Obstetric and psychosocial risk factors for Australian-born and non-Australian born women and associated pregnancy and birth outcomes: a population based cohort study

Multidimensionality within the Edinburgh postnatal depression scale: application issues of specific structure

OBJECTIVE AND BACKGROUND

The 10-item Edinburgh Postnatal Depression Scale (EPDS) is a widely-used screening measure for postnatal depression. Factor analysis studies have suggested an embedded sub-scale could be used for screening for anxiety disorders. The current investigation sought to replicate and extend a recent study supporting this assertion.

METHODS

A cross-sectional design. EPDS data were collected at up to two years postpartum. Confirmatory factor analysis, correlational and distributional characteristics of the measure were examined. Participants were a large sample (N = 985) of postpartum women in the Czech Republic.

RESULTS

Factor structure findings substantially replicated the models evaluated by Della Vedova et al. (2022). Bifactor models, however, offered a better fit to data. A general factor of depression explained most of the variance in data in most models compared to embedded sub-scales across models.

CONCLUSION

The model proposed by Della Vedova et al. (2022) offered an excellent fit to data. However, the findings from the bifactor modelling suggest the dominance of a general factor of depression which indicates the potential application of an embedded anxiety sub-scale for screening may be overstated.

Perinatal outcomes among Indian-born mothers in Australia

OBJECTIVE

To examine the incidence of adverse perinatal outcomes and the risk of adverse perinatal outcomes for Indian-born mothers compared to other mothers living and giving birth in Australia.

DESIGN, SETTING AND PARTICIPANTS

This retrospective cohort study was designed to investigate all births in Australia in 2012 and those in the Monash Health Birthing Outcomes System (BOS) 2014 to Indian-born mothers in Australia. Data sets were analysed involving descriptive statistics using Statistical Package for Social Sciences (SPSS vs. 23).

RESULTS

Indian-born mothers in Australia are at increased risk of induced labour, emergency caesarean section, very preterm birth (20-27 weeks), babies with low to very low birth weight, and low Apgar score (0-2) at 5 min, gestational diabetes, hypothyroidism, iron deficiency anaemia and vitamin B12 deficiencies compared to other mothers giving birth in Australia. This is despite a range of protective factors (25-34 years, married, nonsmokers, and a BMI < 30) that would normally be expected to reduce the risk of adverse perinatal outcomes for mothers giving birth in a developed country.

CONCLUSION

In the absence of many of the recognized maternal risk factors, Indian-born mothers continue to face increased risk of adverse perinatal outcomes, despite access to high quality maternity care in Australia. Recommendations arising from this study include the need for an intervention study to identify maternal risk factors for Indian-born mothers in mid to late pregnancy that contribute to the risk for very preterm birth and low birth weight.

Antenatal depression screening and psychosocial assessment in an Australian private hospital: An evaluation

BACKGROUND

Universal mental health screening and psychosocial assessment during pregnancy have been recommended as best practice, but uptake of universal programs in the private hospital system has been slow.

AIM

The aim of this study was to evaluate the Pre-admission Midwife Appointment Program (PMAP), an antenatal mental health screening program at the Mater Hospital, Sydney.

MATERIALS AND METHODS

In this mixed-methods design study, PMAP interview data were collected for a consecutive series of 485 women who attended the PMAP during a 10-month period. Women also completed two postnatal telephone interviews (10 weeks and 9 months postpartum). The interviews involved depression screening and questions about the program.

RESULTS

Of the 485 participants, 4.1% screened positive for depression on the Edinburgh Postnatal Depression Scale. In total, 19% were identified as currently suffering from, or at risk of developing, perinatal mental health issues; referrals to support services were provided for the 13% who were not already linked in with appropriate supports. All women displayed a decrease in depressive symptom severity from pregnancy to 10 weeks and 9 months postpartum. The PMAP was viewed positively by consumers, with >93% viewing the program as helpful and >98% saying that they would recommend the program to others. Additional program benefits identified included opportunities to gain practical information and prepare for motherhood and to think/reflect on their emotional well-being.

CONCLUSIONS

Given the observed rates of psychosocial risk among this sample, related referral opportunities and positive consumer feedback, we recommend other Australian private hospitals consider implementing PMAP or similar programs.

The Bidirectional Relationship between Gestational Diabetes and Depression in Pregnant Women: A Systematic Search and Review

This systematic search and review aims to understand the two-way relationship between gestational diabetes and depression. This study assesses gestational diabetes in relation to a history of depression, depression during pregnancy and postpartum depression. Searches were conducted on PubMed and Scopus. Studies were excluded due to being duplicates, not available, published before 2015 or did not include both gestational diabetes and depression. Of the 915 articles initially identified, 22 articles were included for review. Of the included studies, 18 were cohorts, 2 were case-controls, 1 was cross-sectional and 1 was a claims analysis. A meta-ethnography was conducted, and a bidirectional relationship was observed between a history of depression, depression during pregnancy, postpartum depression and gestational diabetes. Differing methodologies between studies were a limiting factor throughout this review. A two-way relationship between gestational diabetes and depression was observed; the diagnosis of gestational diabetes may lead to an increased risk of depression, both during the pregnancy and in the postpartum period, and a history of depression or symptoms of depression during pregnancy may lead to an increased risk of gestational diabetes.

The antenatal risk questionnaire-revised: Development, use and test-retest reliability in a community sample of pregnant women in Australia

BACKGROUND

Routine psychosocial assessment during pregnancy and the first postnatal year is a public health strategy that prioritises early identification of known risk factors for poor perinatal mental health. We aimed to report on the development and use of the Antenatal Risk Questionnaire-Revised (ANRQ-R), contribute normative data for a community sample of pregnant women and examine its test-retest reliability.

METHODS

The ANRQ-R was developed in consultation with an expert advisory group. Women completed the ANRQ-R with their midwife at their first antenatal appointment. Test-retest analysis was restricted to women who consented to follow-up and completed a repeat ANRQ-R within four weeks.

RESULTS

7183 women completed the ANRQ-R (total score M = 12.05, Mdn=10; range =5-49). There were some statistically significant differences in total score across maternal age group (χ²=69.75, p<.001), country of birth (χ²=144.01, p<.001) and socioeconomic quintiles (χ²=20.13, p<.001), however the effect sizes of all differences were either small or not clinically significant. Test-retest reliability for the ANRQ-R total score was good (N = 1670; ICC=0.77). Item-level test-retest reliabilities were moderate to good (ICC range=0.65-0.80; kappa coefficient range=0.31-0.74).

LIMITATIONS

The study was conducted at a single site. Although there was significant diversity in terms of maternal age and country of birth, the majority of participants were partnered and resided in socio-economically advantaged areas, limiting the generalisability of results.

CONCLUSIONS

This study contributes significant normative data for the ANRQ-R and offers valuable insights for clinicians and researchers working with particular sub-groups of the perinatal population. Additional psychometric examination of the ANRQ-R, including its concurrent and predictive validity, is required.

Antenatal psychosocial assessment and depression screening in an Australian Private Hospital setting: A qualitative examination of women's perspectives

BACKGROUND

In Australia, clinical practice guidelines have been developed to support the implementation of antenatal psychosocial assessment and depression screening in routine clinical obstetric care. While there has been widespread uptake of such programs in Australian public hospitals, implementation in private hospitals has been slower. However, the situation in this regard may be changing, with the emergence of examples of midwife delivered screening programs in a number of private hospital settings. At present, patient experiences of these programs are largely unknown.

AIM

The aim of this study was to gain feedback from women who participated in the 'Pre-admission midwife appointment' program at an Australian private hospital about their experiences of, and perspectives about, the program.

METHODS

Semi-structured interviews were conducted with 20 women (Mage 36.04 years, range 30-48) who had given birth to a child between 9 and 14 months prior to the interview (M = 11.87 months, SD = 1.76) and who had attended the Pre-admission midwife appointment program during the pregnancy. Interviews were transcribed and analysed using an inductive thematic analysis approach with an essentialist-realistic theoretical framework.

FINDINGS

Data analysis revealed five major themes: 'increased awareness and support for perinatal mental health issues', 'enhanced quality of care provided at the hospital', 'experience with the midwife impacts perceptions of the program'; 'partners', and 'preparation for the program'.

DISCUSSION

This study provides useful information from the perspective of consumers, about a psychosocial assessment and depression screening program at an Australian private hospital. It highlights a number of program benefits for pregnant women, their partners, and the hospital, as well as factors facilitating program success.

A systematic review and meta-analysis of gestational diabetes mellitus and mental health among BAME populations

BACKGROUND

Gestational diabetes mellitus (GDM) is a common complication of pregnancy and is associated with an increased risk of mental health (MH) disorders including antenatal and postnatal depression (PND), anxiety and post-traumatic-stress-disorder (PTSD). We hypothesized GDM and MH disorders will disproportionately affect individuals from Black, Asian and Minority Ethnic backgrounds.

METHODS

A systematic methodology was developed, and a protocol was published in PROSPERO (CRD42020210863) and a systematic review of publications between 1st January 1990 and 30th January 2021 was conducted. Multiple electronic databases were explored using keywords and MeSH terms. The finalised dataset was analysed using statistical methods such as random-effect models, subgroup analysis and sensitivity analysis. These were used to determine odds ratio (OR) and 95% confidence intervals (CI) to establish prevalence using variables of PND, anxiety, PTSD and stress to name a few.

FINDINGS

Sixty studies were finalised from the 20,040 data pool. Forty-six studies were included systematically with 14 used to meta-analyze GDM and MH outcomes. A second meta-analysis was conducted using 7 studies to determine GDM risk among Black, Asian and Minority Ethnic women with pre-existing MH disorders. The results indicate an increased risk with pooled adjusted OR for both reflected at 1.23, 95% CI of 1.00-1.50 and 1.29, 95% CI of 1.11-1.50 respectively.

INTERPRETATION

The available studies suggest a MH sequalae with GDM as well as a sequalae of GDM with MH among Black, Asian and Minority Ethnic populations. Our findings warrant further future exploration to better manage these patients.

FUNDING

Not applicable.

Health professional perspectives on an antenatal mental health screening program in a private hospital

BACKGROUND

Perinatal mental ill-health is a global health priority. Mental health screening during pregnancy is a routine part of clinical practice in many public hospital obstetric services across Australia, but implementation in the private hospital system has lagged.

AIMS

This study explored health professionals' perspectives on the Pre-admission Midwife Appointment Program (PMAP), an antenatal mental health screening program at the Mater Hospital, Sydney.

MATERIALS AND METHODS

Nine midwives and three medical specialists participated in focus groups or individual interviews; key themes were determined using thematic qualitative analysis.

RESULTS

Five major themes and three sub-themes were identified: immediate benefits to women (identifying women at risk; referrals to support services; supporting and educating women); enhanced overall quality of care at the hospital; the dilemma of partners attending; factors that make the program successful; and recommendations for improvement.

CONCLUSIONS

Results will inform the implementation of antenatal mental health screening programs at other private hospitals across Australia.

Intimate Partner Violence: A Risk Factor for Gestational Diabetes

The early detection and management of gestational diabetes mellitus (GDM) is an important public health goal. GDM, which is defined as a glucose intolerance that develops during pregnancy, affects about 14% of pregnancies globally, and without effective treatment, it is associated with adverse short- and long-term maternal and neonatal outcomes. Risk-factor screening is an acceptable and affordable strategy to enable risk stratification and intervention. However, common biological risk factors such as overweight or obesity, excessive gestational weight gain, and family history of diabetes often have poor predictive ability, failing to identify a large proportion of women at risk of developing GDM. Accumulating evidence implicate psychosocial factors in contributing to GDM risk. As such, intimate partner violence (IPV), through its contributing effects on maternal stress and depression, presents a plausible risk factor for GDM. Experiencing IPV during pregnancy may dysregulate the hypothalamus-pituitary-adrenal (HPA) axis, leading to increased cortisol secretion and insulin resistance. These effects may exacerbate the insulin-resistant environment characteristic of pregnancy, thus increasing GDM risk. This review explores the relationship between IPV and GDM. We highlight studies that have linked IPV with GDM and propose a biological mechanism that connects IPV and GDM. Recommendations for IPV screening strategies to prevent GDM are discussed.

Association Between Gestational Diabetes and Mental Illness

The rates of both gestational diabetes mellitus (GDM) and mental illness in pregnancy are rising. There is an association between type 2 diabetes and major depressive disorder, anxiety and schizophrenia, thus there is a need for greater understanding of the relationship between GDM and mental illness. This review suggests that there is a bidirectional and complex relationship between antenatal depression, gestational diabetes and postpartum depression. The combined effect of both a history of depression and gestational diabetes significantly increases the risk of postpartum depression. There is an association between severe mental illness and GDM; however, it is strongly mediated by antipsychotic medications and psychosocial factors, in addition to the disease itself. Medication has a major role in treating mental illness during pregnancy and is not directly linked with GDM in either depression or psychosis. Health-care providers should be mindful of the association between GDM and mental illness to appropriately screen and treat both disorders.

Perinatal psychosocial assessment of women of refugee background

BACKGROUND

Women of refugee background may be particularly vulnerable to perinatal mental illness, possibly due to increased exposure to psychosocial stressors associated with their forced migration and post-resettlement adjustment.

AIM

This study aimed to compare psychosocial risk factors reported by women of refugee background receiving maternity services at a public hospital, to those reported by Australian-born women in the same hospital. It further aimed to examine the referrals offered, and accepted, by the women of refugee background reporting psychosocial risk factors for perinatal mental illness.

METHODS

A retrospective hospital record review was conducted to compare the antenatal and postnatal psychosocial risk factors of 100 women of refugee background and 100 Australian-born women who gave birth at a public hospital in Victoria between 1 July 2015 and 30 April 2016, and who had completed the Maternity Psychosocial Needs Assessment.

FINDINGS

Women of refugee background were more likely than Australian-born women to report financial concerns and low social support at antenatal assessment, but were less likely to report prior mental health problems than Australian-born women at either assessment point. Both groups reported low rates of family violence compared to published prevalence rates. Of the women of refugee background assessed antenatally, 23% were offered referrals, with 52% take-up. Postnatally, 11.2% were offered referrals, with 93% take-up.

DISCUSSION/CONCLUSION

This study showed elevated rates of psychosocial risk factors among women of refugee background, however, possible under-reporting of mental health problems and family violence raises questions regarding how to assess psychosocial risk factors with different cultural groups. Lower antenatal referral take-up suggests barriers to acceptance of referrals may exist during pregnancy.

Maternal health and birth outcomes in a South African birth cohort study

Background

Maternal physical and mental health during pregnancy are key determinants of birth outcomes. There are relatively few prospective data that integrate physical and mental maternal health measures with birth outcomes in low- and middle-income country settings. We aimed to investigate maternal health during pregnancy and the impact on birth outcomes in an African birth cohort study, the Drakenstein Child Health Study.

Methods

Pregnant women attending 2 public health clinics, Mbekweni (serving a predominantly black African population) and TC Newman (predominantly mixed ancestry) in a poor peri-urban area of South Africa were enrolled in their second trimester and followed through childbirth. All births occurred at a single public hospital. Maternal sociodemographic, physical and psychosocial characteristics were comprehensively assessed. Multivariable linear regression models were used to explore associations between maternal health and birth outcomes.

Results

Over 3 years, 1137 women (median age 25.8 years; 21% HIV-infected) gave birth to 1143 live babies. Most pregnancies were uncomplicated but gestational diabetes (1%), anaemia (22%) or pre-eclampsia (2%) occurred in a minority. Most households (87%) had a monthly income of less than USD 350; only 27% of moms were employed and food insecurity was common (37%). Most babies (80%) were born by vaginal delivery at full term; 17% were preterm, predominantly late preterm. Only 74 (7%) of babies required hospitalisation immediately after birth and only 2 babies were HIV-infected. Food insecurity, socioeconomic status, pregnancy-associated hypertension, pre-eclampsia, gestational diabetes and mixed ancestry were associated with lower infant gestational age while maternal BMI at enrolment was associated with higher infant gestational age. Primigravida or alcohol use during pregnancy were negatively associated with infant birth weight and head circumference. Maternal BMI at enrolment was positively associated with birth weight and gestational diabetes was positively associated with birth weight and head circumference for gestational age. Smoking during pregnancy was associated with lower infant birth weight.

Conclusion

Several modifiable risk factors including food insecurity, smoking, and alcohol consumption during pregnancy were identified as associated with negative birth outcomes, all of which are amenable to public health interventions. Interventions to address key exposures influencing birth outcomes are needed to improve maternal and child health in low-middle income country settings.

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.

Depression and risk of gestational diabetes: A meta-analysis of cohort studies

AIMS

To systematically assess the association between depression and risk of gestational diabetes by a meta-analysis of cohort studies.

METHODS

We searched multiple electronic databases for cohort studies investigating depression and risk of gestational diabetes before December 31th, 2018. Pooled odds ratios (ORs) and confidence intervals (CIs) of the included articles were calculated using a fixed- or random-effect model. Publication bias was detected using the Egger's and Begg's tests.

RESULTS

We obtained 5 cohort studies with a total number of 122,197 women. Women with a history of depression compared with those without it had a significantly increased risk of gestational diabetes (pooled OR = 1.20, 95% CI: 1.09, 1.33) but borderline significant evidence of heterogeneity was observed (I² = 45.1%, P for heterogeneity = 0.12). Subgroup analysis by study design showed a stronger association in prospective cohort studies than that in retrospective cohort studies (pooled OR: 1.61 [1.17, 2.21] vs. 1.16 [1.05, 1.29]), though the difference was not statistically significant (P for interaction = 0.26). We observed some evidence of publication bias; however, correction for such bias using "trim-and-fill" analysis yielded similar results.

CONCLUSION

Women with a history of depression may be at an increased risk of gestational diabetes. Future prospective studies of high quality are needed to confirm our findings.

The burden of personality disorders on the DSM 5 addiction to tobacco during pregnancy

BACKGROUND

Tobacco smoking is a major health concern. Many women smoke during their reproductive years, some of them during their pregnancy. Adverse outcomes for the newborns physical health are well recognized, while the influence on their mental health is still under investigation. We aim at demonstrating the contribution of maternal personality disorders in maintaining addiction to tobacco during pregnancy, to underline their role and the need of their detection as a preventive effort.

METHOD

150 women, consecutively admitted to the Perinatal Psychiatric Outpatient Department were tested with the SCID II, CTQ, WHOQOL-BREF, EPDS, BDI and BAI. Tobacco use disorder was attested with the fulfillment of DSM 5 criteria.

RESULTS

46% (n = 69) of the sample was affected by at least one personality disorder ("PD⁺"). "PD⁺" showed a significant higher rate of pregnant women addicted to tobacco (p = 0.021). The average number of cigarettes per day was notably distinct, since patients affected by "NPD" smokes twice the amount compared to "PD^-" and "other PDs", while those affected by Borderline PD has a halfway consumption (7.20 ± 5.54 vs 3.37 ± 4.62 vs 3 ± 3.39 vs 5.50 ± 4.10). ANOVA and POST HOC showed a significance between "NPD" and "other PDs" (p = 0.035), and "other PDs" has significantly the highest rate of active smokers.

CONCLUSION

Personality disorders demonstrate to be a clear contributor in supporting addiction to tobacco during pregnancy. Short and long term health and mental consequences attested in the newborn, encourage awareness in detecting tobacco dependency during this sensitive period. The inclusion of personality evaluation and management in tobacco dependency treatment programs is strictly encouraged to boost their efficiency and increase tobacco abstinence.

Establishing a coherent and replicable measurement model of the Edinburgh Postnatal Depression Scale

The 10-item Edinburgh Postnatal Depression Scale (EPDS) is an established screening tool for postnatal depression. Inconsistent findings in factor structure and replication difficulties have limited the scope of development of the measure as a multi-dimensional tool. The current investigation sought to robustly determine the underlying factor structure of the EPDS and the replicability and stability of the most plausible model identified. A between-subjects design was used. EPDS data were collected postpartum from two independent cohorts using identical data capture methods. Datasets were examined with confirmatory factor analysis, model invariance testing and systematic evaluation of relational and internal aspects of the measure. Participants were two samples of postpartum women in England assessed at three months (n = 245) and six months (n = 217). The findings showed a three-factor seven-item model of the EPDS offered an excellent fit to the data, and was observed to be replicable in both datasets and invariant as a function of time point of assessment. Some EPDS sub-scale scores were significantly higher at six months. The EPDS is multi-dimensional and a robust measurement model comprises three factors that are replicable. The potential utility of the sub-scale components identified requires further research to identify a role in contemporary screening practice.

The relationship between intimate partner violence reported at the first antenatal booking visit and obstetric and perinatal outcomes in an ethnically diverse group of Australian pregnant women: a population-based study over 10 years

OBJECTIVES

Intimate partner violence (IPV) is a global health issue affecting mainly women and is known to escalate during pregnancy and impact negatively on obstetric and perinatal outcomes. The aim of this study is to determine the incidence of IPV in a pregnant multicultural population and to determine the relationship between IPV reported at booking interview and maternal and perinatal outcomes.

DESIGN

This is a retrospective population-based data study. We analysed routinely collected data (2006-2016) from the ObstetriX system on a cohort of pregnant women.

SETTING AND PARTICIPANTS

33 542 women giving birth in a major health facility in Western Sydney.

PRIMARY OUTCOMES

Incidence of IPV, association with IPV and other psychosocial variables and maternal and perinatal outcomes.

RESULT

4.3% of pregnant women reported a history of IPV when asked during the routine psychosocial assessment. Fifty-four per cent were not born in Australia, and this had increased significantly over the decade. Women born in New Zealand (7.2%) and Sudan (9.1%) were most likely to report IPV at the antenatal booking visit, with women from China and India least likely to report IPV. Women who reported IPV were more likely to report additional psychosocial concerns including Edinburgh Postnatal Depression Scale scores > 13 (7.6%), thoughts of self-harm (2.4%), childhood abuse (23.6%), and a history of anxiety and depression (34.2%). Women who reported IPV were more likely to be Australian born, smoke and be multiparous and to have been admitted for threatened preterm labour (Adjusted Odds Ratio (AOR) 1.8, 95% CI 1.28 to 2.39).

CONCLUSIONS

A report of IPV at the first antenatal booking visit is associated with a higher level of reporting on all psychosocial risks, higher antenatal admissions, especially for threatened preterm labour. More research is needed regarding the effectiveness of current IPV screening for women from other countries.

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.