Bond Between Mother and Child: Postpartum Depression in Immigrants

Introduction

A population which is often overlooked, and is especially susceptible to postpartum depression, is the immigrant and refugee population. It is a major issue both culturally and systemically. There is a substantial body of evidence that suggests that the impact of postpartum depression on mother and child can be lifelong, affecting the bond between mother and child. The effects of postpartum depression are not limited to what the name suggests. There is a substantial body of evidence that suggests that the impact of postpartum depression on mother and child can be lifelong. Reduced mother-child interactions have shown to cause consequently impaired maternal caretaking behaviours (O’Hara & McCabe, 2013).

Examples include: decreased rates of breastfeeding, decreased coordination and interaction with the infant, hostility, and unresponsiveness (O’Hara & McCabe, 2013). There are also a variety of implications on the future state of the mother-child relationship, and infant behavioural, cognitive development, and physical health (O’Hara & McCabe, 2013). This paper will focus exclusively on the area of Surrey, BC and the large South Asian immigrant population residing in this area. In Surrey specifically, 37% of the immigrant population is from India followed by the Philippines (11%) and China (8.4%) (NewToBC, 2018). While postpartum depression is an issue affecting the lives of many women in the general population, immigrant women face a unique set of sociocultural factors which put them at a 1.5-2 times higher risk of developing this mental health issue (Hassani, Shiri, Vigod, & Dennis, 2015).

Challenges Faced by Immigrant Mothers

This essay will explore the context behind postpartum depression in South-Asian immigrant populations, the social barriers they face reaching out for help (such as language differences), and the deep stigma associated with mental illness. It will also examine the systemic barriers such as socioeconomic status, lack of education, and income and health care disparities that contribute to the lack of support these women have. This essay will also highlight recommendations to improve health outcomes through culturally competent education programmes and resources and creating awareness within the community to support the recovery of this population.

Postpartum depression is classified under the umbrella of postpartum mood disorders (Perry, Hockenberry, Lowdermilk, & Wilson, 2013).  Examples of postpartum mood disorders include postpartum anxiety, obsessive compulsive disorder, and psychosis (Perry et al., 2013).  In addition to these mood disorders, women are four times more likely to be admitted to a psychiatric hospital within the first four weeks following childbirth (Perry et al., 2013).  While up to 80% of women may experience sadness after the birth of a child (characterized by mild sadness, exhaustion, and unstable mood), postpartum depression is a major depressive disorder that impairs normal functioning (Vliegen, Casalin, & Luyten, 2014).  There are a variety of risk factors associated with postpartum depression such as:  history of depression and anxiety, stressful life events, poor social support, low socioeconomical status, being single, and obstetrical complications (O’Hara & McCabe, 2013). 

The symptoms and criteria outlined by the DSM-5 include: depressed mood, change in appetite or weight, fatigue, decreased concentration, sleep disturbance, inappropriate guilt, psychomotor disturbance, or thoughts of self-harm or suicide (DelRosario et al., 2013).  For diagnosis purposes of major depressive disorder, at least five of these symptoms must be present within a two-week period with depressed mood being one of the five symptoms (DelRosario et al., 2013).  To be classified as postpartum depression, these symptoms must be present within a four-week timespan of childbirth (DelRosario et al., 2013).  The DSM-5 criteria however is limited as it does not consider that depressive symptoms can also occur after this four-week time span following childbirth (Brummelte & Galea, 2016).  It also does not distinguish between the pre and postnatal onset of depressive symptoms, therefore the specific consequences of each type of onset cannot be classified (Brummelte & Galea, 2016).

The etiology of postpartum depression has been studied as according to the dramatic hormonal changes that occur during pregnancy.  According to Brummelte & Galea (2016) the hormonal changes post pregnancy “coincide with the greatest risk to develop depression during a woman’s lifetime” (p. 156). This suggests an intimate link between specific biomarkers (such as steroid ovarian hormones, glucocorticoids, and oxytocin levels) and the risk of developing postpartum depression or other postpartum mood disorders (Brummelte & Galea, 2016).  These hypotheses, however, have been challenged intensely in the literature.  While all women experience these dramatic hormonal shifts, only a subset develop postpartum depression (O’Hara & McCabe, 2013).  Furthermore, little evidence has been produced which supports that hormonal levels following childbirth differ significantly between postpartum depressed and nondepressed women (O’Hara & McCabe, 2013).  Decreased levels of omega-3-polyunsaturated fatty acids (PUFA) and docosahexaenoic acid (DHA), alterations in the hypothalamic-pituitary axis, thyroid dysfunction, and genetic predisposition to environmental factors are also other additional areas of research in the realm of postpartum depression as well (DelRosario et al., 2013).

Impact of Postpartum Depression on Mother and Child Bond

On average, 20% of immigrant or refugee women experience post-partum depression in the first year after childbirth (Hassani et al., 2015). Immigrant women often derive from lower socioeconomic statuses due contributing factors such as lower incomes, and lower education levels. They also may not have the same social support as Canadian women since they are in a foreign country and may not know many people. According to O’Mahony, Donnelly, Bouchal, & Este, (2012) other issues immigrant women face are “stressful migration experiences, language barriers, marginalization and minority status, lowered socioeconomic status, lack of social supports, poor physical health, and difficulty adapting to host cultures” (p. 312). In other countries around the world, post-partum depression may not be considered a real aliment due to the stigma associated with mental health issues. For many immigrant and refugee women, there is a deep stigma associated with experiencing post-partum depression. Many feel ashamed, isolated, discriminated against by their community or family members, or too scared to connect with medical and social supports (O’Mahony et al., 2012). Many also may have little understanding about mental illness, and about their symptoms (O’Mahony et al., 2012). Language differences could hinder the ability of immigrant women to access resources as well (Hassani et al., 2015). Creating resources which are available in different languages, or which use simple/plain English are possible strategies. Also, spreading educational programs through diverse media and community events will help target this at-risk population (Bodolai, Celmins, & Viloria-Tan, 2014).

Using culturally competent teaching methods is essential, as well as providing access to economical or free educational resources to immigrant women post-partum. According to Moller and Burgess, educational brochures can help increase mental health awareness in South Asian women (p. 208, 2016). Health promotion and education programs at community centers should also be established as well. The objectives to this education plan would be to provide important information and create awareness amongst immigrant women in Surrey, BC about PPD and the resources available in the community. Because a lot of South Asian immigrant women may be reluctant to ask questions or voice concerns, in-person presentations will be limited to just mothers, and not their spouses, partners, or other family members. Post-Partum Depression should be broken down into a number of different categories. The first session should serve as an overview of PPD such as what it is, what causes it, what are the symptoms, and how it is diagnosed. The second portion should cover topics to engage women with the knowledge and provide them access to resources and tips to help overcome PDD. Many women may feel stigmatized and have a lack of support from family members, when it comes to post-partum depression (Hassani et al., 2015). Therefore, special consideration should be given to ensure that women understand that their emotions are not something to be ashamed about. For this health education plan, the three different domains of learning must be considered (affective, cognitive, psychomotor) (Stoeckel & Miller, 2017). This is so that the education/health promotion provided is the most effective. Sociocultural education theory should also be applied. The following instructional methods should be applied power point, brochures, videos, internet/Youtube videos, brainstorm sessions, roundtable discussions and art methods etc. for expression.

In addition to other strategies, post-partum depression screening should be emphasized for immigrant women due to their elevated risk. Screening should be offered in various languages to accommodate the different immigrant populations in Surrey, BC. Healthcare professionals should also refer immigrant women in the prenatal phase to get the screening. It is important for immigrant women to be screened because many may lack the mental health literacy to understand they are suffering from post-partum depression (Hanna, Jarman & Savage, 2004). A possible screening tool that could be implicated is the Edinburgh Postnatal Depression Scale (EPDS). it is a 10‐item, self‐report scale that evaluates both mood and emotional states to detect post-partum depression (Hanna et al., 2004). Scores higher than 10 indicate symptoms of post-partum depression, and further referral is needed (Fritz & McGregor, 2013). By using this scale, it provides physicians with critical data and that they can forward women to receive a psychiatric assessment, and access to other community services (Hanna, Jarman & Savage, 2004). This screening tool has been used around the world and has been translated and validated into Punjabi and proved effective in South Asian populations (Fritz & McGregor, 2013). It is the only culturally appropriate screening tool for post-partum depression, as other screening tools focus solely on western populations and may not account for different cultural beliefs (Fritz & McGregor, 2013). For example, the translated EPDS takes in account that Punjabi women may experience discrimination after the birth of their baby if it is a female due to the preference of boys in Punjabi culture (Fritz & McGregor, 2013). They may also answer the questions better on paper due to fear of speaking of their issues aloud, and maintaining their own privacy (Fritz & McGregor, 2013). It will allow them to answer honestly and the answers will not be based on the expectations that others have set for them. Due to the large portion of Surrey South-Asian immigrant population residing from Punjab this will reduce the cultural, and language barriers and they encounter. They also may be more inclined to take the screening if it is developed specifically based on their cultural needs because they will be able to understand the context.

Support for Immigrant Mothers

Creating a safe environment, where women feel like they will not be judged for their feelings, is essential for bringing awareness to this issue. Immigrant women, in particular, face social isolation and language barriers which put them at an elevated risk for experiencing post-partum depression. Having culturally competent and aware health care providers that are able to meet their individual needs is important in accommodating cultural differences (Bodolai et al., 2014). Specifically, in the South-Asian community women prefer to discuss their issues with other women and may be hesitant to have men involved (Fritz & McGregor, 2013). Thus, it is crucial that women (whether as a translator or as the family physician) be involved in care to ensure a safe space for them. Also, providing women with translators to decrease language disparities will make them feel more comfortable and allow them to express concerns over their own health (Bodolai et al., 2014). By applying cultural competency, it will allow health professionals to establish rapports with their patients, improve communication, and treatment adherence (Austin & Boyd, 2019). According to Austin & Boyd (2019), individuals who had a negative view about accessing mental health services were less likely to utilize them. In South-Asian cultures experiencing mental illness is considered very shameful. Helping to reduce the stigma or the shame that many women experience when struggling with post-partum depression is a consideration as well to improve client safety. Health care providers can decrease stigma by being empathetic and addressing patient concerns, rather than being dismissive of the symptoms that women experience post-partum. In addition, this stigma can also be reduced by creating support groups with other immigrant women (Bodolai et al., 2014). This would not only reduce the stigma of post-partum depression but also reduce social isolation, increase self esteem, and help relationships between the women (Bodolai et al., 2014).

Creating initiatives that target immigrant women from Surrey, BC can help to ensure that the appropriate resources are provided to both mother and baby. In additional to creating these resources, community engagement is an important consideration as well. Through community engagement techniques, South Asian women (as well as other stakeholders and community members) can feel more empowered. Empowerment helps to improve health outcomes as community members participate more readily in caring for and seeking help with both mental and physical health. Working closely with the community to design such programs and initiatives will also help foster effective healthcare provider-client relationships as well.

By creating these initiatives, it can help to improve the mental health status of new mothers post-partum. The most important implication of this research is that both social, and systemic barriers are acknowledged in South Asian women, and are addressed by health-care professionals accordingly. A future avenue for research would be to further investigate the impact of family discrimination that South Asian immigrant women may face post-partum, and how this may contribute to their post-partum depression. Another avenue for research is how cultural stigma and gender roles within the South Asian community play a role in women seeking help for post-partum depression.

Conclusion

While many strides have been made towards creating awareness about postpartum depression, there is still substantial progress to be made.  For the immigrant and refugee population especially, nurses and other healthcare providers must use culturally competent teaching methods in addition to providing access to economical or free resources.  Emphasizing post-partum depression screening tools for immigrants is crucial to preventing the negative impacts of post-partum depression on both the mother and child. Lastly, creating a safe environment, where women feel like they will not be judged for their feelings, is essential for bringing awareness to this issue. Helping to reduce the stigma or the shame that many women experience when struggling with postpartum depression is an additional consideration as well. 

References

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