gms | German Medical Science

The transition to motherhood has a decisive influence on women’s personal development and health [37], [49], [63]. Moreover, starting a family reshapes professional identity, as many women do not want to, or cannot choose between family and career after the birth of their children but instead try to reconcile the two aspects, with all the challenges this brings [18], [24]. When mothers have to manage the return to work, the new transition phase resulting from the different structure of daily life and organisation can negatively impact their well-being [5], [18]. One-to-one tailored preventative advice services provided to mothers in preparation for the return to work after the end of maternity leave can promote good health. However, such services do not appear – also in other countries – to be a widely established integral component of the health and social care system.

The various political regulations in the different countries influence women’s return to work following their maternity leave [79]. In Germany, 50% of mothers intend to return to work when their youngest child is 0–2 years of age [21], [22], [81]. The share of mothers who go back to work around the first birthday of their child, in particular, is on an upward trend [24], [86]. The introduction of parental benefits in 2007 with the German Parental Allowance and Parental Leave Act (Bundeselterngeld- und Elternzeitgesetz, BEEG) aims to provide universal financial support for families during the early stage of parental leave with a view to helping them reconcile work and family life [19]. While in Germany, a maximum of 14 months of parental allowance is paid (including partner months) and parents are entitled to three years of parental leave [20], in other countries, such as the UK, parental leave is shorter, but like in Germany, parental leave policies there are universally applied at national level. The situation is similar in the Northern European countries (Denmark, Iceland, Sweden and Norway), as well as the Benelux countries [85]. In the USA, in contrast, there is no paid maternity leave regulated by law, aside from 12 weeks of unpaid leave under the Family and Medical Leave Act [85], [115]. This possibility is being partially extended through very heterogenous employer-dependent parental leave conditions [52], which only cover 50% of working women, however [12].

In the Northern European countries (except Finland), as well as the Benelux countries and France, many mothers return to work within the first two years of life of their youngest child [81], [83]. The reasons for this are, among other factors, a well-established, comprehensive public childcare system and a high level of social acceptance of childcare, especially for children under the age of three [87], [120]. While in Germany and other European countries with similar regulations, mothers with better vocational education (with the exception of Denmark and Sweden) and a higher income (a less relevant factor for Denmark and Germany) are more likely to return to work early [87], mothers in the USA who return early tend to be less well educated and work in lower-paid jobs [29].

Overall, we find that when it comes to the decision for or against a return to work, political and economic conditions, the values and norms observed in the family, as well as social acceptance all have a role to play. Consequently, geographical, social and cultural factors are all of relevance when it comes to the (early) reconciliation of work and family life [5], [104].

Taking the aforementioned aspects into consideration, in terms of the health of women with young children, it is shown that mothers’ subjective health perception and behaviour is exposed to multidimensional influences which, taking into account individual life situations, have not yet been systematically researched for Germany. These factors are highly relevant for family policy and health economics, particularly against the backdrop of Germany’s rising birth rate [39], [92], [110] and women’s increasing labour force participation [109]. The overall aim of this study is thus to provide a systematic representation of the physical, mental and general health of mothers, while balancing work and family life, taking the aforementioned factors of influence into account.

An important difference between a scoping review and a conventional systematic review is that the former provides an overview of the existing evidence, irrespective of the quality of the individual studies included [119]. A scoping review can be useful if the literature has not yet been comprehensively evaluated or if it comprises a complex or heterogenous problem so that a more precise, systematic review of the evidence is not required [119]. Given that there has been no systematic treatment of the issue of “women’s health in the context of reconciling work and family life” at national or international level, in light of the complexity of the relevant factors of influence, a scoping review is a suitable method to answer the research question.

For this scoping review, a systematic literature review [119] was conducted from September 2016 to December 2018 in the Medline via Pubmed, PsycINFO, PsycARTICLES and GESIS (Sowiport) databases. The review was limited to the period from 2007 to 2018 and focused on the research question of what work-related and family-related factors influenced the physical and mental health of women in the context of reconciling work and family life. We limited the timescale because the life situation of mothers has changed at different points over the last 15 years or so due to the increase in women’s labour market participation worldwide, depending on the political and social conditions (e.g. introduction of parental allowance/parental leave).

The literature review was conducted in the Medline via Pubmed, PsycINFO, PsycARTICLES and GESIS (Sowiport) databases based on the following terms including MeSH terms (Medical Subject Headings), both separately and in combination, also using variants:

(((((((((("women's health"[MeSH Terms] OR ("women's"[All Fields] AND "health"[All Fields]) OR ("woman's"[All Fields] AND "health"[All Fields]) OR "woman's health"[All Fields]) OR (mother's[All Fields] AND ("health"[MeSH Terms] OR "health"[All Fields]))) OR ("maternal health"[MeSH Terms] OR ("maternal"[All Fields] AND "health"[All Fields]))) OR ("women's health"[MeSH Terms])) OR (mother's[All Fields] AND wellbeing[All Fields])) OR (woman's[All Fields] AND wellbeing[All Fields])) OR (women's[All Fields] AND wellbeing[All Fields])) OR (("mothers"[MeSH Terms] OR "mothers"[All Fields] OR "maternal"[All Fields]) AND wellbeing[All Fields])) AND (((((demand[All Fields] OR demand'[All Fields]) OR (resource[All Fields] OR resource'[All Fields])) OR ("Stress"[Journal] OR "stress"[All Fields])) OR ("conflict (psychology)"[MeSH Terms] OR ("conflict"[All Fields] AND "(psychology)"[All Fields]) OR "conflict"[All Fields])) OR ("balance"[All Fields])) AND ("work"[MeSH Terms] OR "work"[All Fields])) AND ("family"[MeSH Terms] OR "family"[All Fields])).

For the German-language literature review, the above search terms were translated into German. Further studies were identified by means of a manual search of the literature determined as relevant. The search history is shown in Figure 1 [Fig. 1] and the search strategy is summarised in Table 1 [Tab. 1].

The inclusion and exclusion criteria as well as the target criteria were primarily determined by the main author in continuous communication with her co-authors. The following three target criteria were derived from the research question. Their fulfilment is one of the criteria for a publication to be included in the further analysis:

1.

Health (physical/mental/general), well-being, stress, depressive symptoms

2.

Mothers

3.

Employment or reconciliation of work and family life

The inclusion criteria with regards to the sample was formulated as follows: the studies included must involve working and non-working mothers with one or more children living in the household, in particular children aged 12–36 months, in the context of the return to work in Germany. Due to the multidimensional cultural, social, political and medical influences, both on women’s health and on the factors related to the reconciliation of work and family life, only studies from Western industrial and similar countries or regions were included. Qualitative, quantitative and mixed methods studies as well as systematic reviews were incorporated, which were written either in German or English, accessible on the university network or through inter-library loan, had an abstract and had been subject to a review process. Conference contributions, commentaries on articles, book chapters, book reviews and political documents were all excluded, as were studies with a particular thematic focus (e.g. mothers with acute or chronic diseases) and studies from developing or similar countries or regions as well as those that did not fulfil the target criteria.

Initially, 1,479 titles and abstracts were examined for their relevance to the research question based on the aforementioned criteria. After removing 32 duplicates, another 1,119 abstracts were excluded for only fulfilling a maximum of one of the target criteria.

As a rule, a scoping review does not involve a formal assessment of the methodological quality of the studies included, as this contradicts the aim of providing an overview of the existing evidence [119]. In accordance with the scoping review methodology, the decision for or against a particular study is based on content-related criteria, since with this methodology, no quality-related criteria are used. Scoping reviews generally do not involve the application of quality criteria [119]. Nevertheless, the quality of the studies was evaluated using the Critical Appraisal Skills Programme (CASP) [33] and the associated checklists by study design. In summary, the criteria relate to the validity of the study, the results and their objectivity and reliability or credibility, as well as the conclusions and their valency. The findings of this assessment are in the possession of the main author. For the reasons described above, however, no study was excluded from the review on the basis of this assessment. That said, in the case of major limitations or reduced quality, this was noted in the text.

A total of 328 full texts underwent the next screening stage, during which, based on content analysis and taking into account the three target criteria, the endpoints and the factors of influence, the studies were selected by the main and second author, independently of each other. This was followed by a thematic clustering to describe the findings. During the course of this thematic clustering, it became evident that the demand-resource model – with the key message that the health status of an individual depends on how the internal and external demands are managed using the available internal and external resources – was a relevant theoretical framework for this study [11]. From the meta perspective, we decided – taking into account health endpoints as well as the clustering of factors of influence (demands versus resources, internal versus external, family versus professional versus personal, fulfilment versus strain) – to subdivide the results into personal, family-related and work-related factors.

The results of the database review are presented in accordance with the PRISMA Statement flow diagram [77] (see Figure 1 [Fig. 1]). No single study precisely fulfilled the inclusion criterion “mothers of children aged between 12 and 36 months”. In light of the international differences in the conditions with regard to the return to work, we decided to incorporate all 86 studies that firstly, include working mothers with children under the age of six and secondly, show mothers as a separate group from the total sample.

In the 86 studies included in the review, different health-related independent variables were defined (see Table 2 [Tab. 2]). If general health terms were used in the studies – without explicit distinctions such as between physical and mental health – the results refer to “health in general” and thereafter to “health” with no further specification. Work and family conditions influence the health of mothers both directly and indirectly via the mothers’ individual assessment of the compatibility of work and family life and the associated demands of the roles, that is subjective stress. In this context, the fulfilment and strain hypotheses are analysed and discussed with the main scientific focus being on the strain factors [17], [25], [43], [52], [53], [78], [106] (see Figure 2 [Fig. 2]).

Healthy women often become healthy mothers [74]. Being able to manage this transitional phase serves as a moderator between experience of the role and mental health [112]. The presence or absence of depressive symptoms among mothers is frequently consistent from the beginning of pregnancy until the end of the first year after the birth of the baby [91] and even beyond [50]. One in five mothers suffers from relevant depressive symptoms [100]. However, the number of children and the age of the mother at the birth of her first child are not shown to have a significant effect on maternal depression [100]. In a study conducted in the USA, young mothers (<20 years of age at the time of the first birth) have significantly higher depression scores than older mothers [43]. This can be explained by greater financial strain and a reduced sense of personal control [43]. A Swedish study showed that older mothers are healthier [44]. A Brazilian study, in contrast, albeit one that only includes women over the age of 34, suggests that older mothers are in fact less healthy [53]. At the same time, there are also indications that mothers’ stress perception decreases with age [100].

One group of mothers at risk of poor health appear to be members of minorities, in particular those also facing precarious living conditions [96]. Some of these mothers have to resolve specific role conflicts [29] and manage health problems [96], all of which is added to the usual demands that affect all mothers.

An inability to adequately manage this transition phase, during which a mother’s own self-image and sensitivity when it comes to fulfilling others’ expectations impacts her health, can have a negative effect on maternal health, resources and work motivation, while successfully managing the phase can strengthen a mother’s personality [4]. A positive attitude towards parenthood results in higher work commitment and improved well-being [40]. Further, a strong feeling of control [120], well-established coping strategies, resilience [4], [94] and greater self-confidence combined with a mother’s better awareness of her own needs, her environment [4], as well as the organisation of daily life [94] has a positive effect on maternal health.

Control – as a subjectively perceived sense of control – also plays an important, albeit controversially discussed role in the context of family-related factors influencing maternal health. Control over household chores [74], [99], along with the ability to make independent decisions, as well as social, emotional and practical support at home [29] are all associated with less stress [99] and better health [74]. In contrast, another study shows that those women with a high level of control over household chores – equated with unwanted sole responsibility – are more likely to be overstrained, because, in this case, control can lead to the mother being overburdened [15].

Whether or not the positive impact of satisfaction with family circumstances on employment can also have an effect on health is not entirely clear [52], [112]. However, maternal depression scores are shown to be reduced by good social support [35]. Mothers in a relationship are at least risk of falling ill, irrespective of their professional status [118]. In addition, satisfaction with this relationship is significantly associated with maternal well-being [6].

Generally, the adjustment phase after the birth of the first child takes longer than with all subsequent children [10]. Mothers with one or two children [120] are more likely to work during the first year after the birth, while for those with three children or more the probability is lower again [28]. The risk of work-life imbalance increases with the number of children, but remains relatively constant after the second child, and is accompanied by a risk to health [54].

A US study showed that 53% of working mothers experienced a family–work conflict, which is influenced, for instance by role preferences and the number of children [51]. The degree of role strain – in the sense of being overtaxed by the existence of too many overlapping roles – increases significantly with the number of children, and this is accompanied by declining satisfaction with non-working time and deteriorating mental health [44], [89]. In one study, mothers with two children are more likely to show stress symptoms than mothers with just one child [32]. For mothers with three children or more, this trend is not confirmed however [32]. Studies that focus on the relationship between the age of the youngest child and the health of the mother show heterogeneous results [6], [45], [97], [100], [111], [118].

Women whose family pressures affect their jobs have poorer mental [112] and general health [55]. Further, it is shown that more time spent on activities of daily life, e.g. household chores, leads to more depressive symptoms among mothers [35] or is associated with poorer health [53]. Yet, other studies show that it is not just the amount of housework that is important for the perceived strain [106] or well-being, but the fair division within the relationship [6], [106]. A higher housework load is associated with poorer mental and self-rated health [41], [106], in particular in the presence of lower energy levels [106]. Women take on more housework [41], [53], even if they work full time [41]. An imbalance between effort and reward when it comes to housework and family-related work [103] is experienced, in particular, by mothers working full time [103] and mothers in demanding professional positions [53], [100], [101], who also bear the main burden of household and family work [103]. Mothers who experience this imbalance have poorer mental and subjective overall health [103]. Moreover, these mothers experience higher levels of stress, tiredness, physical, psychosomatic and general health complaints, as well as more work-related pressure in the family, insufficient time to regenerate and lower satisfaction with their relationships and their own lives [41], [100], [101], [102], [106].

The findings regarding physical and mental health as well as health risks (e.g. stress) and depression among mothers, by relationship status, are heterogenous. In some studies, there is no difference between the health of mothers in a relationship and those who are not [55], [106], [114] and in some cases, the health of single parents is comparatively poorer [44], [47], [78], [90] and/or the stress levels [64], [100] and health risks higher [34], [122]. For this group, an important moderator seems to be the financial difficulties that occur considerably more frequently [17], [34], [47], [61], especially among mothers of small children [121]. The health of single mothers, as compared with mothers in a relationship, benefits more from going out to work [55], [64], [73], [100], in particular long-term employment [73], [124]. With regard to the extent of employment that promotes good health among single mothers, the results are once again heterogenous [78], [124]. Moreover, single mothers have a higher housework load than mothers in a relationship [78]. This is one possible reason that social support is given higher priority among single mothers [17], [34], [121]. Positive experiences of everyday life impact the mental health of mothers, irrespective of their relationship status [17].

Maternal health is improved through the use of childcare [28]. However, insecurities can arise due to doubts about the quality of the care provided [5]. This is closely connected with feelings of guilt due to the double role and a sense of not being a good mother [5]. A partner being in employment is also positively associated with maternal health [120], although employment conditions have no effect [91].

Maternal health particularly suffers when the amount of work involved in managing family and work is very high and there are not enough resources available to compensate for this [42]. A Swiss study shows that all groups that include working women would like to invest less time in their jobs [90]. Possible role strain alone is not necessarily associated with poorer physical and mental health [90], but the dynamic associated with the quality [38] and number of different roles [108] seems to be of relevance here [108]. As the number of roles increases, the probability of poor mental health declines, while a reduction in the number of roles increases the risk of poor mental health, psychiatric illnesses and the amount of absence due to sickness [108]. The subjective perception of the quality of the maternal role and, in particular, the worries connected with the role are significantly associated with psychological stress [38]. This finding emphasises the importance of role experience – subjective role perception – for the well-being of women with children [38].

With regards to the assessment of general health and quality of life, the results of one longitudinal study show no significant differences between working and non-working mothers [93]. It is not employment status that is the key factor here, but rather a positive attitude and identification with the professional role [26]. Mothers seem to be in the best health if they can strongly identify with their jobs [73] and see this role as varied and responsible and thus as a source of fulfilment in their lives [17], [25], [101]. Mothers who prefer to be in work and manage to achieve this have better mental health and are more satisfied with the emotional support they receive [31], but also seem to take more sick days [107]. If, however, the professional status of a mother does not fulfil her expectations, her well-being is likely to be poorer [26], and she will show higher depression scores [59], [116] and perceive less emotional support than mothers who choose to work or stay at home [26], [31]. Non-working mothers who want to work are significantly worse off than mothers who go out to work for economic reasons [31].

Education is a factor that protects people from poor employment conditions and poorer health [53], [71]. Young mothers are more likely not to have completed their school or vocational education, which has both short and long-term negative effects on their mental health [3], [72], although the findings regarding depression scores among those with lower levels of education are ambivalent [71], [100], [117]. If, despite having children at a younger age, mothers manage to go out to work, their mental health is better [56]. If, despite higher levels of education, women’s employment has a negative impact on the family, their health suffers considerably [53].

The essentially positive effect of employment applies to mental health [55], [112], mental well-being [26] and also serves as to protect against depression [16], [93]. Furthermore, employment improves quality of life and promotes mothers’ social relationships [93]. When it comes to subjective health perception, the positive effect is particularly strong if going out to work is perceived as an opportunity to retreat from the domestic environment [98]. If a mother going out to work has an overall positive effect on family life, this acts as a buffer for the conflicts experienced in trying to reconcile work and family life, results in less work-related and family stress [65] and has a positive impact on mental health [10], [52]. Pursuing a profession is also associated with less parental stress [28]. Only two studies show positive correlations between a lack of job and maternal health. In one study, mothers who are exclusively housewives had an overall reduced risk of depressive symptoms [100] and in a second, they had fewer health problems [88]. One factor protecting non-working mothers is their belief that going out to work would be detrimental to their children [26]. One study found that women’s employment was more likely to have consequences for the family than family life having an impact on women’s employment, but does not show a correlation for physical health [52]. Overall, the conflict between work and family, in which women’s own needs frequently take a back seat [96], seems to have negative effects on physical and mental health [10], [53], [96], [98] and well-being [6].

The health-related findings – taking into account depressive symptoms [28], [48], [75], [120] with regard to the timing of mothers’ return to work – are ambivalent [27], [28], [51], [69], [104], [111], [120], particularly when education status is factored in [70], [117]. According to one study, if women return to work within 11 weeks after the birth there are no significant health-related differences compared to the non-working mothers during the return-to-work phase [51]. Two other studies show negative effects on health [27], [104] among mothers taking less than two months of paid maternity leave and returning to work before their child is three months old [27] or in the child’s fourth month [104]. Another study, in contrast, comes to the conclusion that mothers who go back to work within the first six months, are less likely to have poor health than mothers who are not employed [28].

Having a financially secure phase after the birth thanks to parental leave benefits plays a key role in improving maternal mental health [105] and in sustainably reducing the risk of stress [123]. An early return to work within the first three [69] or six months [120] after the baby is born thus poses no health risks for mothers [120] and/or has psychological benefits [69], if they are not forced to go back to work for financial reasons and the return is purely self-motivated [69], [120]. If, however, financial pressure is the reason for an early return to work, this is a risk factor for maternal health [114]. Parental leave beyond the first three or six months of the child’s life as well as monetary benefits are predominantly associated with better mental health [69], [105], [111], [123], in particular for mothers who return to full-time employment [69]. Financial and contractual circumstances allowing mothers to take leave from work during the first year of the child’s life is shown to result in less stress among mothers two to three years after birth and continues to have positive effects on mental health into old age [8].

The mental health of mothers who work full time appears to be comparable with that of the general female population [45], [114], although mothers are more likely to reduce their working hours than women without children [62]. Time stress in particular can result in the desire to reduce working hours [45]. If women can no longer cope with their jobs, this has a negative impact on their well-being and often leads to them changing jobs with the return to work sometimes resulting in a new employment status [5].

Viewed in isolation, the results regarding the mothers’ working hours in the context of health produces heterogenous findings. On the one hand, maternal health improves with increasing working hours [28] or women who work fewer than 39 hours per week seem to have poorer overall health [53]. In particular, women who work fewer than 24 hours per week and would like to work even less have the poorest mental health [15]. Other studies, in contrast, find that women in part-time employment are healthier [73], [118] and experience less conflicts in reconciling work and family life [16] and/or fewer health problems [44] than mothers who work full time. This is confirmed by other studies in which mothers with children under the age of six demonstrate poorer health [97], [111] and/or more reduced well-being [6], the more hours they work [6], [97], [111], although this correlation is moderated by the work–family conflict experienced [6]. An increase in conflicts in reconciling work and family life is associated with more mental uncertainty and time pressure [58]. Particular risk factors for maternal well-being [50] and mental health [52] appear to be high workplace stress [52], in particular in combination with long working hours [50].

It can be stated with relative certainty that women who are happy with the hours they work have better mental health [15] and less stress [55]. If women want to increase their hours and manage to achieve this, this frequently improves their health even further [46], [52], [53], [62]. If, however, work commitment exceeds 50 hours per week, health then suffers [97].

For mothers in a relationship, the work–family conflict has the strongest impact on well-being [17]. If mothers are able to organise their working hours flexibly, there are fewer family conflicts [25], maternal health benefits [10], [40], [64], [91] – particularly in the case of early return to work [28] – and depression is less likely to occur [99]. High-quality employment conditions – characterised by a high degree of autonomy in the form of control, responsibility and decision-making freedoms, security and social support as well as less work-related stress – improve the reconcilability of work and family life, are associated with less depression [35], [116] and promote both mental health [40], [111], [120] and well-being and/or overall health [10], [15], [25], [74], [111]. Good employment conditions also strengthen mothers emotionally [60]. However, it is not just the existence of high-quality working conditions, which can be tailored to the employee’s individual needs, that is a key factor [111], but rather for these conditions to be firmly embedded in and accepted by the company and society [9] rather than being one-off measures [76], [113]. Other work-related resources are income, level of education and employment position [120], although financial benefits alone only have a limited positive effect on well-being [40], [57].

Should the working conditions deteriorate, e.g. as a result of the employer demanding more flexibility [28], [50], [52], [99], [117], job quality tends to suffer, with negative consequences, for example in the form of psychological stress, more difficulties reconciling work and family life as well as reduced well-being [32], [99], greater mental strain [10] and more health impairments, for instance through depression [28], [50], [52], [99], [117]. This does not necessarily apply to women with lower levels of education or a fear of making mistakes as, in these cases, personal responsibility can also be a health risk [7].

Low income is a particular challenge when it comes to reconciling work and family life [91]. Financial stress is the most reliable predictor of physical [114] and mental health [17], [114] as well as stress and depression [71], [100]. Consequently, financial stress is a stronger factor of influence than low income when it comes to poor health. This particularly applies to single mothers, irrespective of their employment status [2]. Only one Swedish study found that the group of high-earning mothers showed a higher probability of impaired health [44].

The return to work has positive effects on maternal health principally if that job is something that is personally desired, the role is perceived as positive and fulfilling and is considered to be compatible with family life [26], [31], [38], [40], [59], [108], [116]. What seems to vary from individual to individual is the timing of the return to work [27], [28], [51], [69], [104], [111], [120], the number of hours worked [6], [15], [16], [28], [46], [50], [52], [53], [62], [73], [97], [111], [118] and the income level [2], [17], [34], [61], [71], [91], [100], [114], [121]. A crucial factor is the overall positive subjective view of going out work in terms of the woman’s own life circumstances [10], [52], [65], [95]. The fundamental heterogeneity of the findings can be explained both by the different ways in which health and the return to work is operationalised and the different political, financial and social conditions [80], [81], [83], [84].

A successful transition to becoming a mother, which fulfils women’s expectations, is an important long-term resource for maternal and family health [36], [68]. Also important for mothers’ health is the amount of time and effort they have to put into everyday life to successfully reconcile work and family life [6], [35], [41], [53], [101], [106]. Here, individual life situations are of particular relevance [41], [44], [53], [56], [74], [100], [101], [102], [103], [106]. Well-being increases if demands can be met with the existing resources. If there are insufficient resources or the resources are not suited to the demands, well-being suffers, in particular if women’s own needs have to take a back seat [10], [42], [96], [101].

Another component that is closely related to individual life situations was shown to be subjective quality of and satisfaction with roles. Mothers who identify with their maternal role more strongly are in better health if they work fewer hours and return to work at a later stage [6], [15], [26], [69], [105], [111], [123], while mothers who have a stronger professional identity frequently benefit [5], [38], [40], [51], [89], [90] from working an increasing number of hours [46], [52], [53], [62] and returning to work earlier [69], [120]. The long-term consequences of the timing of the return to work for maternal health is the subject of heated debate [27], [28], [51], [69], [70], [104], [111], [117], [120]. Paid parental leave allows mothers to decide when they go back to work and also promotes a positive impact on maternal health [69], [105], [111], [114], [120], [123].

The relevance of the number of hours worked, the timing of the return to work as well as the experienced control over the return to work and in daily professional and family life for health depends on the overall context and cannot be analysed in isolation from national system-specific conditions. The reasons behind this are country-specific regulations on maternity leave, parental leave and parental benefits, as well as different definitions of full and part-time employment [1], [9], [30], [42], [66], [73], [79], [81], [82], [85].

As a result of the different ways in which the factors of influence are operationalised and in particular the independent variables related to health, the density of findings on the individual dependent and independent variables and/or the degree of abstraction of the studies differed. Only a small number of studies depicted the complexity of the research question. This is why studies with a limited scope were included in the analysis, especially when it came to very specific questions. Overall, there was considerable heterogeneity with regard to the operationalisation of health and an ambivalent discussion regarding how to obtain a valid measurement of the reconciliation of work and family life, i.e. from which perspective (‘fulfilment’ versus ‘conflict’) and using which parameters (‘strain’, ‘resources’, ‘time’, ‘control’) [53]. The direction of causality in particular, that is whether work and family factors affect health, or whether work and family conditions result from the state of an individual’s health, are often impossible to determine beyond doubt [118]. Added to this is the fact that personal, family and work-related factors are weighted differently from individual to individual/individually weighted and as a consequence, the prioritisation of the factors depends on the context [4], [17], [25], [26], [31], [40], [59], [73], [94], [116], [120].

In order to be able to formulate specific recommendations for action in healthcare practice, building on this scoping review, which was not intended to provide evidence-based findings to be implemented in practice [119], further analyses are required that better incorporate the quality criteria of the individual studies and possibly exclude those studies of more limited scope. One striking finding is that there are very few studies that reflect average mothers in Germany, who return to work between 12 and 36 months after the birth of their child to a part-time position working 20 to 32 hours a week [19], [81]. Transferring our findings to the situation of mothers in Germany is therefore only possible to a limited extent. We deliberately refrained from including more recent studies in the analysis retrospectively to avoid possible bias caused by the SARS-CoV-2 (Severe Acute Respiratory Syndrome-related Coronavirus 2) pandemic. The present scoping view thus provides an overview of the type of evidence available between 2007 and 2018.

Within the different individual life situations of mothers in Germany, the interaction between work and family life has consequences for maternal health. To date, there has been insufficient research on this for mothers in Germany [23], [67]. For this reason, the development of an instrument to measure maternal health – taking into account the individual health-relevant factors impacting the reconciliation of work and family life – is of particular importance for future research [14]. This serves as a basis for further necessary studies, taking the living environment of mothers into account, so that subsequent political measures can be tailored to strengthen women’s and family health in the long term. As well as developing demand and needs-based services, it is also important to consider creating various training programmes for service providers. Midwives are experts on this phase of women’s lives – including family planning, pregnancy, birth, postpartum and breastfeeding period, and support during early parenthood – and as such could, by implementing health-related advisory services in the context of reconciling work and family life, be the first point of contact for mothers. Here it is important that these services are added to the catalogue of benefits covered by statutory health insurance. In light of their knowledge about the individual life circumstances of women and families, using a format like this to enable women to prepare for the return to work, midwives could help protect the health of mothers and their families, even beyond the first year of the child’s life [13].

The authors declare that they have no competing interests.