Paying attention to the postpartum period is important for women to fully recover after childbirth. Women who do not receive proper postpartum care have a high risk of developing postpartum depression (PPD). As well as having negative effects for the mother, untreated PPD can contribute to delays in the development of newborn infants. The effects of PPD are not merely physical. Social positions and experience of culture also have an effect on the way PPD is experienced. O’Mahony, Donnelly, Bouchal and Este (2013) have identified that new immigrant and refugee mothers are at an increased risk of PPD due to several factors. First, there may be a lack of knowledge about the condition. Many immigrant and refugee women are not aware of postpartum depression as a specific health issue, and often describe it as a harmless feeling of sadness and as a natural consequence of childbirth. As a result, they are unlikely to seek the support of healthcare services (O’Mahony et al., 2013). Second, the mental health of immigrant and refugee mothers may be negatively affected by life experiences related to migration; they may have encountered stressful events prior to immigrating, or they may be experiencing cultural and language barriers, marginalization, lower socioeconomic statuses, and poor social supports (O’Mahony et al., 2013). Social exclusion and income level have been identified as social determinants of health according to the Toronto Charter for a Healthy Canada (2002). The purpose of this term paper is to determine how the broad social, cultural, and economic factors that affect immigrant and refugee women shape their risk for PPD. In so doing, a more holistic approach to better the health trajectories for both patients suffering from PPD and their children can be approached.
Schiller, Meltzer-Brody, and Rubinow (2015) stated that Diagnostic and Statistical Manual of Mental Disorders (DSM-5) sets the definition of PPD include major depressive with a perinatal onset as those beginning in either pregnancy or within the first 4 weeks postpartum (p. 49). The symptoms of PPD include lability, irritability, tearfulness, low self-esteem, generalized anxiety, insomnia and appetite changes (Registered Nurses’ Association of Ontario, 2005; Schiller et al., 2015). The pathophysiology of postpartum depression may be related to the body’s inability to properly regulate reproductive hormones such as estrogen, and progesterone, and a failure to properly facilitate an alteration in thyroid function (Schiller et al., 2015; Tobin, Napoli & Beck, 2018). In addition to hormonal changes, there is evidence that PPD can be triggered by stress and sleep deprivation, after the birth of a child, and related to other mental illnesses, such as obsessive-compulsive disorder, posttraumatic stress disorder, or generalized anxiety disorder (Schiller et al., 2015).
Addressing Risk Factors
As PPD relates to social risks, a patient’s income, housing, and education are factors that can exacerbate suffering (O’Mahony et al., 2013). A factor that applies more specifically to immigrant and refugee patients is cultural; cultural upbringing influences both the perceptions of PPD and health-seeking behaviour. As stated previously, the awareness of PPD as a specific problem may differ from culture to culture. As well, cultural beliefs about mental health and stigma may affect willingness to label PPD and seek treatment and support for the condition (O’Mahony et al., 2013).
There are several proposed methods to provide care for refugee and immigrant women suffering from PPD. It is recommended that nurses provide culturally appropriate health care services, which take into consideration the differences in beliefs about PPD as a condition and as a possibly stigmatized condition, so as to consider the wishes of PPD patients. Knowledge about beliefs concerning PPD can make it easier to provide proper mental health treatment, addressing issues such as education on the condition and providing tools of self-assessment and encouraging patients to seek referrals for treatment of PPD (Tobin, Napoli & Beck, 2018) Comment by freakydeath33: how to provide culturally appropriate care? Comment by Hanbin Choi: Please change this if you need to. As “freakydeath33” states, you have to define what culturally appropriate care is.
Tobin, Napoli and Beck (2018) reported that limited English language skills made it difficult for sufferers to seek social support and health care as they are less able to express their experiences with their health. As well, negative feelings associated with perceived lack of ability to communicate made it so that many were hesitant to even seek help. Thus, the use of interpreters, multilingual health care providers, or interpreter services are essential to communicate with migrant patients (O’Mahony et al., 2013; Osarogiagbon & Aquino, 2017; RANO, 2005; Tobin, Napoli &Beck, 2018). In addition, the sense of shame that may come from some marginalized people who do not have access to stable jobs and full social inclusion that comes from lack of ability to communicate in the dominant language should also be addressed. Being able to take advantage of available community-based services, patients can build the personal skills, increase self-esteem, confidence, and sense of control over their circumstances that could encourage patients to seek help and be assured that they will be understood (O’Mahony et al., 2013).
The cultural knowledge and beliefs of immigrant and refugee women also play a huge role in PPD recognition, acceptance, and help-seeking behavior (O’Mahony et al., 2013; Tobin, Napoli & Beck, 2018). There may be cultural factors influencing childrearing expectations that affect women’s willingness to access support systems and make them more vulnerable to PPD. Even listening to their experience of motherhood may allow health care providers to better understand how PPD affects these women. Tobin, Napoli and Beck (2018) stated that health care providers may lack this kind of cultural knowledge, so it is crucial for health care providers to be educated on such cultural differences. This can allow immigrants and refugees experiencing PPD feel more understood, rather than dismissed for their experiences of fear and stigma associated with PPD. Cultural education for health care providers in general is a positive strategy that can increase patients’ confidence in their treatment (Tobin, Napoli & Beck, 2018). Other helpful social strategies for coping with PPD are meetings, such as on the telephone, to keep in touch with family and friends back home for emotional support and communication about their situations that health care providers may not be able to give (Dennis, Hodnett, Reisman, Kenton, Weston, Zupancic, & Stewart, 2009; RANO, 2005). Community centers can also be sources of social support, where patients can meet others in group settings. In such cases, the provision of peer support from other postpartum mothers may alleviate symptoms associated with social exclusion or loneliness (Dennis et al., 2009; RANO, 2005).
Another coping strategy for immigrant and refugee women with PPD may come from spiritual beliefs and religious practices. O’Mahony et al. (2013) show that religion can be a way to promote a patient’s sense of identity and provide narratives to engage in their sense of strength, empowerment, and meaning when coping with their circumstances. Spiritual practices such as meditation, breathing exercises, praying, and attending religious meetings were shown to promote PPD sufferers’ resilience towards their condition and enhance their ability to care for their infants (O’Mahony et al., 2013).
Immigration has been increasing with globalization; people are migrating in search of a better life, better work and education opportunities, or to escape violence within their own countries. According to a report by Canadian Immigration (2019), the federal government of Canada announced that this country will increase its immigration intake, accepting up to 350,000 individuals in a year by 2021. As the government accepts more immigrants and refugees, it may become increasingly difficult for Canadian residents to access health care services due to lack of socioeconomic status or cultural support.
According to Citizenship and Immigration Canada (2018), there is a program called The Resettlement Assistance Program (RAP) that seeks to provide refugees with basic needs such as housing, access to education and health care, and a personal finance budget monthly income support payment. By taking advantage of this government program, migrants should be able to better access their local community clinics and check up regularly for a variety of health concerns, including postpartum care.
According to the Registered Nurses Association of Ontario (RNAO, 2005), there are several recommendations for the prevention and early detection of PPD and other depressive symptoms. The Edinburgh Postnatal Depression Scale (EPDS) is a tool that can help confirm depressive symptoms in postpartum women. EPDS is one of the most widely used tools to identify women with PPD as it is easy to access and discrete as one can be screened in privacy as it utilizes self-reported data. Nurses could also aid immigrant and refugee women using the EDPS who do not speak English fluently and have limited understanding of PPD by referring them to an interpreter service to translate the EPDS. However, interpreting the scores from non-fluent English speakers and those from different cultures, who may interpret the meanings of certain words differently, may be difficult and may result in false positives or negatives. Therefore, according to RANO (2005), the best practices combine using the EPDS with clinical observation and judgement, and updated results from a follow-up physician for an assessment of PPD.
Another possible intervention for PPD is for health care providers to interact with other mothers weekly and visit their homes individually, engaging in interpersonal psychotherapy, cognitive behavior therapy, or non-directive counselling (RNAO, 2005). In particular, non-directive counselling can be helpful as nurses can be present and provide non-judgemental environments, listening to their patients to promote treatment of PPD. One of the trial non-directive counselling methods involves weekly two-hour sessions. In these sessions, participants can support by watching videos and engaging in role play to treat PPD. The study revealed that women in the non-directive counselling group had fully recovered after 13 weeks (RANO, 2005).
Postpartum depression affects the entire family, so it is important for all family members to be involved in the detection and treatment of PPD. Cultural stigma has a negative effect on PPD patients’ willingness to seek help, so it is important that family members are a source of support (O’Mahony et al., 2013; RANO, 2005). Family members can also play an important role in the detection of PPD, since they are often in a position to recognize early symptoms. A study showed that partners being involved in PPD treatment had a positive effect on recovery (O’Mahony et al., 2013; RANO, 2005). It is imperative to encourage close loved ones to support PPD patients when they express feeling of anxiety, loneliness and distress. Partners who were more supportive and understanding of postpartum depression had a positive effect on their partners with PPD (RANO, 2005). Comment by Hanbin Choi: it might be wise, when you see “positive effect” to write what the positive effect was. Uplifted mood? Faster recovery? Reports of less symptoms? Etc etc.
Another nursing intervention to consider is promoting self-care for all women during the postpartum period. This includes exercise, adequate sleep, well-balanced nutrition, and engaging in supportive group interaction. Fatigue is a common issue that significantly affects the development of PPD in the early postpartum period. When fatigued, women tend to feel an overwhelming need to rest and sleep. In order to reduce fatigue, nurses can assist the new mother in planning for her daily activities. During support group sessions, it may also be useful to provide time and space for the PPD sufferer to rest or sleep if she feels it necessary, and to offer help care for the baby care while she rests (Higginbottom, Morgan, Alexandre, Chiu, Forgeron, Kocay, & Barolia, 2015; RANO, 2005). By taking care of themselves, PPD sufferers may be better able to find ways to promote positive emotional well-being.
Tobin, Napoli and Beck (2018) described that participants in their study among immigrant and refugee women experience of different and individual of childbearing due to different culture background. In western cultures, postpartum women are seen more independent, autonomous, they are more focused on treating with medication than other natural remedies. Many immigrant women do not choose as their first choice to take any antidepressant medication to treat it. There is still research limitation that treating with antidepressant medication and taking antidepressant is safe while breastfeeding and no harm to their infants (RNAO, 2005). In other word, lack of knowledge about and limited understanding of postpartum depression, fear of stigma, limited social support, limited English language skills can contribute to disclose their symptoms and not reaching out for help (Tobin, Napoli & Beck, 2018). By contrast, they prefer and get more beneficial for treatment getting counselling, more community social support, group therapy more culturally appropriate mental health care services instead of taking medication for immigrant and refugee women living in Canada (Tobin, Napoli & Beck, 2018).
Canada is a multicultural country consisting of people from various cultural backgrounds and the high number for immigrations and refugees in living Canada. Despite the increase of population from other counties, the immigrants and refugees’ women who are suffer from postpartum depression are limited to access health care services due to lack of community support, language barriers, unstable socioeconomic status, lack of knowledge, and different cultural background and perspective. In order to prevent postpartum depression among immigrant and refugee women, healthcare providers should advocate and provide care more culturally competence appropriate way for treatment strategies for this population to meet their goal of mental health improve (prognosis) by awareness their culture, educated in the recognition and care PPD with family member, emotional support, and referrals to help women promote the postpartum experience and improve maternal and infant positive outcomes.
- Dennis, C. L., Hodnett, E., Reisman, H. M., Kenton, L., Weston, J., Zupancic, J., Stewart, D. E.,& Kiss, A. (2009). Effect of peer support on prevention of postnatal depression among high risk women: multisite randomised controlled trial. BMJ Online First, 1-9. doi:10.1136/bmj.a3064
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