Postpartum anxiety and depression symptoms in non-birthing parents in Canada: A cross-sectional study

Postpartum anxiety and depression symptoms in non-birthing parents in Canada: A cross-sectional study | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Postpartum anxiety and depression symptoms in non-birthing parents in Canada: A cross-sectional study View ORCID Profile Justine Dol , View ORCID Profile Christine T. Chambers , View ORCID Profile Emily Cameron , View ORCID Profile Cindy-Lee Dennis , View ORCID Profile Jennifer M. Goldberg , View ORCID Profile Jennifer A. Parker doi: https://doi.org/10.1101/2025.08.15.25333775 Justine Dol 1 IWK Health Centre , Halifax, NS, Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Justine Dol For correspondence: Justine.dol{at}dal.ca Christine T. Chambers 2 IWK Health Centre; Department of Psychology & Neuroscience, Department of Pediatrics, Dalhousie University , Halifax, NS, Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Christine T. Chambers Emily Cameron 3 Faculty of Education, Simon Fraser University , Burnaby, BC, Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Emily Cameron Cindy-Lee Dennis 4 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto; Lunenfeld-Tannenbaum Research Institute, Sinai Health , Toronto, ON, Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Cindy-Lee Dennis Jennifer M. Goldberg 5 McMaster Midwifery Research Centre, McMaster University , Hamilton, Ontario, Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jennifer M. Goldberg Jennifer A. Parker 1 IWK Health Centre , Halifax, NS, Canada Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jennifer A. Parker Abstract Full Text Info/History Metrics Data/Code Preview PDF ABSTRACT Introduction The postpartum period is a vulnerable time for parents. While the focus of most research is on the birthing parent, evidence of postpartum mental health challenges for fathers and sexual minority parents is lacking. The study objective was to determine the prevalence of postpartum depression and anxiety in non-birthing parents, overall and by on sex, gender, and sexual orientation. Methods An online cross-sectional study was conducted with non-birthing parents from across Canada who had an infant <12 months of age. Recruitment occurred via social media and an online survey company. Parents completed questionnaires, including the Edinburgh Postpartum Depression Scale (EPDS) and General Anxiety Disorder (GAD). Scores >9 and >10 on the EPDS and GAD, respectively, were considered positive for postpartum depression and anxiety symptoms. T-tests were used to determine if there were differences based on sex, gender, or sexual orientation. Results A total of 133 non-birthing parents participated (54.9% first-time parents, 90.2% fathers). Overall, 56.4% of non-birthing parents had postpartum depression, 23.3% had postpartum anxiety, and 21.8% had comorbid postpartum anxiety and depression. There were no differences based on sex or gender; however, sexual minority parents had a significantly higher prevalence of both postpartum depression (73.3%) and anxiety symptoms (46.7%) than heterosexual parents (52.5% and 16.8%), respectively. Discussion The postpartum mental health of non-birthing parents is of critical concern with 1 in 2 experiencing symptoms of depression and 1 in 4 experiencing symptoms of anxiety. More work is needed to better support these parents during their first year postpartum. INTRODUCTION Within the postpartum period, much of the clinical care and research is often focused on the transition to parenthood for birthing parents (e.g., cisgendered, heterosexual mothers) [ 1 , 2 ], while evidence on the transition experience for the non-birthing partner (e.g., fathers, sexual minority partners) is lacking [ 3 – 5 ]. The postpartum period, up to 12 months post-birth, is an extremely vulnerable time, with a high risk for parents of developing or experiencing exacerbated mental health issues [ 6 ]. Even in uncomplicated pregnancies and births, one in eight mothers and one in ten fathers will experience postpartum mental health concerns [ 7 – 10 ], which can have negative impacts on parenting relationships and child outcomes [ 11 – 14 ]. Non-birthing parents, specifically fathers, often face challenges in their mental health in the postpartum period and frequently feel unsupported and left out by healthcare providers delivering perinatal services [ 3 – 5 , 15 – 18 ]. The prevalence of postpartum anxiety and depression in fathers increased during the COVID-19 pandemic, with Canadian estimates around 58.3% for depression and 33.3% for anxiety [ 19 ]. However, it is unknown whether this increased prevalence was only during the pandemic or if non-birthing parents continue to experience high levels of mental health struggles after the birth of a child. There is even less research on perinatal mental health in 2SLGBTQA and sexual minority non-birthing parents [ 20 , 21 ]. This gap in knowledge is despite a growing number of diverse and non-normative family structures, with the percentage of same-sex child-rearing couples in Canada growing from 8.6% in 2001 to 12.0% in 2016 [ 22 ]. There is even less research on trans parents, with one study finding that 25% of probability-sampled trans people identified as parents, many experiencing parenting challenges and external stressors [ 23 ]. Challenges related to heteronormativity and cisnormativity are consistently identified by sexual minority parents during pregnancy, childbirth, and the postpartum period [ 6 , 24 , 25 ]. Furthermore, there are differences experienced between sexual minority people who birth children compared to non-birthing parents, with the latter experiencing further exclusion and isolation [ 6 ]. 2SLGBTQ+ non-birthing parents can face social exclusion and isolation and lack of support [ 26 ], which can contribute to perinatal mental health challenges such as depression and anxiety [ 27 ]. Therefore, this study aimed to (1) determine the prevalence of postpartum depression and anxiety in non-birthing parents living in Canada; (2) determine if there is any difference in prevalence based on sex, gender, or sexual orientation. METHODS A cross-sectional online survey was conducted to explore the postpartum experience of non-birthing parents living in Canada. This is part of a larger study exploring the overall postpartum experience for non-birthing parents in Canada. Setting & Sample This study recruited a convenience sample of non-birthing parents. Eligible non-birthing parents included anyone who: (1) identified as a non-birthing parent; (2) had a partner who gave birth within the past 12 months; (3) was over 18 years of age; (4) could read and understand English, and (5) lived in Canada. As this study is exploratory, no sample size calculation was done. Instead, in line with a pragmatic approach that balances resource constraints and feasibility [ 28 , 29 ], we recruited participants over a period of four months to obtain as many responses as possible. Data Collection All data collection occurred remotely via an online survey hosted on Qualtrics with data stored on a secure hospital server. Recruitment occurred through an open call (promoted on social media, posters, and partner outreach) as well as through an online survey company (Leger). Participants who were recruited through the open call between April 3, 2024 and August 14, 2024 had the opportunity to enter a draw for one of five $25 electronic gift cards. Participants were recruited through the survey company between December 4, 2024 and December 10, 2024 and were compensated through the platform. All participants first completed an online consent and eligibility screening questionnaire before beginning the survey. The survey contained several questionnaires about their postpartum experience as well as demographic information. The survey took approximately 43 minutes to complete (standard deviation (SD): 30.73 minutes, range: 8-196 minutes). Studies completed in full were eligible for inclusion in the analysis. Participants were allowed to stop the survey at any time by exiting; incomplete responses were excluded from the analysis. All data were de-identified prior to analysis to ensure confidentiality. Ethical Procedures Institutional ethical approval was obtained from the IWK Health research ethics board (REB#1029967). Outcome Measures Postpartum depression symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS) [ 30 ], a self-report screening scale with 10 items that can indicate if a respondent has symptoms related to perinatal depression [ 30 , 31 ]. The EPDS is valid for assessing depressive symptoms in all people across the perinatal period [ 32 ] with higher scores indicating higher symptomology. A score of 9 or higher on the EPDS is the cut-off score indicating probable depression in community-based settings [ 33 ]. Postpartum anxiety symptoms were measured using the Generalized Anxiety Disorder (GAD-7) scale [ 34 ], which includes 7-items to assess generalized anxiety disorder, with scores ranging between 0 and 21. A cut-off score of 10 or greater indicates anxiety at a moderate/severe level. It is important to note that these scales are only screening tools, not diagnostic; however, they were used to reflect measurement tools used in community practice. Data Analysis Quantitative data were analyzed descriptively using Statistical Package for the Social Sciences (SPSS, version 29). Frequencies and other descriptive statistics were used to report demographic characteristics and prevalence rates. Means and standard deviations were calculated to determine the non-birthing parents’ level of postpartum anxiety and depression symptoms. Independent t-tests were used to examine differences between groups based on sex (male, female), gender (cisgender, non-cisgender), or sexual orientation (heterosexual, sexual minority). A p-value of 0.05 was considered statistically significant for all outcomes. To ensure the validity of the responses to the online survey, best practice strategies were used to mitigate and manage potentially inaccurate responses [ 35 , 36 ]. CAPTCHA, a common security measure for online surveys that helps ensure respondents are human, was used on the consent page to minimize the likelihood of bot attacks. We also set up security checks within the survey itself, including attention checks (i.e., asking questions like ‘If you are reading this, check ‘nearly every day’’ in the middle of a survey), double-checks (i.e., asking the infant’s date of birth twice and participant’s date of birth), and honeypots (i.e., hidden questions that are invisible to humans but automatically completed by bots). Prior to including responses in the analysis, we verified: (1) IP addresses, names, and emails were not duplicated, (2) speed of survey completion to ensure it is realistic (no less than 8 minutes, reflecting 1/3 of estimated completion time); and (3) ensure there were no poor-quality responses (e.g., nonresponse responses to open-ended questions, inconsistent responses across questions). Any responses that had two or more of these concerns were removed from the analysis. RESULTS Participants A total of 133 non-birthing parents completed the survey, including 120 (90.2%) who identified as fathers and 13 (9.8%) who identified as non-birthing parents (see Table 1 ). In terms of sex, 123 identified as male (92.5%); in relation to gender identity, the majority were cisgender men (n=109, 82.0%). Of the 131 parents who identified their sexual orientation, most were heterosexual (n=101, 76.0%). View this table: View inline View popup Table 1. Demographic characteristics of study participants (n=133) Participants reported a mean age of 35.6 years (SD=6.0 years) and their children were on average 6.5 months old at the time of survey completion (SD=3.5 months, range: 0-12 months). Overall, non-birthing parents, most identified as the biological father (n=115, 86.5%) and 54.9% were experiencing parenthood for the first time. Non-birthing parents were predominantly white (n=86, 64.7%), had an undergraduate degree (n=61, 45.9%), and were from Ontario (n=62, 46.6%), followed by British Columbia (n=19, 14.3%). Across all non-birthing parents, 56.4% (n=75) met the clinical cut-off for postpartum depression symptoms (M=9.5, SD=5.9) and 23.3% (n=31) for postpartum anxiety symptoms (M=5.8, SD=5.3, Table 2 ). While 42.1% of non-birthing parents did not have either postpartum depression or anxiety symptoms, 21.8% of non-birthing parents had clinical levels of comorbid postpartum anxiety and depression symptoms. These prevalence rates remained consistent when considering geographical regions within Canada ( Supplementary Table S1 and S2 ). View this table: View inline View popup Download powerpoint Table 2. Prevalence of postpartum depression and anxiety symptoms in non-birthing parents When examining by sex and gender, there were no differences between groups on postpartum anxiety or depression symptoms or prevalence rates ( Supplementary Tables S3 and S4 ). However, non-birthing parents who self-identified as a sexual minority parent ( Table 1 ) had significantly higher postpartum depression and anxiety symptoms than those who identified as heterosexual ( Table 3 ). Furthermore, as shown in Table 2 , sexual minority non-birthing parents have a significantly higher prevalence of both postpartum depression (73.3%) and anxiety symptoms (46.7%) than heterosexual parents (52.5% and 16.8%, respectively). View this table: View inline View popup Table 3. Postpartum depression and anxiety symptom scores based on sexual orientation of non-birthing parent DISCUSSION This cross-sectional study sought to determine the prevalence of postpartum anxiety and depression symptoms in non-birthing parents across Canada while also determining if there were any differences in prevalence based on sex, gender, and sexual orientation. Overall, over half of non-birthing parents surveyed had postpartum depression symptoms, almost a quarter had postpartum anxiety symptoms, and one-fifth had comorbid postpartum anxiety and depression symptoms. While there were no differences based on sex or gender, parents who identified as a sexual minority parent (e.g., bisexual, asexual, lesbian, gay, queer, or pansexual) had significantly higher postpartum anxiety and depression symptoms than those who identified as heterosexual. This research highlights not only the high prevalence of postpartum depression and anxiety symptoms in non-birthing parents across the first year postpartum broadly, but also for sexual minority parents specifically. Previous meta-analytic work found that between 5.6% to 8.4% of fathers experience postpartum depression and 9.5% of fathers experience postpartum anxiety [ 37 , 38 ]. In a recent Canadian study, 22.4% of fathers had comorbid anxiety and depression at some time during the first year postpartum, with approximately 11% experiencing postpartum depression and 22% experiencing postpartum anxiety symptoms between 3-12 months [ 39 ]. In the current study, postpartum depression prevalence was considerably higher than these findings, even when separated by sex, gender, and sexual orientation. Compared to Dennis et al. [ 39 ], our study found similar rates of postpartum anxiety across approximately a quarter of all non-birthing parents. This suggests that non-birthing parents are experiencing high rates of postpartum anxiety and depression symptoms which may not be managed effectively. Interestingly, data from these studies anxiety [ 37 – 39 ] were collected prior to the COVID-19 pandemic, with recent work suggesting that fathers experienced higher rates of postpartum anxiety and depression during the pandemic than before [ 40 ]. In a study conducted early in the pandemic in 2020, 58.3% of Canadian fathers with a child between the ages of 0 and 18 months had postpartum depression and 33.3% had postpartum anxiety [ 19 ]. These figures are more consistent with our findings, suggesting that postpartum anxiety and depression prevalence rates remain high post-pandemic and there is a need to better integrate postpartum mental health support for non-birthing parents. Our study builds on the limited evidence available on the prevalence of postpartum anxiety and depression for sexual minority non-birthing parents. Our findings indicate that sexual minority non-birthing parents are experiencing significantly higher rates of both postpartum anxiety and depression compared to heterosexual fathers. Previous work has found that sexual minority women (e.g., lesbian, bisexual) had higher postpartum depression scores compared to heterosexual women [ 41 – 46 ]. Postpartum depression for gay fathers is approximately 12% [ 47 ], with evidence suggesting that the experiences of gay fathers is distinct from heterosexual fathers yet infrequently studied [ 48 , 49 ]. This suggests that there may be a multitude of factors within the sexual minority non-birthing parent population that influence postpartum mental health. Further research is needed to understand why sexual minority non-birthing parents not only experience higher postpartum mental health challenges but also to examine differences within this heterogeneous group. Other reviews have identified similar gaps in the literature, highlighting the lack of evidence on perinatal mental health in transgender and non-binary parents (Greenfield and Darwin, 2020) and limited evidence on how race, ethnicity, and sexuality intersect to impact non-birthing parents’ mental health [ 51 ]. Clinical Implications Given the high rate of postpartum anxiety and depression symptoms among non-birthing parents in their first year after childbirth, it is essential to improve mental health screening and support specifically for this often-overlooked group. Addressing this need is vital not only for the well-being of non-birthing parents—by offering timely, appropriate interventions, treatments, and ongoing support—but also for maintaining a healthy family dynamic. Mental health struggles in one parent can create additional stressors and obstacles that hinder the birthing parent’s recovery and impact the child’s emotional and developmental progress. Research confirms that co-parenting maternal and partner mental health are linked, and untreated issues in one caregiver can adversely affect parenting, the couple’s relationship, and the child’s overall health [ 51 ]. There is a need to focus on postpartum mental health not as a single parent issue, but one that impacts both parents and therefore the family unit. To effectively address this issue, it is essential to enhance education and awareness efforts at multiple levels. Healthcare providers require specific training and tools to help them identify and screen for postpartum mental health issues in non-birthing parents. Besides individual screenings, educational initiatives should aim to normalize postpartum mental health challenges for all types of parents, including fathers, partners, and those outside traditional heterosexual or cisgender roles, so that non-birthing parents feel more comfortable discussing their experiences without fear of stigma or dismissal. Additionally, specialized training is particularly important for healthcare teams to reduce heteronormative assumptions and unconscious biases that could lead to structural discrimination against sexual minority parents [ 52 ]. By actively fostering more inclusive and affirming healthcare environments, we can help ensure that all parents receive the mental health support they need during the postpartum period, ultimately supporting healthier and more resilient family systems. Strengths and Limitations The primary strength of this study lies in its inclusive approach to identifying non-birthing parents, which fills a gap in the literature. Including non-birthing parents across the first 12 months postpartum anywhere in Canada provides a comprehensive picture of postpartum anxiety and depression symptoms in non-birthing parents across sexual identities. However, several limitations should be acknowledged. First, despite attempts to recruit non-birthing parents to complete the survey, we were only able to collect 133 eligible responses during the period of data collection. This challenge has been identified by others researching non-birthing parents in the postpartum period [ 19 ], and opportunities to expand targeted data collection is warranted. Furthermore, within this sample, most non-birthing parents identified as male, high socioeconomic status, cisgender, and heterosexual. There was also a lack of diversity in racial identities. Our findings should be interpreted with this in mind as results may not be generalizable to groups who experience multiple intersecting oppressions. More research is needed on non-birthing parents outside this limited demographic to ensure that their voices are heard, and their experiences are understood. Another limitation is that most participants were from Ontario, with no representation from Prince Edward Island, New Brunswick, or the Territories, nor was information on rural versus urban collected, limiting the representation and deeper analysis based on geographical location. Finally, our sample of adoptive parents was extremely small, yet evidence suggests that important differences exist for parents who adopt compared to biological parents, which warrants further attention [ 53 ]. Conclusions In this cross-sectional study, non-birthing parents reported high prevalence rates of both postpartum anxiety and depression, with sexual minority non-birthing parents experiencing higher rates than heterosexual non-birthing parents. Postpartum mental health of non-birthing parents is of critical concern, with more research needed to understand how to support non-birthing parents during the first year postpartum and beyond. Funding JD is supported by a Canadian Institutes of Health Research Postdoctoral Fellowship (no. 181869). CTC is supported by a CIHR Operating Grant (no. 167902), a Canada Research Chair (Tier I), with infrastructure support from the Canada Foundation for Innovation. Data Availability The data that support the findings of this study are available from the corresponding author, JD, upon reasonable request. Conflicts of Interest None declared. Author Contribution Conceptualization: JD, CTC, JAP, CLD Data Curation: JD Funding Acquisition: JD, CTC, Methodology: JD, CTC, JAP, CLD Project Administration: JD Resources : CTC Supervision : CTC, JAP Visualization : JD Writing – Original Draft Preparation : JD Writing – Review & Editing: All SUPPLEMENTAL MATERIAL View this table: View inline View popup Download powerpoint Table S1. Postpartum depression symptomatology prevalence by Canadian region View this table: View inline View popup Download powerpoint Table S2. Postpartum anxiety symptomatology prevalence by Canadian region View this table: View inline View popup Download powerpoint Table S3. Postpartum depression and anxiety scores and prevalence based on sex View this table: View inline View popup Download powerpoint Table S4. Postpartum depression and anxiety scores and prevalence based on gender Footnotes christine.chambers{at}dal.ca emily_cameron{at}sfu.ca cindylee.dennis{at}utoronto.ca jengoldberg{at}mcmaster.ca jennifera.parker{at}iwk.nshealth.ca References [1]. ↵ Prinds C , Hvidt NC , Mogensen O , Buus N. Making existential meaning in transition to motherhood-A scoping review . Midwifery 2014 ; 30 : 733 – 41 . doi: 10.1016/j.midw.2013.06.021 . OpenUrl CrossRef PubMed [2]. ↵ Walker SB , Rossi DM , Sander TM . Women’s successful transition to motherhood during the early postnatal period: A qualitative systematic review of postnatal and midwifery home care literature . Midwifery 2019 ; 79 : 102552 . doi: 10.1016/j.midw.2019.102552 . 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