Research Commentary  April 2019
Apr 9, 2019
This commentary focuses on New Zealand and International studies of perinatal depression in CALD women. Of the 4.7 million people who live in New Zealand, more than 25 per cent were born overseas. Of all regions, Auckland has the highest proportion (40 %) of overseas-born. We have relatively high fertility rates. Between 12 and 20 per cent of women experience a mental health issue during pregnancy or in the first year following birth. The most common diagnoses are depression and/or anxiety in both antenatal and postnatal periods. The reviewed information include: risk factors associated with antenatal and postnatal depression; evaluation of postnatal support groups for migrant women; CALD women’s experiences of perinatal mental health services; recognising PND symptoms in migrant women; and the association between acculturation and postnatal depression among migrant women.
Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development
The following articles are reviewed:
Article 1: A Longitudinal Study of Pre-pregnancy and Pregnancy Risk Factors Associated with Antenatal and Postnatal Symptoms of Depression: Evidence from Growing Up in New Zealand.
This study found that Asian and Pacific women living in New Zealand were at higher risk of perinatal depression. Pacific or Asian women accounted for 26 per cent of the entire sample but this group accounted for 37.7 per cent of the 875 women who had depression symptoms at the antenatal interview or 9 months after childbirth and 46.5 per cent of the 158 women who had significant depression symptoms at both time points. The research, part of the Growing Up In New Zealand study, showed that the proportion of mothers born in New Zealand to the ethnic groups, Pacific Peoples and Asian were respectively 47 per cent and 6 per cent.
In the study, Pacific and Asian women were disproportionally represented among those with antenatal depression symptoms (ADS) only (a known predictor of postnatal depression symptoms (PDS)), PDS only and depression symptoms at both time points. Interestingly, the authors report that this did not appear to be related to immigration since the country of birth was not significantly associated with ADS or PDS, while studies in the international literature find that migration and more specifically acculturation is strongly associated with higher levels of PND symptoms as assessed on Edinburgh Postnatal Depression Scores (EPDS) (Alhasanat-Khalil et al., 2018).
Many of the pre-pregnancy and pregnancy risk factors associated with depression symptoms in the study were related to the women’s mental health; pre-pregnancy depression, anxiety before and during pregnancy and perceived stress during the third trimester of pregnancy. The findings suggest that migrant women in particular need extra support during pregnancy if they are unemployed, their pregnancy was not planned, they experience moderate to severe nausea, have anxiety or panic attacks before and during pregnancy and they have a difficult relationship or family environment.
Women who have difficult relationships and family environments are also most at risk of being in the persistent depression group and these mothers could be more carefully monitored and supported. Women who report relationship difficulties may be experiencing domestic abuse. As such, maternity service providers should be aware of interventions for domestic abuse during pregnancy and after childbirth. Further research on risk factors for migrant women are explored in the subsequent articles reviewed.
References: Alhasanat-Khalil, D., Giurgescu, C., Benkert, R., Fry-McComish, J., Misra, D.P. & Yarandi, H. (2018). Acculturation and Postpartum Depression among Immigrant Women of Arabic Descent. J Immigr Minor Health, doi: 10.1007/s10903-018-0837-z. [Epub ahead of print]. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/30456725
Author: Underwood, L., Waldie, K.E., D'Souza, S., Peterson, E.R. & Morton, S.M.
Citation: Underwood, L., Waldie, K.E., D'Souza, S., Peterson, E.R. & Morton, S.M. (2017). A Longitudinal Study of Pre-pregnancy and Pregnancy Risk Factors Associated with Antenatal and Postnatal Symptoms of Depression: Evidence from Growing Up in New Zealand. Matern Child Health J, 21 (4), 915-931. doi: 10.1007/s10995-016-2191-x.
Article 2: Acculturation and Postpartum Depression among Immigrant Women of Arabic Descent
Acculturation has been related to the risk of postpartum depression (PPD) among immigrant women globally. The purpose of this study was to examine the relationship between acculturation and Postpartum depression (PPD) symptoms among U.S. immigrant women of Arabic descent. Immigrant women reported higher levels of PPD symptoms than native women. There are numerous factors which may contribute to higher PPD symptoms among immigrant women. In addition to stressful life events, low family income and socioeconomic status, and a lack of social support, this research indicates that acculturation may also be an important risk factor for PPD which may contribute to higher rates among immigrant women.
Immigrants are faced with two fundamental questions in contact with the new culture: “Is it valuable to retain one’s traditional culture?” and “Is it valuable to have positive relations with the larger society?”. Based on how individuals answer these questions, different acculturation strategies are used to adapt to the host culture. Higher maternal years of education predicted higher levels of PPD symptoms. Women with higher levels of education reported more attraction to western culture, less attraction to Arabic culture, and higher levels of PPD symptoms. The authors conclude that women with higher levels of education may have more exposure to western culture and may experience unique psychosocial and cultural stressors such as experiences of racial discrimination which have a negative impact on their mental health.
Antenatal anxiety was one of the strong predictors of PPD symptoms among immigrant women of Arabic descent. Higher levels of marginalisation were related to higher levels of antenatal anxiety. It is highly recommended that clinicians screen immigrant women for anxiety during antenatal visits to prevent future development of PPD symptoms.
The study design has several strengths which are instructive for further research with migrant women. For example, the study questionnaires were offered in Arabic and English languages for mothers to choose. This flexibility of language preference gave the opportunity to recruit non-English-speaking mothers to participate in the study. Additionally, the authors utilised a reliable and valid, multi-dimensional acculturation questionnaire to accurately measure acculturation and in doing so uncovered a potentially important link between one acculturation state (marginalisation) and PPD.
Authors: Alhasanat-Khalil, D., Giurgescu, C., Benkert, R., Fry-McComish, J., Misra, D.P. & Yarandi, H.
Citation: Alhasanat-Khalil, D., Giurgescu, C., Benkert, R., Fry-McComish, J., Misra, D.P. & Yarandi, H. (2018). Acculturation and Postpartum Depression among Immigrant Women of Arabic Descent. J Immigr Minor Health, doi: 10.1007/s10903-018-0837-z. [Epub ahead of print]
Article 3: The pilot and evaluation of a postnatal support group for Iraqi women in the year following the birth of their baby
As can be seen in the two previous studies reviewed, social support is an important factor to consider in risk for PND particularly in relation to CALD women. Social support acts as a buffer to the risk of PND. This study involved conducting a pilot test of a culturally sensitive support group programme developed to assist Iraqi women in the year following the birth of their baby in Perth, Western Australia. The aim of the study was to evaluate the social validity of the programme. It was hypothesised that women involved in the programme would find it to be socially valid and culturally appropriate, and would also report lower levels of depressive symptomatology and higher levels of social support, following the group intervention. Participants were 12 Iraqi Arabic speaking women, who had a child less than 12 months of age. The programme was based on Iraqi women's explanatory models (Di Ciano et al., 2010; Kleinman, 1978) of the birth and motherhood experience.
Two female, Arabic and English speaking bilingual workers were recruited to assist in the delivery of session content of the study. These bilingual workers were actively involved in the development and refinement of the questions that were used to assess the social validity of the programme, providing recommendations and adjustments to items in order to make sure they were culturally appropriate. All of the measures used in the study were translated into Arabic, and then back translated into English.
Initial consent to participate in a programme is a good indicator of a programme's global social validity. It is important to note when setting up support groups for migrant women that in this study initial attempts by child health nurses to recruit women directly into the intervention were unsuccessful. However, the use of an Iraqi bi-lingual worker resulted in an initial recruitment rate of 76%. The results demonstrated that high levels of programme participation could be obtained when sessions were delivered by culturally sensitive facilitators who are prepared to incorporate participants' explanatory models into the programme. Participants disclosed a desire for longer sessions with English classes incorporated, and more opportunities to socialise with each other during the course of the programme. Results support findings that indicated women from non-English speaking backgrounds may be more socially isolated as a result of language barriers. However, findings also highlight the desire of these women to overcome these barriers, and suggest an inability to access services on their own accord.
The results of the study suggest that disseminating information through groups may be a more effective way of addressing the low use of services such as child health clinics and other health and social services. The participants indicated they found the sessions on parenting in a multicultural society the most useful, reporting they would be the most highly utilised of all the modules.
There was a significant decrease in EPDS scores from pre-test to post-test following the intervention, a decrease that was maintained at the 6-week follow up. This significant decrease in EPDS symptoms suggests that the intervention may have been instrumental in reducing symptoms of postnatal depression. However, the results of this pilot study should be treated with caution because of the small sample size, which included only 12 participants and lack of a control group. Without a control group, it is difficult to conclude that the significant reduction in PND symptoms were due to the group or other factors.
The use of a group intervention that targets the whole community rather than individuals within that community appeared to provide an opportunity for education and support whilst decreasing the stigma surrounding their perceived inability to cope. Employing culturally sensitive facilitators who were able to build trust and confidence within the group and were prepared to work within the clients' explanatory models was important for the success of this intervention. In addition, the provision of practical components such as transport, childcare facilities and interpreters appeared to have been essential in facilitating attendance.
Di Ciano T., Rooney R., Wright B., Hay D., Robinson L. (2010). Postnatal social support group needs and explanatory models of Iraqi Arabic speaking mothers in Perth, Western Australia. Adv. Ment. Health, 9, 162–176 10.5172/jamh.9.2.162. Retrieved from: https://www.tandfonline.com/doi/abs/10.5172/jamh.9.2.162
Kleinman, A. (1978). Concepts and a model for the comparison of medical systems as cultural systems. Soc. Sci. Med. 12, 85–93. Retrieved from: https://pdfs.semanticscholar.org/34cf/fffdc077e388aac11e6c4a83bdf5210705e5.pdf
Authors: Rooney, R.M., Kane, R.T., Wright, B., Gent, V., Di Ciano, T. & Mancini, V.
Citation: Rooney, R.M., Kane, R.T., Wright, B., Gent, V., Di Ciano, T. & Mancini, V. (2014). The pilot and evaluation of a postnatal support group for Iraqi women in the year following the birth of their baby. Front Psychol, 30, (5), 16. doi: 10.3389/fpsyg.2014.00016. eCollection 2014.
Article 4: Vulnerable migrant women and postnatal depression: A case of invisibility in maternity services?
Immigration New Zealand has received 1,871 applications from asylum seekers in the past 5 years from countries including: China, India, Sri Lanka, Saudi Arabia, Iran, Malaysia, Pakistan, Bangladesh, Zimbabwe, Egypt, Russia, South Africa and Myanmar. Women arriving as asylum seekers are at risk of mental health issues. This British study, which is informative for New Zealand maternal health service providers, explores the issues surrounding vulnerable migrant women which increase their risk of developing postnatal depression and presents reasons why this may go unrecognised by health professionals such as midwives. Vulnerable migrant women are defined as asylum seekers, refugees, trafficked persons and those living without legal status. Vulnerable migrant women engage less with maternal health services than the average woman for reasons including a lack of knowledge of the health system, fear of being charged for care, or fear that contact with clinicians will negatively affect their immigration status.
Rates of postnatal depression can be as high as 42 per cent in vulnerable migrant women, while their access to antenatal care is typically less than 50 per cent, partly due to a fear of being charged for services (Shortall et al, 2015). Risk factors may be classed as pre- or post-migratory. Women may be fleeing war or persecution based on their religion, sexuality and political beliefs, and vulnerable migrant women may have witnessed or experienced sexual violence either in their home country, during refugee flight or while in refugee camps. These experiences may lead to psychological conditions such as depression, anxiety or PTSD, which are a documented risk factor for future long-term mental health problems. Post-migratory issues are frequently practical as well as emotional, and include social isolation, language barriers and separation from family members. Asylum seekers face an application procedure that can be long and arduous, during which women can feel fearful of the application being rejected and being deported back home. Due to restricted benefit entitlement, poverty also has an impact on women’s ability to make social networks and access consistent maternal healthcare appointments.
Migrant women may not have knowledge of the role of the midwife or the health system of the host country. Clarifying the clinician’s role and responsibilities, particularly regarding influence on immigration proceedings and eligibility for free maternal health care may increase a woman’s engagement with services. Continuity of care, as for any woman, is more likely to lead to a trusting relationship and the ability to have sensitive, meaningful discussions about mental health.
Midwives are in a key position to improve the recognition of women displaying symptoms of postnatal depression, which may present somatically as physical health issues, or be a response to the trauma surrounding leaving their home country and the journey to a western country.
Immigration New Zealand (INZ) (2019). Refugee and Protection Unit, Statistics for Refugee and Protection Status Claims. INZ: Wellington. Retrieved from: https://www.immigration.govt.nz/documents/statistics/statistics-refugee-and-protection-status-pack
Shortall, C., McMorran, J., Taylor, K. et al. (2015). Experiences of Pregnant Migrant Women receiving Ante/Peri and Postnatal Care in the UK: A longitudinal follow-up study of Doctors of the World’s London drop-in clinic attendees. https://b.3cdn.net/droftheworld/08303864eb97b2d304_lam6brw4c.pdf
Authors: Firth, A. & Haith-Cooper, M.
Citation: Firth, A. & Haith-Cooper, M. (2018). Vulnerable migrant women and postnatal depression: A case of invisibility in maternity services? British Journal of Midwifery, 26 (2), 78-84.
Article 5: A systematic review of ethnic minority women’s experiences of perinatal mental health conditions and services in Europe
The aim of this review was to explore ethnic minority women’s experiences of perinatal mental ill health, help-seeking and perinatal mental health services in Europe. The review aimed to address the following questions:
1. What are the experiences and perceptions of perinatal mental health amongst ethnic minority women in Europe?
2. What are the experiences and perceptions of perinatal mental health services amongst ethnic minority women in Europe?
3. What factors influence the help-seeking behaviours of ethnic minority women in Europe in relation to perinatal mental health disorders?
The systematic review applied the principles of mixed-methods research to integrate results from qualitative, quantitative and mixed methods studies, based on the rationale that the retrieval of qualitative and quantitative data within a review can maximise the usefulness of the synthesis by providing an understanding of human experience alongside empirical evidence about a particular phenomenon.
What women want?
Women identified a number of ways that perinatal mental health service provision for women from ethnic minority backgrounds could be improved. They highlighted that services need to address the full range of mental ill health during the perinatal period and that better multi-agency working was needed, particularly between the health service and voluntary organisations. They suggested that health professionals would benefit from cultural competency training, and that culturally specific support should be provided. Women wanted the opportunity to have early assessment and intervention, and to be provided with information about perinatal mental health problems and services that were available. Women wanted interventions that were regular, designed around women’s individual preferences and which could be flexible in terms of length, as they felt that some problems required support for longer periods of time than was currently offered. Women also identified that they wanted the opportunity to meet other mothers in similar situations either in group settings or in community-based peer support schemes.
Authors: Watson, H., Harrop, D., Walton, E., Young, A. & Soltani, H.
Citation: Watson, H., Harrop, D., Walton, E., Young, A. & Soltani, H. (2019). A systematic review of ethnic minority women’s experiences of perinatal mental health conditions and services in Europe. PLoS ONE 14(1): e0210587.