Life with a new baby: how do immigrant and Australian-born women's experiences compare?

A systematic review of migrant women's experiences of successful exclusive breastfeeding in high-income countries

The World Health Organisation recommends exclusive breastfeeding for the first 6 months after childbirth. However, since breastfeeding is influenced by cultural practice, it differs between migrant mothers and nonmigrant mothers. This systematic review examined migrant mothers' perceptions and experiences impacting achievement of exclusive breastfeeding after immigration from a low-middle-income country to a high-income country. CINAHL, Medline, Scopus, Web of Science, PsycINFO and Emcare were searched for qualitative studies published from 2010 to August 2022. Eleven studies met inclusion criteria. We used meta-ethnographic synthesis to identify overarching themes, resulting in five themes: Migrant mothers (1) 'recognised the differences in breastfeeding practice between their home and host country'. During acculturation, mothers modify or stick to their breastfeeding practice in their host country based on their (2) 'breastfeeding knowledge' by combining their (3) 'original ethnic identity' with the (4) 'influence of family members, healthcare workers, infants, peers and workplace'. Although they face barriers, their (5) 'autonomy' motivated them to continue breastfeeding in a country where the breastfeeding norm differs from where they come from. Intrapersonal and interpersonal socio-ecological factors played a significant role in their breastfeeding practice in the host country. Findings indicate public health policy and practice to support breastfeeding for migrant women in high-income countries can be improved, particularly by emphasising the importance of providing affirmative, comprehensive and practical support from healthcare professionals.

The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis

BACKGROUND

There are one billion migrants globally, of whom 82 million are forced migrants. Pregnant migrants face pre-migration stressors such as conflict, transit stressors including poverty, and post-migration stressors including navigating the immigration system; these stressors can make them vulnerable to mental illness. We aimed to assess the global prevalence of and risk factors for perinatal mental health disorders or substance use among women who are migrants.

METHODS

In this systematic review and meta-analysis, we searched OVID MEDLINE, Embase, PsycINFO, CENTRAL, Global Health, Scopus, and Web of Science for studies published from database inception until July 8, 2022. Cohort, cross-sectional, and interventional studies with prevalence data for any mental illness in pregnancy or the postnatal period (ie, up to a year after delivery) or substance use in pregnancy were included. The primary outcome was the prevalence of perinatal common mental health disorders among women who are migrants, globally. Data for study quality and risk factors were also extracted. A random-effects meta-analysis was used to calculate pooled prevalence estimates, when appropriate. Sensitivity analyses were conducted according to study quality, sample representativeness, and method of outcome assessment. Risk factor data were synthesised narratively. This study is registered with PROSPERO, CRD42021226291.

FINDINGS

18 650 studies were retrieved, of which 135 studies comprising data from 621 995 participants met the inclusion criteria. 123 (91%) of 135 studies were conducted in high-income host countries. Five (4%) of 135 studies were interventional, 40 (30%) were cohort, and 90 (66%) were cross-sectional. The most common regions of origin of participants were South America, the Middle East, and north Africa. Only 26 studies presented disaggregated data for forced migrants or economic migrants. The pooled prevalence of perinatal depressive disorders was 24·2% (range 0·5-95·5%; I² 98·8%; τ² 0·01) among all women who are migrants, 32·5% (1·5-81·6; 98·7%; 0·01) among forced migrants, and 13·7% (4·7-35·1; 91·5%; 0·01) among economic migrants (p<0·001). The pooled prevalence of perinatal anxiety disorders was 19·6% (range 1·2-53·1; I² 96·8%; τ² 0·01) among all migrants. The pooled prevalence of perinatal post-traumatic stress disorder (PTSD) among all migrant women was 8·9% (range 3·2-33·3; I² 97·4%; τ² 0·18). The pooled prevalence of perinatal PTSD among forced migrants was 17·1% (range 6·5-44·3; I² 96·6%; τ² 0·32). Key risk factors for perinatal depression were being a recently arrived immigrant (ie, approximately within the past year), having poor social support, and having a poor relationship with one's partner.

INTERPRETATION

One in four women who are migrants and who are pregnant or post partum experience perinatal depression, one in five perinatal anxiety, and one in 11 perinatal PTSD. The burden of perinatal mental illness appears higher among women who are forced migrants compared with women who are economic migrants. To our knowledge, we have provided the first pooled estimate of perinatal depression and PTSD among women who are forced migrants. Interpreting the prevalence estimate should be observed with caution due to the very wide range found within the included studies. Additionally, 66% of studies were cross-sectional representing low quality evidence. These findings highlight the need for community-based routine perinatal mental health screening for migrant communities, and access to interventions that are culturally sensitive, particularly for forced migrants who might experience a higher burden of disease than economic migrants.

FUNDING

UK National Institute for Health Research (NIHR); March of Dimes European Preterm Birth Research Centre, Imperial College; Imperial College NIHR Biomedical Research Centre; and Nuffield Department of Population Health, University of Oxford.

Feasibility of an evidence-based educational intervention in screening immigrant mothers for postpartum depression: A pretest-posttest experimental design

BACKGROUND

Screening immigrant mothers for postpartum depression has been shown to be challenging for health care professionals in handling cultural implications of postpartum depression, communicating through interpreter and applying translated versions of the screening scale.

AIM

The aim of the study was to test the feasibility of an evidence-based educational intervention for Child Health Services nurses in screening non-native-speaking immigrant mothers for postpartum depression.

ETHICS

The approval was obtained from Swedish Ethical Review Authority, 2018/1063.

METHOD

Thirty Child Health Services nurses who conducted screening with assistance of interpreter at least three times per year participated. The study was registered at ClinicalTrials.gov (NCT04167709) and a one-group pretest-posttest experimental design was applied. Data on the participants' acceptability and response to outcomes of the intervention were collected by an evaluation questionnaire, the Clinical Cultural Competency Training Questionnaire, the General Self-efficacy Scale and by self-reported data on general performance of the task. Descriptive statistics were used to present the results of the evaluation questionnaire and general performance of the task. Paired t-test were used to compare the scores on the General Self-efficacy scale, while Wilcoxon signed-ranked test was used to compare the scores on the Clinical Cultural Competency Training Questionnaire. Qualitative data were analysed by content analysis.

RESULTS

All 30 participants stated that they found the content of the intervention satisfying. The intervention was shown to provide new knowledge and improved their ability to meet the requirements linked to the screening procedure. The intervention affected their self-estimated cultural competence in some aspects but not their self-efficacy or general performance of the task.

CONCLUSIONS

The intervention was found feasible but require adjustment in the design of the practical training sessions. The use of the provided material, a comic strip on parental support and interpreter information needs further evaluation.

Loneliness in pregnant and postpartum people and parents of children aged 5 years or younger: a scoping review

BACKGROUND

Despite evidence that loneliness increases during times of transition, and that the incidence of loneliness is highest in young adults, loneliness during pregnancy and new parenthood has not been developed as a program of research. Because loneliness research has primarily focused on older adults and other high-risk populations, the concept of loneliness and its effects on this population are not well understood, leaving a gap in our understanding of the psychosocial needs and health risks of loneliness on pregnant people and new parents. A scoping review has been completed in order to map and synthesize the literature on loneliness experienced during pregnancy and the first 5 years of parenthood prior to the COVID-19 pandemic.

METHODS

To address the aim of this review, a wide net was cast in order to detect experiences of perinatal or parental loneliness and/or instances where loneliness was measured in this population. Among the inclusion criteria were loneliness in people who were pregnant, who were parents in the postpartum period, or who had children aged 5 years or younger. A search for literature was conducted in December 2020 using nine databases: MEDLINE (Ovid), EMBASE (Elsevier), SCOPUS (Elsevier), Cochrane Library including CENTRAL (Wiley), CINAHL (Ebscohost), PsycINFO (Ebscohost), Dissertations & Theses Global (ProQuest) and Sociological Abstracts (ProQuest), and the Web of Science Core Collection (Clarivate).

RESULTS

Perinatal and parental loneliness studies are limited and have rarely been targeted and developed through a program of research. Loneliness inquiry in this population was frequently studied in relation to other concepts of interest (e.g., postpartum depression). Alternatively, the importance of loneliness emerged from study participants as relevant to the research topic during qualitative inquiry. Across studies, the prevalence of loneliness ranged from 32 to 100%. Loneliness was commonly experienced alongside parenting difficulties, with parents feeling as though they were alone in their struggles.

CONCLUSIONS

As loneliness has been called a sensitive indicator of mental wellbeing, we believe screening will help healthcare professionals identify common difficulties and early signs of depression experienced during pregnancy and parenthood.

SYSTEMATIC REVIEW REGISTRATION

The protocol is available on Open Science Framework at DOI 10.17605/OSF.IO/BFVPZ.

“Worn-out but happy”: Postpartum Women's Mental Health and Well-Being During COVID-19 Restrictions in Australia

Background: From late 2019, COVID-19 disease has infiltrated the global population causing widespread challenges to public health. One cohort that has received less attention, but who may be more vulnerable to the mental and physical health related impacts of COVID-19 restrictions are postpartum mothers. The aim of this study was to explore the mental health, well-being, and health behaviours of mothers up to 12 months postpartum whilst living in Australia under COVID-19 level 3 and 4 restrictions.

Methods: 351 women in their first year postpartum residing in Australia whilst under level 3/4 social distancing restrictions (during April 13 and June 11, 2020) were recruited to participate in an online questionnaire. The survey measured symptoms of depression, anxiety, and stress (DASS), wellness (SF-36), physical activity (Godin-Shephard score), perceived value of health outcomes, diet, and sleep. Descriptive statistics and linear regressions were performed.

Results: Data was analysed for 139 eligible women. Of these women, 74% scored “normal” for depression, 84% for anxiety, and 72% for stress. Over half (58%) of women reported being worn out all, most, or a good bit of the time and 77% reported being a happy person all, most, or a good bit of the time. Analysis of the perceived values of health outcome revealed women had high value for “getting out of the house,” “achieving a better overall mood,” and “to feel better physically.” Women were considered physically active according to the Godin Leisure score, however only 41% of women met the current Australian national physical activity guidelines of 150 min.week⁻¹.

Conclusions: Overall the majority of postpartum mums that were surveyed, have normal mental health symptoms, and despite being worn out most are happy at least a good bit of the time. This study highlights the importance of health values in maintaining leisure physical activity and mental health. In addition it appears women may benefit from virtual group exercise and community programs to encourage being physically active and socialising with friends simultaneously.

Fathers' involvement in perinatal healthcare in Australia: experiences and reflections of Ethiopian-Australian men and women

Background

Family-centred maternity care models include the expectation that fathers prepare for and attend the birth. In Australia over 20% of the population is from a culturally and linguistically diverse background. Public policies espouse culturally competent healthcare. Little is known about the experiences of perinatal health care of men from culturally and linguistically diverse (CALD) communities living in high income countries. The aim was to understand the experiences, attitudes and beliefs about father’s inclusion in perinatal healthcare, from the growing, and recently settled community of Ethiopian families living in Australia.

Methods

A qualitative study using semi-structured individual interviews with Ethiopian-Australian men and women who had experienced Australian maternity care and were sampled for diversity of time since migration, and parity. Interviews were in English, audio-recorded, transcribed and then analysed thematically.

Results

Participants were seven women and six men all born in Ethiopia, including two couples. Key themes included: the loss of extended family through migration, new roles for both parents and the need to establish ‘family-like’ relationships with friendship groups in Australia. There was a willingness to involve male partners in the Ethiopian community in Australia, although it was recognised as a cultural change. Experiences of male partner involvement were mixed among healthcare types, with men attending Maternal and Child Health (MCH) appointments less frequently than antenatal (ANC) appointments.

Conclusions

Results suggests men may be missing out on the education provided during antenatal appointments and may benefit from an alternative. There were not universally high levels of cultural competency among healthcare professionals, with further training still required. Commitment to paid employment remains a barrier to men’s involvement, suggesting that flexible working conditions and increased paternity leave would support their involvement. Alternatively services could utilise flexible delivery methods such as phone and zoom to include fathers.

Language Proficiency and Migrant-Native Disparities in Postpartum Depressive Symptoms

Migrant women have a higher risk of developing postpartum depressive symptoms (PPDS) than do native women. This study aimed to investigate the role of host-country language proficiency in this disparity. We analysed the data of 1475 migrant and 1415 native women who gave birth at a Portuguese public hospital between 2017 and 2019 and were participants in the baMBINO cohort study. Migrants’ language proficiency was self-rated and comprised understanding, speaking, reading, and writing skills. PPDS were assessed using the Edinburgh Postnatal Depression Scale with a cut-off score of ≥10. Multivariable logistic regression models were fitted to estimate the association between language proficiency and PPDS. PPDS were experienced by 7.2% of native women and 12.4% among migrants (p < 0.001). Increasing proportions of PPDS were observed among decreasing Portuguese proficiency levels; 11% among full, 13% among intermediate, and 18% among limited proficiency women (ptrend < 0.001). Full (aOR 1.63 (95% CI 1.21–2.19)), intermediate (aOR 1.68 (95% CI 1.16–2.42)), and limited (aOR 2.55 (95% CI 1.64–3.99)) language proficiencies were associated with increasingly higher odds of PPDS among migrant women, compared to native proficiency. Prevention measures should target migrant women at high risk of PPDS, namely those with limited language skills, and promote awareness, early detection, and help-seeking, in addition to facilitating communication in their perinatal healthcare encounters.

The process of culturally adapting the Healthy Beginnings early obesity prevention program for Arabic and Chinese mothers in Australia

Background

Behavioural interventions for the early prevention of childhood obesity mostly focus on English-speaking populations in high-income countries. Cultural adaptation is an emerging strategy for implementing evidence-based interventions among different populations and regions. This paper describes the initial process of culturally adapting Healthy Beginnings, an evidence-based early childhood obesity prevention program, for Arabic and Chinese speaking migrant mothers and infants in Sydney, Australia.

Methods

The cultural adaptation process followed the Stages of Cultural Adaptation theoretical model and is reported using the Framework for Reporting Adaptations and Modifications-Enhanced. We first established the adaptation rationale, then considered program underpinnings and the core components for effectiveness. To inform adaptations, we reviewed the scientific literature and engaged stakeholders. Consultations included focus groups with 24 Arabic and 22 Chinese speaking migrant mothers and interviews with 20 health professionals. With input from project partners, bi-cultural staff and community organisations, findings informed cultural adaptations to the content and delivery features of the Healthy Beginnings program.

Results

Program structure and delivery mode were retained to preserve fidelity (i.e. staged nurse calls with key program messages addressing modifiable obesity-related behaviours: infant feeding, active play, sedentary behaviours and sleep). Qualitative analysis of focus group and interview data resulted in descriptive themes concerning cultural practices and beliefs related to infant obesity-related behaviours and perceptions of child weight among Arabic and Chinese speaking mothers. Based on the literature and local study findings, cultural adaptations were made to recruitment approaches, staffing (bi-cultural nurses and project staff) and program content (modified call scripts and culturally adapted written health promotion materials).

Conclusions

This cultural adaptation of Healthy Beginnings followed an established process model and resulted in a program with enhanced relevance and accessibility among Arabic and Chinese speaking migrant mothers. This work will inform the future cultural adaptation stages: testing, refining, and trialling the culturally adapted Healthy Beginnings program to assess acceptability, feasibility and effectiveness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10270-5.

Indian migrant women's experiences of motherhood and postnatal support in Australia: A qualitative study

BACKGROUND

The postpartum period can be challenging for many women. For migrant women, the arrival of a new baby brings unique issues. This study aimed to explore the experiences of motherhood and postpartum support of Indian migrant mothers.

METHODS

A qualitative descriptive naturalist inquiry was adopted, with data collected through face-to-face, semi-structured, in-depth interviews with a purposive sample of 11 English speaking Indian migrant women over 18 years old, (6 weeks to 6 months postpartum) in 2016. The data were thematically analysed.

FINDINGS

Four themes were found in this study: the role of social support in postpartum care, support from health services, a psycho-emotional journey with socio-cultural expectations and struggling to bridge two cultures. Many of the women felt alone and were distressed with undertaking household duties and caring for older children, as this would not have happened in India. The women expressed needing practical support until they settled back into their normal lives. Women never sought professional advice for their ongoing mental health concerns. Conflicting advice from health professionals left some women confused about their expectations of traditional and modern postnatal care.

CONCLUSION

This study gives a unique insight into the experiences of Indian migrant women following birth. There is a need for culturally sensitive and appropriate postnatal services that encourage Indian men to support their partners and help women to find alternative sources of culturally appropriate support. It is vital that mental health support is a key component of any such program of care.

Provider Perspectives on Facilitators and Barriers to Accessible Service Provision for Immigrant Women With Postpartum Depression: A Qualitative Study

Background

Immigrant women are at greater risk for postpartum depression than native-born women and face multiple barriers to accessing services. Service providers themselves face challenges in delivering accessible care for immigrant women with postpartum depression.

Purpose

This research explored provider perspectives on facilitators and barriers providers faced in terms of providing accessible services.

Methods

The study used an interpretive descriptive design, shaped by an integrated knowledge user–researcher partnership. Fourteen health and social service providers participated in individual in-depth interviews. Using a socioecological framework as an organizing structure, an inductive thematic content analysis was conducted.

Results

Providers identified attributes that foster relationship building, including building trust, addressing power dynamics, understanding women’s experiences, enacting cultural competence, involving family members, providing adequate time, and facilitating system navigation. Organizational features shaping accessibility included assessment and treatment approaches, wait times, gate keeping, and the ability to address social health determinants. Different organizational approaches could facilitate or discourage service coordination across organizations. Finally, providers believed that health and immigration system mechanisms could work more effectively for optimal postpartum depression support.

Conclusion

Health service providers are critical in supporting immigrant women with postpartum depression and facilitating service accessibility. Organizational and system gaps restrict optimal postpartum depression service provision and integration.

Breastfeeding rates in immigrant and non-immigrant women: A systematic review and meta-analysis

Breastfeeding benefits mothers and infants. Although immigration in many regions has increased in the last three decades, it is unknown whether immigrant women have better breastfeeding outcomes than non-immigrants. The aim of this study was to conduct a systematic review and meta-analysis to determine whether breastfeeding rates differ between immigrant and non-immigrant women. We searched Medline, Embase, PsycINFO, CINAHL and Google Scholar, 1950 to 2016. We included peer-reviewed cross-sectional and cohort studies of women aged ≥16 years that assessed and compared breastfeeding rates in immigrant and non-immigrant women. Two independent reviewers extracted data using predefined standard procedures. The analysis included 29 studies representing 1,539,659 women from 14 countries. Immigrant women were more likely than non-immigrants to initiate any (exclusive or partial) breastfeeding (pooled adjusted prevalence ratio 1.13, 95% confidence interval [CI] 1.07-1.19; 11 studies). Exclusive breastfeeding initiation was higher but borderline significant (adjusted prevalence ratio 1.20, 95% CI 1.00-1.45; 5 studies, p = 0.056). Immigrant women were more likely than non-immigrants to continue any breastfeeding between 12- and 24-week postpartum (pooled adjusted risk ratio 2.04, 95% CI 1.79-2.32; 3 studies) and > 24 weeks (adjusted risk ratio 1.33, 95% CI 1.02-1.73; 6 studies) but not exclusive breastfeeding. Immigrant women are more likely than non-immigrants to initiate and maintain any breastfeeding, but exclusive breastfeeding remains a challenge for both immigrants and non-immigrants. Social and cultural factors need to be considered to understand the extent to which immigrant status is an independent predictor of positive breastfeeding practices.

‘Happy that someone cared’—Non-native-speaking immigrant mothers’ experiences of participating in screening for postpartum depression in the Swedish child health services

Immigrant mothers who have immigrated during the last ten years and do not speak the language of the new country are found to be at particular risk of being affected by postpartum depression (PPD). Still they choose to participate to a lesser extent in screening for PPD and are not screened out as frequently as can be expected. In this study, non-native-speaking immigrant mothers' experiences of participating in screening for PPD in the Swedish Child Health Services were elucidated. Thirteen qualitative interviews were performed with the help of an interpreter and analysed using latent content analysis. The possibility to participate in screening was appreciated by the mothers even though the concept of PPD in general was unclear. Cultural beliefs about mental ill health, negative expectations connected to their perceived value as a woman, shame at not being grateful enough for their new life and negative experience of the interaction during the screening challenged them in speaking about their mood. To facilitate the screening procedure for this vulnerable group of mothers, it is important to be aware of possible challenges when speaking about their mood and to strive for a trusting clinical interview with the assistance of a female interpreter on-site.

Common maternal health problems among Australian-born and migrant women: A prospective cohort study

BACKGROUND

Migrant women of non-English speaking background make up an increasing proportion of women giving birth in high income countries, such as Australia, Canada and the United Kingdom. The aim of this study was to assess the prevalence of common physical and psychosocial health problems during pregnancy and up to 18 months postpartum among migrant women of non-English speaking background compared to Australian-born women.

METHODS

Prospective pregnancy cohort study of 1507 nulliparous women. Women completed self-administered questionnaires or telephone interviews in early and late pregnancy and at 3, 6, 9, 12 and 18 months postpartum. Standardised instruments were used to assess incontinence, depressive symptoms and intimate partner violence.

FINDINGS

Migrant women of non-English speaking background (n = 243) and Australian-born mothers (n = 1115) reported a similar pattern of physical health problems during pregnancy and postpartum. The most common physical health problems were: exhaustion, back pain, constipation and urinary incontinence. Around one in six Australian-born women (16.9%) and more than one in four migrant women (22.5%) experienced intimate partner abuse in the first 12 months postpartum. Compared to Australian-born women, migrant women were more likely to report depressive symptoms at 12 and 18 months postpartum.

CONCLUSION

Physical and mental health problems are common among women of non-English speaking background and Australian-born women, and frequently persist up to 18 months postpartum. Migrant women experience a higher burden of postpartum depressive symptoms and intimate partner violence, and may face additional challenges accessing appropriate care and support.

Postpartum depression and social support in a racially and ethnically diverse population of women

Lack of social support is an important risk factor for postpartum depression (PPD), whereas the presence of social support can buffer against PPD. However, the relationship between social support and PPD in racial/ethnic minority women is still largely unknown. Our purpose was to examine the role of social support in a large, diverse population of PPD cases and controls. Participants (N = 1517) were recruited at the routine 6-week postpartum visit (± 1-2 weeks) from four different outpatient clinics in North Carolina. Case status was determined using the MINI International Neuropsychiatric Interview. Social support was measured using the Medical Outcomes Social (MOS) Support survey and the Baby's Father Support Scale (DAD). We found that higher levels of social support had a strong protective association against PPD (MOS total score OR, 0.23; 95% CI, 0.19-0.27; p = 6.92E-90; DAD total score OR, 0.89; 95% CI, 0.88-0.92; p = 1.69E-29), and the effects of social support did not differ when accounting for race/ethnicity. Additionally, PPD symptom severity is significantly and negatively correlated with the degree of social support. Our findings suggest that multi-dimensional aspects of social support may be protective for racial/ethnic minority women. We believe this study is currently the largest and most robust characterizing PPD case status and its association with social support in a diverse cohort of mothers. Future work is required to understand how best to implement culturally sensitive interventions to increase social support in minority perinatal women.

Adverse Pregnancy Outcomes: A Comparison of Risk Factors and Prevalence in Native and Migrant Mothers of Portuguese Generation XXI Birth Cohort

Epidemiological studies report conflicting findings regarding association between maternal immigration status and pregnancy outcomes. In this study we compared risk factors and prevalence of adverse pregnancy outcomes in native Portuguese and migrants. Cross-sectional analysis was conducted using information collected at delivery from the participants of Generation XXI birth cohort. Logistic regression models were fitted to assess the association between migrant status and adverse pregnancy outcomes. Prevalence of risk factors for adverse pregnancy outcomes varied between native Portuguese and migrants: teenage mothers (5.6 and 2.0%), primiparae (57.1 and 63.9%), smoking during pregnancy (23.0 and 19.1%), twins (3.2 and 8.0%), and caesarean section (35.2 and 45.7%). Among singleton births, prevalence of low birthweight, preterm birth and small for gestational age were 7.3 and 3.9%, 7.5 and 6.2%, and 15.1 and 7.6%, respectively for native Portuguese and migrants. The native Portuguese had an adjusted significantly higher risk of low birthweight (OR 2.67, 95% CI 1.30, 5.48) and small for gestational age (OR 2.01, 95% CI 1.26, 3.21), but a similar risk for preterm birth (OR 1.38, 95% CI 0.81, 2, 34). Migrant mothers presented a lower risk of low birthweight and small for gestation and data suggest a healthy immigrant effect.

Demographic Predictors of Family Functioning and Its Change Over the First 5 Years Postpartum: Findings From the Healthy Beginnings Trial

There are very few longitudinal studies examining family functioning in early childhood. This was a prospective cohort study to identify maternal sociodemographic factors associated with family functioning over the first 5 years postpartum, using data from the Healthy Beginnings Trial. Family functioning was measured using the General Functioning Subscale of the McMaster Family Assessment Device. A total of 667 first-time mothers participated, of which 369 remained at 5 years. Family functioning did not change significantly over the 5 years. Mothers being Australian born, being employed, and having a partner were predictors for healthy family functioning. Targeting support for immigrants, low-income and single-mother families may therefore improve family functioning.

The physical and mental health problems of refugee and migrant fathers: findings from an Australian population-based study of children and their families

OBJECTIVES

The aim of this study was to report on the physical and mental health of migrant and refugee fathers participating in a population-based study of Australian children and their families.

DESIGN

Cross-sectional survey data drawn from a population-based longitudinal study when children were aged 4-5 years.

SETTING

Population-based study of Australian children and their families.

PARTICIPANTS

8137 fathers participated in the study when their children were aged 4-5 years. There were 131 (1.6%) fathers of likely refugee background, 872 (10.7%) fathers who migrated from English-speaking countries, 1005 (12.4%) fathers who migrated from non-English-speaking countries and 6129 (75.3%) Australian-born fathers.

PRIMARY OUTCOME MEASURES

Fathers' psychological distress was assessed using the self-report Kessler-6. Information pertaining to physical health conditions, global or overall health, alcohol and tobacco use, and body mass index status was obtained.

RESULTS

Compared with Australian-born fathers, fathers of likely refugee background (adjusted OR(aOR) 3.17, 95% CI 2.13 to 4.74) and fathers from non-English-speaking countries (aOR 1.79, 95%CI 1.51 to 2.13) had higher odds of psychological distress. Refugee fathers were more likely to report fair to poor overall health (aOR 1.95, 95% CI 1.06 to 3.60) and being underweight (aOR 3.49, 95% CI 1.57 to 7.74) compared with Australian-born fathers. Refugee fathers and those from non-English-speaking countries were less likely to report light (aOR 0.25, 95% CI 0.15 to 0.43, and aOR 0.30, 95% CI 0.24 to 0.37, respectively) and moderate to harmful alcohol use (aOR 0.04, 95% CI 0.10 to 0.17, and aOR 0.14, 95% CI 0.10 to 0.19, respectively) than Australian-born fathers. Finally, fathers from non-English-speaking and English-speaking countries were less likely to be overweight (aOR 0.62, 95% CI 0.51 to 0.75, and aOR 0.84, 95% CI 0.68 to 1.03, respectively) and obese (aOR 0.43, 95% CI 0.32 to 0.58, and aOR 0.77, 95% CI 0.61 to 0.98, respectively) than Australian-born fathers.

CONCLUSION

Fathers of refugee background experience poorer mental health and poorer general health than Australian-born fathers. Fathers who have migrated from non-English-speaking countries also report greater psychological distress than Australian-born fathers. This underscores the need for primary healthcare services to tailor efforts to reduce disparities in health outcomes for refugee populations that may be vulnerable due to circumstances and sequelae of forced migration and to recognise the additional psychological stresses that may accompany fatherhood following migration from non-English-speaking countries. It is important to note that refugee and migrant fathers report less alcohol use and are less likely to be overweight and obese than Australian-born fathers.

Prevalence and risk of mental disorders in the perinatal period among migrant women: a systematic review and meta-analysis

This study was conducted in order to evaluate the prevalence and risk of mental disorders in the perinatal period among migrant women. Six databases (including MEDLINE) were searched from inception to October 19th, 2015, in addition to citation tracking. Studies were eligible if mental disorders were assessed with validated tools during pregnancy and up to 1 year postpartum among women born outside of the study country. Of 3241 abstracts screened, 53 met the inclusion criteria for the review. Only three studies investigated a mental disorder other than depression. Unadjusted odds ratios were pooled using random effects meta-analysis for elevated depression symptoms during pregnancy (n = 12) and the postpartum (n = 24), stratified by study country due to heterogeneity. Studies from Canada found an increased risk for antenatal (OR = 1.86, 95% CIs 1.32-2.62) and postnatal elevated depression symptoms (OR = 1.98, 95% CIs 1.57-2.49) associated with migrant status. Studies from the USA found a decreased risk of antenatal elevated depression symptoms (OR = 0.71, 95% CIs 0.51-0.99), and studies from the USA and Australia found no association between migrant status and postnatal elevated depression symptoms. Low social support, minority ethnicity, low socioeconomic status, lack of proficiency in host country language and refugee or asylum-seeking status all put migrant populations at increased risk of perinatal mental disorders.

Migrant women's experiences, meanings and ways of dealing with postnatal depression: A meta-ethnographic study

Aim

To conduct a meta-ethnographic study of the experiences, meanings and ways of ‘dealing with’ symptoms or a diagnosis of postnatal depression amongst migrant women living in high income countries.

Background

Prevalence of postnatal depression is highest amongst women who are migrants. Yet many women do not seek help for their symptoms and health services do not always respond appropriately to migrant women’s needs. Studies have reported migrant women’s experiences of postnatal depression and it is timely to synthesise findings from these studies to understand how services can be improved.

Design

A meta-ethnographic synthesis of 12 studies reported in 15 papers

Data sources

Five databases were searched for papers published between January 1999 and February 2016

Review methods

The quality of included studies was assessed using the Critical Appraisal Skills Program tool. The synthesis process was guided by the seven steps of meta-ethnography outlined by Noblit and Hare.

Findings

Four key metaphors were identified: “I am alone, worried and angry—this is not me!”; ‘Making sense of my feelings’ ‘Dealing with my feelings’ and ‘What I need to change the way I feel!’. Primarily women related their feelings to their position as a migrant and as women, often living in poor socio-economic circumstances and they were exhausted keeping up with expected commitments. Many women were resourceful, drawing on their personal strengths and family / community resources. All the studies reported that women experienced difficulties in accessing appropriate services.

Conclusion

The meta-ethnographic study demonstrates the impact of migration on perinatal mental health, particularly for women lacking family support, who have no employment, a precarious migration status and/or relationship conflict. Migrant women are resourceful and this requires support through appropriate services. Further research is needed to evaluate effective support strategies for migrant women in the perinatal period.

Sri Lankan-born women who have given birth in Victoria: a survey of their primary postpartum health-care needs

Women who migrate are vulnerable after giving birth. Normal postpartum adaptive challenges are heightened by separation from family and lack of familiarity with local services. The aim was to investigate primary care needs among Sri Lankan-born women with at least one Victorian-born child aged under 2 years. Health care, information and support needs and unmet needs were assessed in a structured Sinhala or English survey offered in print, online or by telephone. Fifty women provided data. Most (80%) had at least one relative from Sri Lanka to stay for postpartum support. Despite this, many had difficulties settling (62%), feeding (58%) and soothing (42%) their babies. They used significantly fewer health services on average (2.3) than mothers in the general community (2.8) (P<0.004). Only 32% of primiparous women attended at least one First-Time Parents' group session. Of women experiencing infant care difficulties, only two-thirds accessed care from a Maternal and Child Health Nurse and only one-third from a General Practitioner. Sri Lankan-born mothers have significant unmet needs for primary care, which are not reduced by informal support. A two-pronged approach is indicated in which women are informed about primary care availability, and the cultural competence and client friendliness of services is strengthened.

Challenges Faced by Refugee New Parents from Africa in Canada

This study examines challenges faced by refugee new parents from Africa in Canada. Refugee new parents from Zimbabwe (n = 36) and Sudan (n = 36) were interviewed individually about challenges of coping concurrently with migration and new parenthood and completed loneliness and trauma/stress measures. Four group interviews with refugee new parents (n = 30) were subsequently conducted. Participants reported isolation, loneliness, and stress linked to migration and new parenthood. New gender roles evoked marital discord. Barriers to health-related services included language. Compounding challenges included discrimination, time restrictions for financial support, prolonged immigration and family reunification processes, uncoordinated government services, and culturally insensitive policies. The results reinforce the need for research on influences of refugees' stressful experiences on parenting and potential role of social support in mitigating effects of stress among refugee new parents. Language services should be integrated within health systems to facilitate provision of information, affirmation, and emotional support to refugee new parents. Our study reinforces the need for culturally appropriate services that mobilize and sustain support in health and health related (e.g., education, employment, immigration) policies.

Prevalence of postpartum depression among immigrant women: A systematic review and meta-analysis

The aims of this systematic review and meta-analysis were threefold: to estimate the prevalence of postpartum depressive symptoms in immigrant women, compare this prevalence to non-immigrant women, and determine risk factors for postpartum depressive symptoms in immigrant women. Literature searches were conducted in PubMed, Embase, PsycINFO, Web of Science, Scopus, ResearchGate and Google Scholar databases from 1950 until October 2014. Twenty-four studies met the inclusion criteria of which 22 (12 cross-sectional and 10 prospective cohort) contributed data for meta-analyses. Heterogeneity and publication bias were assessed. The prevalence of postpartum depressive symptoms in immigrant women was 20% (95% confidence interval [CI] 17-23%, 18 studies, N = 13,749 women). Immigrant women were twice more likely to experience depressive symptoms in the postpartum period than non-immigrant women (pooled unadjusted odds ratio [OR] = 2.10 [95% CI 1.62-2.73, 15 studies, N = 50,519 women] and adjusted OR = 2.18 [95% CI 1.60-2.96, 7 studies, N = 35,557 women]). There was, however, evidence of publication bias with the pooled adjusted OR reduced to 1.63 (95% CI 1.22-2.17) after adjustment for bias. Risk factors associated with postpartum depressive symptoms among immigrant women included shorter length of residence in the destination country, lower levels of social support, poorer marital adjustment, and perceived insufficient household income. This study suggests that postpartum depression is a common condition among immigrant women. Moreover, immigrant women are at higher risk of postpartum depression than non-immigrant women. Further prospective studies on the risk factors of postpartum depression among immigrant women verified by a clinical diagnosis are needed.

Birthing, Nativity, and Maternal Depression: Australia and the United States

This study analyzes two birth cohort surveys, the Longitudinal Study of Australian Children (n=3944) and Early Childhood Longitudinal Study (n=7700), to examine variation in maternal depression by nativity, duration of residence, age at migration, and English proficiency in Australia and the United States. Both countries have long immigrant traditions and a common language. The results demonstrate that US immigrant mothers are significantly less depressed than native-born mothers, but maternal depression does not differ by nativity in Australia. Moreover, the association between duration of residence and maternal depression is not linear: recent arrivals and long-term residents exhibit the highest depression levels. Lack of English proficiency exacerbates maternal depression in Australia, but protects against depression in the United States. Differences in immigration regimes and welfare systems likely contribute to the differing salience of nativity for maternal depression.

Closing the gap in maternal and child health: a qualitative study examining health needs of migrant mothers in Dandenong, Victoria, Australia

We conducted a qualitative study that explored the views and perceptions of migrant women in, Dandenong, Victoria, Australia about sociocultural barriers and health needs during pregnancy and in the postnatal period. The study was informed by the Social Identity Theory and the Acculturation Theory. It involved five focus group discussions with 35 migrant mothers from Afghanistan, Africa, China, Palestine, Lebanon, Syria, Iran and Jordan. Five themes emerged from the analysis: (1) the need for family support and complex social environments; (2) dealing with two cultural identities; (3) the health of mother and offspring; (4) access to the health system; and (5) life-skills for better health. Pregnancy and motherhood are challenges that are made more difficult by migration. The findings point towards the need for policies and interventions: (1) to reduce the negative impact of social isolation and lack of support during pregnancy and postnatally; (2) to support greater fathers' involvement in childcare; and (3) to reconcile different practices and expectations between traditional cultures and Australian norms. They also suggest a need to test culturally competent interventions that address health and lifestyle needs in migrant women and education programs for mothers that effectively address their concerns about maternal and child health.

Prevalence, nature and determinants of postpartum mental health problems among women who have migrated from South Asian to high-income countries: a systematic review of the evidence

BACKGROUND

Women of reproductive age constitute a significant proportion of immigrants from South Asia to high-income countries. Pregnancy, childbirth and the postpartum period place increased demands on women׳s psychological resources and relationships. The aim of this review was to evaluate the available evidence about the prevalence, nature and determinants of postpartum mental health problems among South Asian women who have migrated to high-income countries.

METHODS

Using a systematic strategy, CINAHL, Medline, PsychInfo and Web of Science databases were searched.

RESULTS

Fifteen studies conducted in different high-income countries met inclusion criteria. Prevalence estimates of clinically significant symptoms of postpartum depression (CSS-PPD) varied widely (1.9-52%): the most common estimates ranged from 5 to 20%. Five studies found approximately a two-fold increase in risk of CSS-PPD (Odds Ratios 1.8-2.5) among overseas born women with a South Asian subgroup. The most common determinants appeared to be social factors, including social isolation and quality of relationship with the partner. Barriers to accessing health care included lack of English language proficiency, unfamiliarity with local services and lack of attention to mental health and cultural factors by health care providers.

LIMITATIONS

The settings, recruitment strategies, inclusion and exclusion criteria, representative adequacy of the samples and assessment measures used in these studies varied widely. Many of these studies did not use formally validated tools or undertake specific subgroup analyses.

CONCLUSIONS

Reductions in postpartum depression could be achieved by increasing awareness of available services and ensuring health care professionals support the mental health of women from diverse cultural and linguistic backgrounds.

Born in another country: women's experience of labour and birth in Queensland, Australia

BACKGROUND

Women born outside Australia make up more than a fifth of the Queensland birthing population and like migrants in other parts of the world face the challenges of cultural dislocation and possible language barriers. Recognising that labour and birth are major life events the aim was to investigate the experiences of these women in comparison to native-born English speaking women.

METHODS

Secondary analysis of data from a population based survey of women who had recently birthed in Queensland. Self-reported clinical outcomes and quality of interpersonal care of 481 women born outside Australia who spoke a language other than English at home were compared with those of 5569 Australian born women speaking only English.

RESULTS

After adjustment for demographic factors and type of birthing facility, women born in another country were less likely to be induced, but more likely to have constant electronic fetal monitoring (EFM), to give birth lying on their back or side, and to have an episiotomy. Most women felt that they were treated as an individual and with kindness and respect. However, women born outside Australia were less likely to report being looked after 'very well' during labour and birth and to be more critical of some aspects of care.

CONCLUSION

In comparing the labour and birth experiences of women born outside the country who spoke another language with native-born English speaking women, the present study presents a largely positive picture. However, there were some marked differences in both clinical and interpersonal aspects of care.

Improving population-level maternal health: a hard nut to crack? Long term findings and reflections on a 16-community randomised trial in Australia to improve maternal emotional and physical health after birth [ISRCTN03464021]

BACKGROUND

Community level interventions to improve maternal and child health have been supported and well evaluated in resource poor settings, but less so in developed countries. PRISM--Program of Resources, Information and Support for Mothers--was a primary care and community-based cluster-randomised trial in sixteen municipalities in Victoria, Australia, which aimed to reduce depression in mothers and improve their physical health. The aim of this paper is to report the longer term outcomes of PRISM and to reflect on lessons learned from this universal community intervention to improve maternal health.

METHODS

Maternal health outcome data in PRISM were collected by postal questionnaire at six months and two years. At two years, the main outcome measures included the Edinburgh Postnatal Depression Scale (EPDS) and the SF-36. Secondary outcome measures included the Experience of Motherhood Scale (EOM) and the Parenting Stress Index (PSI). A primary intention to treat analysis was conducted, adjusting for the randomisation by cluster.

RESULTS

7,169/18,424 (39%) women responded to the postal questionnaire at two years -3,894 (40%) in the intervention arm and 3,275 (38%) in the comparison arm. Respondents were mostly representative on available population data comparisons. There were no differences in depression prevalence (EPDS≥13) between the intervention and comparison arms (13.4% vs 13.1%; ORadj = 1.06, 95%CI 0.91-1.24). Nor did women's mental health (MCS: 48.6 vs 49.1) or physical health scores (PCS: 49.1 vs 49.0) on the SF-36 differ between the trial arms.

CONCLUSION

Improvement in maternal mental and physical health outcomes at the population level in the early years after childbirth remains a largely unmet challenge. Despite the lack of effectiveness of PRISM intervention strategies, important lessons about systems change, sustained investment and contextual understanding of the workability of intervention strategies can be drawn from the experience of PRISM. Trial Registration. Controlled-Trials.com ISRCTN03464021.

Interactions between perceptions of relationship quality and postnatal depressive symptoms in Australian, primiparous women and their partners

The present study aimed to investigate interactions between perceptions of quality of intimate partner relationship and postnatal depressive symptoms in members of heterosexual couples 6 months after the birth of their first infant, while controlling for other relevant risk and protective factors. Secondary analysis was conducted on data from a prospective community cohort study of Australian, primiparous women and their partners. The outcome measure was Edinburgh Postnatal Depression Scale score. Quality of intimate partner relationship, personality factors and infant behaviour were assessed using the standardised Intimate Bonds Measure, Vulnerable Personality Style Questionnaire and Barr Chart respectively. Complete data were available for 161 couples. Associations between Edinburgh Postnatal Depression Scale scores and own and partner ratings of the intimate partner relationship were estimated simultaneously using multilevel modelling. When other relevant factors were controlled, relationships in which partners were perceived as critical, coercive or intimidating were associated with significantly more depressive symptoms in individuals (P = 0.004) as well as their partners (P = 0.008). In both women and men, vulnerable personality traits, coincidental adverse life events and more infant crying and fussing were also associated with significantly more depressive symptoms. Thus, the quality of the intimate partner relationship is significantly associated with postnatal mental health in both women and men, especially in the context of coincidental stressful events including infant crying.

Prevalence and determinants of complementary and alternative medicine use during pregnancy: results from a nationally representative sample of Australian pregnant women

BACKGROUND

Pregnant women have been identified as high users of complementary and alternative medicine (CAM). However, no research to date has provided a detailed analysis of the prevalence and determinants of CAM consumption amongst pregnant women.

AIM

To examine the prevalence and determinants of CAM use by pregnant women, utilising a national representative sample.

METHODS

The study sample was obtained via the Australian Longitudinal Study on Women's Health. This paper is based on a sub-study of 1,835 pregnant women, administered in 2010. The women answered questions about CAM use, demographics, pregnancy-related health concerns and health service utilisation.

RESULTS

Complementary and alternative medicine use was found to be high with 48.1% (n = 623) of pregnant women consulting a CAM practitioner and 52.0% (n = 842) of women using CAM products (excluding vitamins and minerals) during pregnancy. CAM practitioner visits were more likely for selected pregnancy-related health concerns, namely back pain or back ache, neck pain and labour preparation. Women were less likely to consult a CAM practitioner if they suffered with headaches/migraines. Employment was also found to be predictive of pregnant women's visits to a CAM practitioner. Significant health history and demographic predictors of CAM product use were tiredness and fatigue, embarking on preparation for labour and having a university education.

CONCLUSION

Most pregnant women are utilising CAM products and/or services as part of their maternity care and obstetricians, general practitioners and midwives need to enquire with women in their care about possible CAM use to help promote safe, effective coordinated maternity care.

Accessing maternal and child health services in Melbourne, Australia: reflections from refugee families and service providers

BACKGROUND

Often new arrivals from refugee backgrounds have experienced poor health and limited access to healthcare services. The maternal and child health (MCH) service in Victoria, Australia, is a joint local and state government operated, cost-free service available to all mothers of children aged 0-6 years. Although well-child healthcare visits are useful in identifying health issues early, there has been limited investigation in the use of these services for families from refugee backgrounds. This study aims to explore experiences of using MCH services, from the perspective of families from refugee backgrounds and service providers.

METHODS

We used a qualitative study design informed by the socioecological model of health and a cultural competence approach. Two geographical areas of Melbourne were selected to invite participants. Seven focus groups were conducted with 87 mothers from Karen, Iraqi, Assyrian Chaldean, Lebanese, South Sudanese and Bhutanese backgrounds, who had lived an average of 4.7 years in Australia (range one month-18 years). Participants had a total of 249 children, of these 150 were born in Australia. Four focus groups and five interviews were conducted with MCH nurses, other healthcare providers and bicultural workers.

RESULTS

Four themes were identified: facilitating access to MCH services; promoting continued engagement with the MCH service; language challenges; and what is working well and could be done better. Several processes were identified that facilitated initial access to the MCH service but there were implications for continued use of the service. The MCH service was not formally notified of new parents arriving with young children. Pre-arranged group appointments by MCH nurses for parents who attended playgroups worked well to increase ongoing service engagement. Barriers for parents in using MCH services included access to transportation, lack of confidence in speaking English and making phone bookings. Service users and providers reported that continuity of nurse and interpreter is preferred for increasing client-provider trust and ongoing engagement.

CONCLUSIONS

Although participants who had children born in Melbourne had good initial access to, and experience of, using MCH services, significant barriers remain. A systems-oriented, culturally competent approach to service provision would improve the service utilisation experience for parents and providers, including formalising links and notifications between settlement services and MCH services.

The influence of poverty and social support on the perceived health of children born to minority migrant mothers

OBJECTIVE

Poverty and low social support are common among minority migrant families. Little is known about their impact on the health of children of minority migrants to Canada. This study examined the associations between maternal perception of child's health and migration status, and examined the specific role of poverty and low social support in these associations.

DESIGN

Data from the first two rounds of the Quebec Longitudinal Study of Child Development (QLSCD) were analysed. The sample included 1990 children at 17 months of age, classified according to their mother's migration status: children of minority migrant mothers (n=165) and Canadian-born mothers (n=1825). Maternal perception of child's health status and social support were measured at 17 months, household income was measured at 5 and 17 months. Multivariable logistic regressions were performed; interactions of migration status with poverty and social support were tested.

RESULTS

Poverty and low social support were more common among minority migrant mothers than among Canadian-born mothers. Children of minority migrant mothers who were 'never poor' and reported high levels of social support were perceived in better health (OR 0.42; 95% confidence interval (CI): 0.19-0.91) than children of Canadian-born mothers (reference group). In contrast, children of minority migrant mothers who were 'always poor' and reported low social support were perceived in worse health (OR 6.32; 95% CI: 1.69-23.71) compared to the reference group.

CONCLUSION

In Quebec, economic hardship and lack of social support are common realities among minority migrants with young children. Combined exposure to poverty and low social support is most detrimental to the perceived health of children of minority migrants.