role of a primary caregiver and to be, as Lottie put it, “a perfect mum”’ [18]

1.2 Self-isolation & hiding depressive symptoms compounds loneliness

‘The participants described a withdrawal from others by hiding their true thoughts and feelings by isolating themselves. One mother described vividly how her strong feelings of shame made her actively conceal her real feeling and thoughts. Another mother described how she exhausted herself by putting on a happy mask and doing her best to keep up appearances’ [69]

‘There was also a tendency in depressed women to isolate themselves. Women described a strong desire to not have to leave the house but rather be alone and for others to go away: “I didn’t want to see anyone – even though I needed support I just wanted everyone to leave me alone” [28]

2. Sense of emotional disconnection associated with perinatal depression fuels loneliness

2.1 ‘Inauthentic relationships’ with other mothers and feeling misunderstood

“This girl I knew. .. I said “Oh, do you feel like that, do you?” and she’d say “Oh, no, no, no” and I said “Oh-oh, pull yourself together dummy. .. you’re alright.” and then I’d get home and think “She doesn’t feel like that, perhaps it isn’t normal”. ... That was the one thing that really got to me through it all, that I couldn’t find anyone who felt like I did, and I felt like I was going through it on my own. ... I couldn’t find anyone who said “Oh yes, I felt like that, don’t worry, you’ll get better”. ... I felt really isolated and lonely through it.’ (Pam)’ [61]

2.2 Disconnection from baby

“Several women also described difficulties bonding with their babies, for example feeling “nothing”, “numb”, “terrified of them” or like their baby “wasn’t a part of me”. For some mothers, a baby’s need to be close to them could feel uncomfortable, even threatening, yet a lack of closeness also resulted in high levels of distress. As Emma explained: “[My baby] used to have to sleep on my chest and, because I didn’t want him near me, it was really hard having him on my chest. So he used to just lay there and scream in pain and I used to just sit in another part of the room and just cry.”’ [18]

2.3 ‘Dislocation’ in sense of self after birth

‘….feelings of dislocated identity clearly included a strong sense of loneliness and desolation, as the mothers described themselves becoming confined to their homes with their babies, isolated from the wider world, and disconnected from their past lives and social networks. A dislocated self was particularly evident in the narratives of first-time mothers who had stopped working or taken maternity leave to have a baby.’ [18]

3. Mismatch between expected and actual support associated with loneliness

3.1 Subjective lack of emotional and practical support from the wider family and community

‘Anna left a safe, secure social network back home to find a very precarious situation in her new country: The biggest problem that I faced was arriving late in my pregnancy and didn’t have a specialist. So when it’s time for delivery they said go to the ER. .. I was so stressed the words were gone and was unable to speak. Everything is new. .. you are alone and not with your family and don’t know their system, so this is scary.. .’ [66]

3.2 Lack of support and gender imbalance in partner relationship

‘Women spoke about feeling isolated and alone and overwhelmed with anxiety by being the sole caregiver for their infants while their partner was at work.’ [60]

What made loneliness better for women with perinatal depression?

4. Validation from trusted healthcare professionals

I recognise she can only come to the house once a week and then only for 2 hours but they are the two most important hours in my week. My volunteer is more like a friend than a person in a ‘working relationship’ [56]

5. Peer support from other mothers with perinatal depression

‘Groups are a safe place to say ‘This isn’t the greatest time of my life’, and getting some support that you are a good mom, and that your baby does feel loved, even though you’re not, like, jumping up and down for joy, and that it will get better.’ [60]

‘All participants within this study were recruited from mother and baby groups. For those mothers who were feeling particularly isolated, these groups provided not only a source of support and knowledge but also gave women a sense of community, which is embedded within collectivist West African culture: ……… [when you start going to the group] you know that you are not alone. So many mothers are going through what you are going through. And some are even MORE than yourself…….. [I think] there should be a gathering for mothers……. So you can chat with another mother.…. it does help. – Participant 1’ [55]

6. Practical and emotional support from family

‘Health services often did not accommodate women’s children during treatment sessions, and therefore some women relied on informal childcare to enable them to access this formal support. I’ve been having counselling every week and I’ve come on in leaps and bounds… my Mum and Dad kept these two (children) and it’s so helpful. (Tina, postnatal depression and post-traumatic stress disorder, rural village)’ [57]

What made loneliness worse for women with perinatal depression?

7. Lack of professional support, groups and facilities

“There’s nothing really in this area for mothers. I found it very difficult to meet up locally. ... I would have liked to have known. .. other mothers around, and if there was sort of a central meeting place in this area’ [61]

8. Conflict and separation from partner, family & community

‘Most participants expressed that being a newly immigrated mother without the familiar, preexisting support networks could predispose women to PPD. Women felt that they were vulnerable because of the lack of family support after childbirth. For Anna, being connected was the norm back home: “The families are so big and so supportive. We’re always in touch. .. always gathering around someone.” Kate maintained that PPD is more commonly found here because of the lack of familial support and the stress of being alone. She felt that isolation and solitude are the biggest problems in developed countries.’ [66]