Autism is a developmental problem that experiences various conditions (W.H.O., 2023) . Characteristics of children with autism include difficulties in social interaction and communication, unusual ways of moving and behaving, difficulty in moving from one activity to another, having an unusual detail focus, and unusual reactions to sensations (W.H.O., 2023) . Autism traits can usually be seen and detected during childhood, but it is not uncommon to be diagnosed later (W.H.O., 2023) . It is estimated that in the world today, about 1 in 100 children have autism (W.H.O., 2023) .

Recent studies have revealed that the global median prevalence of autism is 100 per 10,000 population, with a drastically varying range of 1.09 to 436 per 10,000 population. This variability reflects the dynamic interaction between biological and social factors, including public awareness, access to healthcare, and sociodemographic determinants (Zeidan et al., 2022) . A systematic review conducted in developed countries with high-income levels found that parents face challenges in accessing health services, which then trigger stress, especially for mothers (Mcstay et al., 2015) . A scoping review conducted in low-income countries revealed a scarcity of research on managing stress among mothers of children with autism. However, the review highlighted positive coping as a key finding. Identified strategies included spiritual approaches, planning, acceptance of autism, and sharing burdens. (Rahmita & Pratiwi, 2020) .

Health system disparities between developed and developing countries pose significant challenges for mothers caring for children with autism. In developing countries, limited healthcare access and inadequate therapy facilities hinder optimal care. Meanwhile, developed countries, despite having more organized systems, face issues such as high costs and long waiting times. Comparing these experiences helps identify unique challenges and opportunities in each context, contributing to the development of more inclusive and effective global policies (Aurora, 2019) (Samiun et al., 2024) .

Stress due to parenting a child with autism is related to the negative emotions, the high cost of therapy, the difficulty in interacting with others, and the difficulty in guiding worship (Rahmanawati et al., 2022) . Psychological, physical, and social challenges are often faced by mothers caring for children with autism. It is important to provide support in the form of good parenting to allow parents to get some help from family, significant others, and community members to help the parents (Appiah & Appiah, 2023) . Mothers of children with autism often find it difficult to come together despite using a variety of strategies, including isolating themselves from others (Moorthy et al., 2023) . The importance of the spiritual aspect of health is considered as part of a holistic, person-centered care in modern society (Stripp et al., 2023) .

Coping mechanisms are influenced by family demographics, maternal distress, depression levels, child age, and type of disorder. The study found that seeking spiritual support is significantly associated with marital status, with married mothers scoring higher in this area. Additionally, having more children and older children was linked to increased reliance on spiritual support. As children and mothers age, existential concerns and anxiety about the child's future often lead mothers to seek greater spiritual support (Ntre et al., 2022) .

The objectives of this qualitative systematic review were (1) to identify the initial response of mothers when their child is diagnosed with autism, (2) to identify how spiritual coping strategies influence the psychological well-being of mothers in caring for children with autism in developed and developing countries, and (3) to identify supporting and barrier factors in mothers' spiritual coping strategies in developed and developing countries.

This qualitative systematic review adopted the ENTREQ Guide (Tong et al., 2012). This review is OSF-accredited with DOI https://doi.org/10.17605/OSF.IO/PJR4Z. Review questions are prepared based on the PEOS framework. Where (P) mother (E) mother with a child with autism and people living in developed and developing countries (O) mother's spiritual coping strategy (S) qualitative research. Considerations for selecting contexts in developed and developing countries include providing more comprehensive information about the spiritual coping strategies of mothers of children with autism from both country contexts. Boolean codes and truncation include the terms coping strategy* OR spiritual* coping strategy* AND mother OR women AND child* under eight AND child* with autism AND autism spectrum disorder AND developing country* OR developed country*. Search conducted from November 2023 to January 2023. The databases used included PubMed, Wiley, EBSCO, ProQuest, and Science Direct. Manual searches were carried out via Google Scholar and Research Rabbit.

The eligibility criteria were based on the criteria shown in (

Figure 1

). Articles that did not meet the eligibility criteria were excluded. Critical appraisal refers to the Joanna Briggs Institute (JBI) critical appraisal tool guide. The types of tools used are the JBI checklist for qualitative research and the JBI checklist for textual evidence: Narrative. The reasons for choosing JBI tools are varied, including a reputation for being a reliable and trustworthy critical assessment tool, a clear framework and guidelines, and a focus on quality scientific evidence. These eighteen studies had clear objectives and applied the chosen methodology. All studies used a purposive sampling method except study A3, which used accidental sampling, and study B6, which needed to be explained in detail. There is one article in study A2 that uses a participatory approach. Articles with a participatory approach are still included because sampling techniques, data collection, and analysis still rely on qualitative research principles. Overall, it is evident that the research reported in the article (study B4) is of higher quality and has a high level of transparency. This can be seen in the article (study B4), which includes a detailed list of questions asked during the interview. In addition to that, the article (study B4) explains in detail the protocol approved by the ethics committee and its number. The article (study B6) is one of the articles that has the lowest quality of the eighteen articles included. This is based on the fact that the article (study B6) did not specifically explain the sampling technique and inclusion criteria. Table 1 describes the eligibility criteria for this study.

As shown in Figure 1, searches through various electronic databases such as PubMed, Wiley, EBSCO, ProQuest, and Science Direct, as well as manual searches through Google Scholar and Research Rabbit, resulted in the identification of 2,171 unique records, with 14 duplicates detected. After the screening process, only 144 studies had been screened and had their titles and abstracts matched, and 104 studies still needed to be assessed for eligibility. Furthermore, 86 studies were excluded because they were not full text (n=58), quantitative research (n=25), literature review (n=2), and dissertation (n=1). Thus, the remaining 18 articles were included in the review. The eighteen articles consisted of 278 participants who were included in the studies, in Table 2.

This systematic review identified five themes: acceptance and love in adversity, resilience through emotional turmoil, navigating social and cultural complexity, finding strength in community and shared experiences, and empowerment and advocacy. These themes aligned with the research objectives. The first theme, with its subthemes of internal family acceptance and challenges of external assessment, deals with mothers' initial responses to their child's autism diagnosis, highlighting their journey towards acceptance despite societal stigma. The second theme, which dealt with coping with the diagnosis and severe emotional struggles, reflected how spiritual coping strategies influenced psychological well-being by fostering resilience during emotionally challenging times. The third theme, which addressed language barriers, discrimination and lack of support, highlighted the enablers and barriers that affect spiritual coping strategies in developed and developing countries. The fourth theme emphasizes the role of community and shared experiences in reducing isolation and enhancing spiritual coping, while the fifth theme highlights how personal growth, advocacy and access to resources empower mothers in navigating their parenting journey. Together, these findings provide a comprehensive understanding of the diverse experiences of mothers caring for children with autism.

The acceptance of an autistic child in the nuclear family has a major impact on the mother's emotional well-being. In developed countries, the nuclear family is often the main source of support that helps mothers feel emotionally comfortable. This support can be seen in the active role of the husband or other family members in helping with the mother's daily tasks (Jaswal et al., 2020). For example, one mum shared, "We accept you at home, but the big world outside doesn't." (Jaswal et al., 2020). Practical support, such as helping with shopping or accompanying a child's activities, is a tangible way families show their acceptance (Fima, A4). In developing countries, acceptance of autistic children is often linked to religious beliefs. Autistic children are seen as a gift from God, so mothers face the situation with a positive mindset. This creates a more favourable environment for the child's development (Appiah & Appiah, 2023). One mother said, "After accepting that an autistic child is also a gift from God, it became easier to deal with it." (Appiah & Appiah, 2023).

However, external challenges often arise in the form of social stigma. In developed countries, autism is considered a shameful disability. This leads to the autistic child being less accepted in society, creating additional emotional stress for the mother (Smith et al., 2023) . In addition, conflicts within the extended family regarding the child's diagnosis are also common. One mother revealed that her in-laws tried to link her child's condition to the family history, which added to her emotional burden. (Qian-qian, (Hsu et al., 2017) . In developing countries, religious beliefs are an important foundation for dealing with stigma, but social stigma remains a major obstacle to creating inclusive environments (Appiah & Appiah, 2023).

An autism diagnosis often triggers a wave of complex emotions in mothers, both in developed and developing countries. In developed countries, mothers often experience deep sadness, confusion, and even denial of their child's diagnosisn (Smith et al., 2023). One mom revealed, "I was so depressed before he was diagnosed... I have an emotional meltdown every time I think about it..." (Smith et al., 2023). Support from family, friends and mental health professionals is essential to help mothers through this difficult time. In developing countries, mothers often rely on religious beliefs as a source of strength. They believe that an autistic child is a test from God, so prayer becomes the main way to find peace and hope. One mother shared, "If God is giving us this challenge, then we are the chosen ones. Don't worry, leave it to God, and soon I felt calmer." (Amina, (Ilias et al., 2017).

In addition, many mothers in developing countries adopt a positive outlook by comparing their situation with the more difficult conditions of others. They see their child as an individual with unique potential, despite facing great challenges. One mother noted, "When I go to the hospital for my child's therapy, I see other children in worse conditions. I think I should be grateful that my child is physically healthy." (Natrah & Yaacob, 2022) . As stated by Emmons (1999), quoted in (Ekşi & Kardaş, 2017) , engagement in spiritual activities can improve health and well-being. This is also relevant for mothers in developing countries who rely on spirituality as a key support in facing challenges.

Cultural and social barriers create unique challenges for mothers caring for autistic children. In developed countries, language barriers are one significant barrier. For example, a mother in China had difficulty communicating with the National Disability Insurance Scheme (NDIS) because she had to use English, even though she was only fluent in Cantonese (Smith et al., 2023) . In developing countries, social stigma is often exacerbated by incorrect traditional beliefs. In Ghana, for example, autistic children are considered a curse or a bringer of disaster, and in some extreme cases, children are left to die (Appiah & Appiah, 2023) . These beliefs demonstrate a lack of medical understanding of autism, which is often replaced by a belief in witchcraft or supernatural practices, such as visiting sangomas in South Africa (Heydari et al., 2015) . In addition, discrimination is also a significant challenge. In developed countries, ethnic stereotypes against certain communities, such as the Chinese, add to the social pressure for mothers. A quote noted, "They think that because you are Chinese, you are easily pressured... I feel discriminated against" (Smith et al., 2023) . In developing countries, discrimination often comes in the form of denying autistic children basic rights, such as not being provided with art supplies during class. (Hsu et al., 2017) .

Community can be a source of emotional and moral strength for mothers. In developed countries, support groups help mothers feel less alone. One mother said, "We have a group with similar backgrounds... It was very helpful and made a big difference" (Smith et al., 2023) . In developing countries, spiritually-based communities are often a place for mothers to gain moral strength and share experiences. One mother shared, "When we meet for regular check-ups, we, parents of autistic children, encourage each other and share tips to keep going." (P8, (Appiah & Appiah, 2023) . Despite the challenges, many mothers show a positive attitude towards their child and see them as a gift. In developed countries, medical information and professional support help mothers understand autism better. One mother noted, "When the doctor said they were autistic, the world seemed to collapse. But doctors say there is treatment, that some children can make progress. That calmed me down" (Aguiar & Ponde, 2020) .

In developing countries, a spiritual approach is often the main pillar. Mothers believe that prayer can bring miracles and provide solutions to the challenges they face. One mother said, "I visited various temples, hoping for miracles to happen. My son started speaking a few words after I worshipped God." (P5, (Acharya & Sharma, 2021). As stated by (Ekşi & Kardaş, 2017), Spiritual beliefs play an important role in improving maternal well-being. In both developed and developing contexts, communities with similar backgrounds are an important source of support that helps mothers through their challenges (Daulay et al., 2018).

Spiritual coping strategies among mothers of children with autism differ between developed and developing countries. In developed countries, family and social networks play a crucial role in coping, while in developing countries, spirituality and faith serve as the primary pillars of support. Mothers in developing countries rely heavily on internal family support and husband-wife relationships, emphasizing the critical role of spiritual beliefs and community involvement. A global, holistic approach is needed to address cultural and social aspects of support for mothers caring for autistic children, including raising awareness and educating medical professionals.

Medical professionals must consider the social, cultural, and economic contexts of these mothers and provide tailored support, such as facilitating access to support groups and mental health services. Strategies should integrate spiritual elements aligned with the mothers' cultural values and beliefs. Additionally, empowering mothers, enhancing communication skills, and involving them in designing social support policies are essential to improving their mental health and fostering a more inclusive environment for families of children with autism.

I would like to thank Universitas 'Aisyiyah Yogyakarta for providing facilities and support in the completion of this review research article.

GND, the first author, is responsible for the study's conceptualization, manuscript writing, and main analysis. CSP was responsible for the review process and translation of the article. DA is responsible for the review process and translation of the article

This study received no funding.

This review study does not involve human or animal subjects, so it does not require ethical approval.

The data used in this study are available upon request to the first author.

The authors declare that there is no conflict of interest in this study.