Women in the United Kingdom who died during the postnatal period were diagnosed with mental health disorders. Suicide is ranked as the second cause of maternal mortality in the United Kingdom. Women from the black and minority ethnic groups encounter higher levels of PND compared to the majority white population.There is no single factor that can be said to explain the cause of PND among women. However, women from BME groups encounter additional risk factors compared to the white population creating the need to investigate their perceptions, attitudes, and effects. This study examined the attitudes of postnatal depression among women from black and minority ethnic communities in London, United Kingdom. This research makes use of secondary research because it is less time-consuming in data collection, which also provides substantive data on the research topic. The literature search was conducted on various online databases. They include ProQuest, JSTOR, EBSCO, and ERIC. The study established that culture and healthcare had significant roles in the attitudes and perception of postnatal depression among BME populations. Besides, government policy on the use of the EPDS influences the diagnosis of PND. The results from this research demonstrate the need for further studies on the attitudes of PND among the BME women and the need for the health department to address the mental health needs of women from ethnic minority groups by ensuring access to mental health services. Women from the BAME groups encounter multiple obstacles towards seeking help for postnatal mental health risks. Concerns such as the prevalent stigma, wrongly tailored services, and the inappropriate behaviours by the health professionals are some of the barriers towards access to care. Interventions should seek to promote inclusivity, especially for the minority women who are vulnerable to postnatal depression. The future interventions should focus on the designing of safe spaces for postnatal women exposed to mental health issues such as digital solution, virtual networks, and peer support.

 

Chapter 1

1.1.Introduction

The concept of postnatal depression (PND) is perceived differently by individuals from various cultural backgrounds leading to diverse coping mechanisms. The black, Asian, and Minority Ethnic (BAME) communities living in London are no exception when it comes to their perceptions and attitudes towards PND. Being a common mental problem, the ethnic minority groups report a higher burden of mental health illnesses compared to the white majority in the United Kingdom (Watson et al. 2019; World Health Organisation 2017). Postnatal depression (PND) affects women who have already given birth or during the postnatal period, as asserted by Molyneaux et al. (2018). Besides, Gardner et al. (2019) show that postnatal depression usually occurs within four to six weeks after giving birth. It can affect a couple’s relationship and mother-child interaction. According to Greenhalgh (2019), PND’s symptoms may affect the baby’s long-term cognitive and emotional development as it mostly occurs in the first year of life. Some of the symptoms of PND include insomnia, low mood, tiredness, forgetfulness, lethargy, poor functioning, and irritability. Greenhalgh (2019) further states that PND’s symptoms can persist for long, resulting in prolonged mental illnesses in women, and this shows why the mental disorder is a severe public health concern. Gardner et al. (2019) explain that a mother from an ethnic minority group in the UK has an increased chance of developing PND, an idea supported by Biaggi et al. (2016), who states that women from minority communities were highly exposed to antenatal depression owing to an increased level of stress resulting from discrimination. While PND is prevalent in minority women in the UK, cultural constraints inhibit the detection process, thus the need for better tools of identification as well as policies for inclusion in the healthcare system.

1.2.Background

According to Watson et al. (2019), 23% of women in the United Kingdom who died during the postnatal period were diagnosed with mental health disorders. They go further to bring to our attention that suicide is ranked as the second cause of maternal mortality in the United Kingdom. Women from the black and minority ethnic groups report higher levels of PND compared to the majority white population. Additionally, minority groups have poor access to health services. The United Kingdom’s health department has not taken the appropriate steps to ensure proper and adequate health services for minority ethnic populations, for instance, there is a lack of sufficient information on health needs by ethnic group. Additionally, holistic services handling the health needs of the vulnerable groups and asylum seekers are useful in creating trust and tackling complicated and persistent discrimination. Furthermore, Toleikyte (2018) states that the ‘euro centricity’ of mainstream models of mental healthcare delivery inhibits service delivery meant for minority groups.

The tool commonly used to identify PND is the Edinburg Postnatal Depression Scale (EPDS). However, there is a rising debate on the effectiveness of the instrument in detecting PND among women from the black and minority ethnic groups. While the EPDS can be translated into other languages, the tool is not culturally sensitive which makes it unsuitable for use among women from the BME community and has low acceptability to local staff (Ing et al. 2017). As such, direct translation without cultural fitness can increase the risk of misdiagnosis and thus, the need for tools with high cultural sensitivity (Ing et al. 2017). Babatunde and Moreno-Leguizamon (2012) explain that direct translation might be dangerous because some of the cultures do not have a synonymous word to depression, therefore, increasing the chances of misdiagnosis. Templeton et al. (2003) confirm that using the EPDS tool poses a challenge among women from minority groups. Therefore, they verify the claim that more needs to be done to diagnose and manage PND women from black and minority ethnic groups.

A psychological trigger can cause a significant disparity of PND between the BAME group and the white population in the United Kingdom. Some of these triggers might be social isolation, discrimination, migrant status, and deprivation, inequitable access to healthcare services, and refugee or asylum seeker (Edge 2011). Besides, the different cultures of the BAME population might influence their help-seeking behaviour especially for people who had grown up in native countries other than the United Kingdom due to the culturally specific constructs of illness (Memon et al. 2016). The reason for this is that some cultures can associate depression or anxiety with culturally repulsive attitudes aggression (Memon et al. 2016). According to Babatunde and Moreno-Leguizamon (2012), most of the women from the BME population are afraid of how they might be perceived if it gets out that, they are undergoing depression. Hence, their major coping strategies are religion and family. Culture is a crucial part of women from the BAME population, and it largely influences their ability to open about PND hence making it difficult for health practitioners to diagnose PND among these groups. It is important to note that some of the BAME groups do not identify depression as an illness. Apart from culture, it is difficult to ignore the impact of socioeconomic status on depression.

1.3.Project Rationale/Justification

No single factor can explain the cause of PND among women. However, women from BAME group report additional risk factors compared to the white population creating the need to investigate their perceptions and attitudes (Babatunde and Moreno-Leguizamon 2012). Understanding of attitudes and perceptions of PND among women from the BAME population is critical because it identifies the existing gaps in healthcare service delivery among the BAME groups and hence influences the development of future maternal health interventions that address the needs of the BAME population. The information presented in this section concerning PND and the BAME women’s perceptions and attitudes justifies the need to establish measures that support their inclusion into the more extensive treatment plans in the United Kingdom.

1.4.Aim of the Study

The main aim of this study is to examine the attitudes of BAME women in London towards postnatal depression

1.5.Objectives of the study

Objective 1: To assess the prevalence of postnatal depression among the BAME women living in London

Objective 2: To explore the different factors that cause PND among BAME women.

Objective 3: To discuss the behaviours and attitudes of BAME women about PND

Objective 4: To examine the impact of policies and initiatives that aim to tackle postnatal depression among the BAME women living in London.

 

Chapter 2: Literature Review

2.1. Prevalence of Postnatal Depression.

Depression is a major public health issue that affects both men and women. The prevalence among women doubles during the childbearing period compared with that of men. It is the leading mental health infection and is projected to become the second most common health issue in the world (Babatunde and Moreno-Leguizamon, 2012). Worldwide, 10% to 20% of mothers report symptoms of post-partum depression. The exposure and symptoms can begin immediately after birth, or it can emanate from the previous incidences of depression that evolved during pregnancy. According to Shrivastava, Shrivastava, and Ramasamy (2015), the prevalence of this condition among women has gained traction not resulting merely from the increasing global distribution, but also out of the adverse consequences on personal, child development, and family outcomes.

According to Babatunde and Moreno-Leguizamon (2012), depression not merely a condition or disorder but also as an affective state where everyone can encounter at different moments in life. The researchers describe depression as a mood disorder characterised by severe and protracted emotions. Affects refer to the emotional swings, feelings, or psychic expressions at specific points in life. Anybody can experience mood disorders irrespective of the age, religion, education, gender, ethnicity, or class. Being a form of depression, postnatal depression is thus a mood disorder. Babatunde and Moreno-Leguizamon (2012) data show that 1 in 10 women in the UK encounters this condition. According to the proper definition, postnatal depression occurs during one year after women giving birth. It comes as an affective mood disorder that rotates around this period after delivery. Symptoms such as the loss of self-esteem, sadness, and feelings of loss accompany this condition. The scale of postnatal depression can range from mild to severe cases. The mild case requires limited intervention while the severe case (puerperal psychosis) calls for multiple intervention strategies, including long-term support and hospitalisation.

Increased attention is given to ethnic density as an important correlation of mental health in the United Kingdom. According to Du Preez et al. (2016), belonging to a BAME group, particularly the Asian segment or being born in a non-English-speaking country increases the risks for contracting postnatal depression in London. The prevalence of postnatal depression is higher for the non-natives staying in London (such as the Black Caribbean, the Pakistanis, and Indians) compared with most of the British and Irish descent. That said, minority status is also a possible precursor for personality disorder. Most of the BAME groups, especially the Black postnatal women, have high exposure to personality disorder.

2.2. Effects of Postnatal Depression

As revealed through the research by Babatunde and Moreno-Leguizamon (2012), PND has adverse impacts on the economic productivity, social functioning, and quality of life of women and families. The effects of health could translate to the long-term emotional and physical development of the infant and the children. The consequences are also indicative of behavioural and cognitive challenges for a child from 3 years and above. The inability of th health care providers to recognise and address postnatal depression among women could result in safety issues for both mothers and infants.

Several other authors have linked maternal exposure to depression with adverse child outcomes. Glasheen et al. (2013) found out that the exposure increases risks of fussiness as well as challenges in temperament in children and infants. They also report that based on a longitudinal study conducted in England, prenatal depressive symptoms correlated with high emotional risks for the 4-year old boys and girls. Besides, girls had a high exposure to conduct problems while boys were the attention and hyperactivity issues.

 2.3. Role of Healthcare Professionals and Access to Care

Findings by Babatunde and Moreno-Leguizamon (2012) show that health professionals have immense responsibility for the management of the postnatal condition. For instance, the health visitors in the United Kingdom contribute towards the identification and assisting women exposed to postnatal depression in the locality. The range of responsibilities executed includes “supporting families during this period from the birth of the child to the age of five, thus enabling them to provide a prolonged period of contact and support for women affected by it” ( Babatunde and Moreno-Leguizamon, 2012). Regardless of such mentions, evidence indicates that most susceptible group from the BAME population in London do not always have ready access such care and attention. One of the cause is the overlooking of the symptoms. Similarly, most women do not interpret the condition as a health risk. In contrast, others choose to endure in silence due to multiple socioeconomic barriers such as language, minority status, and illiteracy. In most cases, health professionals do not look after them or pick them for diagnosis and therapy. Other women are hesitant, as they fear to disclose the frailty and “stigma,” thus inhibiting the work of health experts in delivering adequate diagnoses or therapy.

2.4. Exposure of the BAME groups to Postnatal Depression

Edge and Bhugra (2016) found a stronger correlation between psychiatric conditions with cultural and ethnic groups. Understanding cultural variation is vital towards offering therapeutic solutions for individuals exposed to mental health issues, including postnatal depression. Due to the continued increase in the BAME population in London, there is a need to recognise their experiences, especially the attitudes of women towards postnatal depression as a way of recommending service delivery. For instance, the African group is the second-leading ethnic minority in Greenwich (Watson et al., 2019). Individual exposed to postnatal depression may also encounter social isolation and challenges resuming their employment. These issues are compounded further by the multiple proves on the correlation of depression and domestic violence, especially for the minority groups. The health professionals may also provide varying conceptualisations of postnatal depression that exacerbate the condition of these groups (Joanna Briggs Institute, 2014).

As reported by Williams, Priest, and Anderson (2016), ethnicity or race and socioeconomic status (SES) have varying exposure to life situations that attract health effects. They are the social categories whose members experience life differently. There is a need to learn that ‘minority ethnicity’ is not a single category but incorporates an assortment of groups of individuals with diverse levels of exposure to the social-economic and health risks. It is also vital to recognise the complexity of the relationships existing between the burden of disease and socioeconomic status (SES), especially since there is extensive proof of non-equivalence of SES in the ethnic groups and the persistent effect of institutional and interpersonal disparity.

Due to such socioeconomic status and ethnic status, Watson et al. (2019) report that in the UK, ethnic minority groups have a higher burden of common mental health conditions as compared with the majority whites. However, the whites have high access to medication while the possibility of detecting ad treating the mental conditions for the minorities is low (Anderson et al., 2017; Prady et al., 2016). Using the longitudinal study, Wallace, Nazroo, and Bécares (2016) research established that the ethnic minority people who encountered racial discrimination reported that the cumulative exposure to ethnic discrimination has progressive and adverse impacts on the mental health of the BAME groups in the UK.

2.5. Reasons for High Exposure

The findings by Anderson et al. (2017) revealed that BAME’s exposure to perinatal mental depression results from the institutionalised factors such as low socioeconomic status, poor proficiency in the English language, refugee-seeking status, and reduced social support. Whereas the causes for such differences are not fully illustrated, minority ethnicity has high exposure to such psychosocial triggers, including social isolation, deprivation, and discrimination (Wallace, Nazroo, and Bécares, 2016). Besides, the status of being a migrant, refugee or asylum seeker further exposes them to psychological problems (Howard et al., 2014). Other causes include inequity in health care access and support (Latif, 2014).  Edge and Bhugra (2016) substantiate these findings further by suggesting that the literacy level of women inhibit their access to care and increase social isolation, especially to the South Asian immigrants in the United Kingdom. Illiteracy further compounds the depression issue because of the inability of these women to express their experiences. Poor command of English also implies a lack of understanding of the healthcare system and thus reducing the possibility of seeking help and obtaining a diagnosis.

2.6. Treatment Options

Based on Watson’s et al. (2019) study, there is a wide recognition that 6 million or more residents of the United Kingdom encounter mental illness or depression. Nevertheless, almost 2 million do not access psychological treatment (Williams, Priest, and Anderson (2016). The secondary study by Redshaw and Henderson (2016) sought to establish the socio-demographic determinants of pregnancy care, childbirth, and postnatal experiences. The focus was to elicit the emotional and mental perceptions and effects of the experiences encountered. More than 4571 women participated in the survey. Most participants (82 %) remembered being inquired on their mental health in pregnancy. Almost all (90 %) suggested that they were asked about their care during the postnatal period. Nevertheless, the minority women especially the aged and those from Asia, were less likely to be inquired or even provided medication in the antenatal period. The differences were more outspoken during the postnatal period. Women from low socioeconomic status, especially the non-white minority as well as those with low education levels had low chances of receiving mental health inquiry, treatment, or support. These findings support the notion of inverse care law. The most vulnerable people in need of care have fewer chances of accessing treatment and support, while those with societal privileges and with less mental health issues have high chances of access to care.

The study by Prady et al. (2016) shows that pharmacological treatment is the common management options for depressive episodes for women in the maternal period. This treatment is adopted for average to the critical form of the depression. Interviews from women showed that pharmacological treatments could stop most of the depressive symptoms and form. Nevertheless, it was not indicated the extent to which non-pharmacological treatment could be served as an alternative. Studies also indicate that the pharmacological treatments provided could not be equivalent to the requirements of the BAME members (Zoega et al., 2015).

Chapter 3: Methodology

3.1. Introduction

This research adopted secondary research since it forms the core of most research. Secondary research provides a researcher with basic knowledge on the research topic. It entails using information from already existing research (Bowman 2014). Data from secondary research is available from different sources. Some of the secondary data sources used include journals, published books and academic databases. One of the fundamental differences between primary and secondary research is that while secondary research depends on data from existing sources, primary data requires the researcher to gather data from non-existing research questions in secondary sources. Primary research is more costly compared to secondary research because it must allocate financial resources to cater to data collection and all the other requirements, including what the collected data is intended to measure. According to Driscoll (2011), the costly nature of primary research makes it necessary to carry out extensive secondary research to confirm existing gaps and ensure time and money are not wasted on primary research, while data for the available information is present in secondary sources.

Secondary research saves time on data collection. Secondly, such sources provided a large amount of information on the research topic. Besides, most of the information was free to access online, making this methodology cost-efficient. Despite the advantages of secondary research, there are limitations associated with this type of research. First, some of the information derived from secondary research might be outdated, making the results of the research inaccurate. Secondly, the existing secondary resources might present biased data, as it is difficult to determine if the data was collected accurately (Nyanchoka et al. 2019). Third, the data from the secondary sources were not collected to meet the current research question hence may not fully meet the present research needs. Lastly, the quality and reliability of secondary data might be questionable, considering the data is, at times, misleading. Regardless of these shortcomings, secondary research was appropriate for carrying out this proposal research because of the available secondary data sources that answer the four primary research objectives in this paper. Furthermore, other researchers such as Templeton et al. (2003) have researched PND depression among women from BME groups, thus supplying relevant information.

3.2. Study Design

A case-control study is a choice that this systematic review adopts. The objective of such a design is to establish whether an exposure correlates with an outcome, in this case, to find out if culture and minority status is a causal factor for postnatal depression among women from the black and minority communities living in London. This review is suitable for observational studies as it assists in determining the outcome (Ranganathan and Aggarwal 2018). It also compares participants that have an outcome versus those without an outcome (Setia 2016). The review will analyse several related studies dealing with the minorities in London versus the white majority and the association of postnatal depression.

3.3. Data Analysis

This research adopts content analysis in interpreting and presenting data. The selection of this approach is with the view to examine themes associated with postnatal depression from the case-controlled studies examined. Using the content analysis, the researcher can evaluate the relationships among themes, concepts, or words; in this case, those related to postnatal depression among the minority women in London. This approach also allows for the examination of both quantitative and qualitative data found in the reviews. Using a relational analysis approach, the research will further reevaluate relationships among themes that can lead to interpretations, inferences, and conclusion.

Examples of themes this research explores and compares include, the influence of culture on PND among BME Women in London, UK; the influence of healthcare on PND among BME women in London; and the impact of current policies and strategies to address PND among women from BME Groups in London, UK.

3.4. Literature Search Strategy

The literature search was conducted on various online databases. The online databases used were ProQuest, JSTOR, EBSCO, and ERIC. The search strategy encompassed five stages, which include the postnatal period, ethnicity, mental health, policies or strategies and research undertaken in the United Kingdom or London. The researcher identified the key terms based on the abstract and title fields. The focus of the search was on the country of publication, without restriction on the dates for data derived from the secondary sources. All documents, regardless of the year of publication, were examined, provided they embodied relevant information. The search strategy did not incorporate any specific language or restrictions. There are instances the literature search utilised controlled vocabulary terms. The Boolean operators such as “and” and “or” were employed. Moreover, the search strategy utilised proximity operators, phrase searching and truncation. The researcher made various modifications to the search syntax of the various databases. EBSCO provided supporting information for the research literature by ensuring a full search strategy.

3.5. Inclusion and Exclusion Criteria

Sources included were those related to the attitudes and perceptions of postnatal depression among women from black and minority ethnic communities in the United Kingdom, duplicate documents or references were deleted. The reference section for selected studies provided further secondary sources for inclusion for this research. The study used titles and abstracts to identify the eligible studies on the topic of postal depression and minority. After extraction, full studies were included, while those with only abstracts were excluded. Inclusion also targeted articles that were open access; those with restrictions were excluded.

Furthermore, the included studies presented discussions on postnatal depression among BME groups and the culture of BME groups in London or the United Kingdom. Studies informing on maternal healthcare provision among women from BME populations and the impact of policies or strategies influencing PND among women from BME populations in the United Kingdom were also included. The study also used a third-party person to review the selected secondary data sources to ensure the sources match the inclusion criteria.

3.6. Ethical Considerations

Since the study employed secondary sources, the researcher had to adhere to ethical issues. First, was the adherence to scholarly practice by recognising the principles and practices in place to ensure that the claims made towards the research subject are valid and reliable before preparing the document accessible to other scholars (Pope, Vanchieri and Gostin 2007).

The second ethical consideration is integrity. The researcher is expected to analyse articles in a way that displays honesty, respect, fairness, and responsibility. Third, it was vital for a researcher to uphold human dignity through the research topic and the results from the research. Additionally, the information in this study demonstrated the diversity of the various BME populations that enhanced the principle of respect for human dignity.

Fourth, ethics requires the avoidance of plagiarism (Munhall 2012). As such, the researcher paraphrased the relevant information from the reference material, cited the appropriate research materials, and quoted the secondary sources to avoid plagiarism. Furthermore, another research misconduct the literature reviewer avoided is falsification and misrepresentation of data. The objective of this study was to present findings as they currently exist, and thus, the researcher avoided all cases of data inaccuracy or falsification.

To ensure transparency of the findings, the researcher restated the ineffectiveness of the EDPS tool concerning accuracy and acceptability from the participants. It was observed that data relating to the use of EPDS as a tool for assessing PND among BME groups might not be useful in this research because of the existing conflict surrounding the instrument. The analysed studies against the use of the tool showed that it is culturally insensitive.

 

 

 

 

 

 

 

 

Chapter 4: Results

 

Table 1. Prisma Flow Diagram

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 2. Characteristics of studies used

Source	Objectives	Samples	Design	Analysis	Assessment tool	Analysis	Confidence
Hewitt at al. (2019),	To assess the best PND screening strategies	Studies selected from 20 electronic databases	A systematic review using a generalised linear mixed model approach to the bivariate meta-analysis was undertaken	Textual narrative approach	Quality Assessment of Diagnostic Accuracy Studies (QUADAS) too	The study established that acceptance criteria for a PND screening programme were not presently achieved	Used the probabilistic decision model
Watson et al. (2019)	To explore BAME women’s experiences of perinatal mental ill-health	15 eligible studies	A mixed-method systematic review	It adopted a convergent approach with a synthesis of data	The study used the qualitative National Institute for Health and Care Excellence (NICE) appraisal tool	Cultural issues and lack of awareness, as well as the prevalent sigma, affected minority from accessing care.	CERQual) approach
Babatunde and Moreno-Leguizamon 2012),	To recognise cultural factors associated with PND and secondly, to assist practitioners in recognising PND signs in BAME women as well as the cultural ambiguities experienced	17 participants from Nigeria, Ghana, Kenya, Somalia, and Sierra Leone	Primary qualitative study	Thematic analysis of the women’s narratives	The logic of qualitative inquiry	Most of the participants struggle with signs of PND, yet they did not recognise it as related to illness.	Approval from The National Health Service Trust
Gardner et al., 2014).	To establish lived experience of PND in West African mothers staying in the UK	Six immigrant mothers from Nigeria and Ghana staying in the UK	Primary Qualitative design using semi-structured interviews	Thematic analysis	Interpretative Phenomenological Analysis (IPA)	Women experienced signs of PND but were less willing to consider them as illness. Cultural and social factors such as stress promoted PND
Prady et al. (2016)	To discuss the occurrence of mental disorders in primary care during the maternal period	8991 women	A systematic review of linked birth cohort and primary care data	Statistical analysis	GHQ scoring method	Persistent disparities in mental disorders exist for BAME women in the maternal period.	Incidence rate ratios (IRRs)
Annexe (2011),	Presents a summary of facts on mental health issues across age, marriage, pregnancy and maternity, minority status, disability, and sex	N/A	Systematic review	Thematic analysis	Different policy and diagnostic instruments	Minority groups have high exposure to mental health issues because of socioeconomic status
Littlewood et al. (2016)	To establish the prevalence rates of perinatal depression among women	It relied on 50 cases of women with depressive symptoms	A primary study involving a mixed-method study. It used quantitative and semi-structured interviews.   Patient with data collected through the	Assessed relied on two-by-two contingency tables to determine predictive value, predictive value, and sensitivity on  perinatal mental health	The study relied on multiple tools such as  somatic symptom severity (PHQ-15); Generalised Anxiety Disorder, GAD-7); and Patient Health Questionnaire, PHQ-9	The proposal suggested that socioeconomic conditions and exposure of women determined their experience with perinatal depression	Clinical interview schedule—revised
Templeton et al. (2003).	To establish experiences of BAME women regarding PND exposure	All women from BAME groups who had conceived during the six months in 1999. The samples were  114 health visitors	Qualitative analysis using  Semi-structured interviews and focus groups	Descriptive thematic analysis	Edinburgh Postnatal Depression Scale (EPDS)	Socioeconomic and cultural risks such as language barrier increased exposure of BAME women to PND	Edinburgh Postnatal Depression Scale (EPDS)
Coates, Ayers and de Visser (2014)	To analyse the experiences of women regarding the variety of emotional distress and how they made sense of each during the postnatal period.	17 women who encountered psychological the first year following the birth	The primary approach using interviews to collect and transcribe data	Descriptive thematic analysis	Interpretative Phenomenological Analysis (IPA)	The study established that there is a need for assessment of  psychological processes in addressing the emotional issues women are exposed to while seeking treatment
Smith et al. (2019)	To establish the  multilevel system barriers and how they inhibit prenatal women from accessing mental health care	35 studies	A systematic review and meta-synthesis of qualitative studies	A meta-synthesis approach	The study adopted “Preferred Reporting Items for Systematic Review” tool to record and synthesise data	Women encounter many barriers towards access to care, and intervention should target the mental health services to assist women with prenatal depression	Critical Appraisal Skills Programme (CASP)

 

4.1. Overview of included sources

After searching the electronic databases, 150 sources were identified with an additional 150 source located through manual search. Afterwards, 225 duplicates were removed. The screening was done based on the titles and abstracts, leading to 25 full-text sources. Ten articles were eventually included in the review. Concerning the prevalence of PND among the BAME groups, five of the ten studies assessed this variable. They include Hewitt at al. (2019), Watson et al. (2019), Moreno-Leguizamon (2012) (Babatunde and Moreno-Leguizamon 2012), and (Gardner et al. 2014). All of these studies assessed the incidence of PND among the BAME women groups. Six studies assessed the influence of culture on PND among the BAME groups. They include Annex (2011), Prady et al. (2016), (Babatunde and Moreno-Leguizamon 2012), Memon et al. (2016), Watson et al. (2019), and Templeton et al. (2003). They assessed the role of culture and influence on BAME’s PND condition. Prady et al. (2016) focused on aspects of culture such as family structure, social stresses, rituals, social organisation, and community defence mechanisms.

 

 

Chapter 5: Discussion

5.1. Prevalence of PND among BME Populations in the UK

Five studies assessed the prevalence of PND among the BAME groups. They include Hewitt at al. (2019), Watson et al. (2019), Moreno-Leguizamon (2012), (Babatunde and Moreno-Leguizamon 2012), and (Gardner et al. 2014). According to Hewitt at al. (2019), the prevalence rate of PND at the international level stands at 13%. PND is among mental health disorders. According to Watson et al. (2019), 13%of women develop mental health disorders after birth. Furthermore, in the United Kingdom, 23% of women deaths in the postnatal period are associated with mental health disorders. Babatunde and Moreno-Leguizamon (2012) indicate that 1 in 10 women in the United Kingdom is affected by PND. Women from ethnic minority groups are at a higher risk of developing mental health disorders compared to the native white population (Babatunde and Moreno-Leguizamon 2012). Over time, the ethnic minority population has grown in the United Kingdom. According to the 2001 census in the UK, 9% of the population comprised of ethnic minority groups (Gardner et al. 2014). The high rate of an ethnic minority population in England necessitates the establishment of measures to assess the attitudes and perceptions of PND among women from BME populations, with the reason that the minority have a higher burden of mental health disorders compared to the majority white (Watson et al. 2019). The information can enhance mental healthcare service delivery among BME populations.

5.2. The Influence of Culture on PND among BME Women in London, UK.

Six studies assessed the influence of culture on PND among the BAME groups. They include Annex (2011), Prady et al. (2016), (Babatunde and Moreno-Leguizamon 2012), Memon et al. (2016), Watson et al. (2019), and Templeton et al. (2003). The BME population comprises a wide range of people or groups, with each having special needs majorly because of their culture. The majority of the minority populations are non-white groups, which comprise the Asians and the black population. Furthermore, minority status is best ascribed based on their racial or ethnic origin. As presented by Annex (2011), the Asian groups comprise the Chinese, Pakistani or Indians, while the black groups might consist of the black Caribbean and black African, to name a few. Hence, the need to assess the influence of the culture of the different BME populations on PND. Culture plays a significant role in influencing the behaviour of an individual. Cultural rules influence a person’s behaviour. According to Prady et al. (2016), some of the critical aspects of culture that influence PND include family structure, social stresses, rituals, social organisation, and community defence mechanisms, with the justification that culture influences a person’s emotions life, then consequently, the PND (Babatunde and Moreno-Leguizamon 2012). It is important to note that culture plays a significant role in influencing health-seeking behaviour and access to treatment services among women experiencing PND.

Some of the BME populations do not externalise depression, therefore, bringing up discussions about depression is culturally unacceptable such that they can associate depression or anxiety with culturally repulsive attitudes aggression (Memon et al. 2016). This is true for women from the Black Caribbean, which according to interview one mother, stated that “I have had two babies now, I don’t know what postnatal depression is supposed to be, how you’re supposed to feel, look or whatever, I don’t know. I have no idea. What exactly is postnatal depression? What are you supposed to be doing, saying, or whatever?” (Watson et al. 2019). The Black Caribbean culture requires women to demonstrate strength as it is their responsibility to hold the family together, which is also the case for some women from South Asia (Watson et al., 2019). Women from BME backgrounds firmly adhere to their culture, which also provides a mechanism of responding to depressive moods such as through religious beliefs and sharing with family members. In the case of depressive symptoms, most of the BME groups suppress them as they find it culturally unacceptable to disclose any emotional issues or problems facing them because it is considered a weakness. They believe that disclosing such information to outsiders will enhance stigma hence making it challenging to diagnose PND among women from these communities (Babatunde and Moreno-Leguizamon 2012). Watson et al. (2019) further explain that women from the Pathan community believe that their health is in God’s hands hence it is not in their place to worry about their health. Furthermore, some of the women from the BME population believe that depression only affects the native white population and thus they do not categorise as an illness in their culture (Watson et al. 2019). Templeton et al. (2003) discuss that language is a cultural barrier that makes it difficult for BME populations to express themselves to health practitioners or seek help when undergoing any health problem, including PND.

5.3. The Influence of Healthcare on PND among BME Women in London

Three studies discussed the influence of healthcare on PND for BAME groups. They include Coates, Ayers and de Visser (2014), Smith et al. (2019), and Watson et al. (2019). Some women from the BME groups are not aware that mental health services exist that can help them deal with PND. Furthermore, various factors influence the help-seeking behaviour of women from BME populations. Some of these factors make women avoid seeking mental health services. Some of the women from the BME population fear that the diagnosis of PND might cause them to be labelled as bad mothers to the extent that they might lose custody of their children (Coates, Ayers and de Visser 2014). Secondly, some women fear a confirmed diagnosis of PND. Hence, they choose to avoid seeking health services. Besides, some do not want to take the medication prescribed for PND. Some of the women fear that if the medications do not help them cope with PND, their children might be taken away from them, yet the mother should be responsible for the child. Third, the service provider influences help-seeking behaviour. Some women are not comfortable seeking mental health services when the health service provider is from a different ethnic background. According to Smith et al. (2019), previous negative experiences from health service providers of a different ethnic origin make some the BME women shy away from seeking mental health services because of the view those health service providers from a different ethnic origin lack compassion.

Furthermore, healthcare providers will not be in a position to understand the women’s culture and religion. The existence of a language barrier between the service provider and client reduces the effectiveness of service delivery as it inhibits effective communication making it challenging to diagnose PND. Some women are not comfortable even in the presence of a language interpreter because of fear of breach of confidentiality.

Maternity care influenced help-seeking behaviour among women from the BME population. According to Watson et al. (2019), it is much easier for women to open up about their PND to a specific healthcare provider who has served them throughout the pregnancy and postnatal period. Frequent change of healthcare providers serving the women minimises the chance of opening about their PND. Furthermore, the attitude of healthcare providers determines help-seeking behaviour. Some women perceive some of the healthcare to be too busy such that they seem not interested in the women’s problems hence making it challenging to diagnose PND. Watson et al. (2019) further explain that it is easier for white women to be offered treatment compared to Asian and black women. Hence, discrimination, according to ethnicity, discourages women from the BME population from seeking mental health services. Some women are uncomfortable when the service providers is a man, especially in the absence of their husbands. Therefore, there is a need to ensure culturally sensitive programs.

5.6. The Impact of Current Policies and Strategies to Address PND among Women from BME Groups in London, UK

Two authors, Littlewood et al. (2016) and Hewitt et al. (2019), analysed the impacts of existing policies on women suffering from PND. Recommendations put forward in various policy documents in the United Kingdom have pushed for the implementation of strategies to address postnatal depression. One of the most common strategies entails the diagnosis of PND. The National Health Service ensures that all local areas have a protocol in place to facilitate PND diagnosis. The most common tool used in screening for PND at all levels is the EPDS. The use of the EPDS has raised discussions, including criticism regarding the use of the instrument. Some of the criticisms against the use of the EPDS includes the mass screening of mothers, the properties the EPDS uses to measure the psychological properties of the patient, the acceptability of the EPDS to mothers and service providers, the factors that define the diagnosis of PND and the effectiveness of the tool in diagnosing EPDS (Littlewood et al. 2016). The EPDS is a ten-question questionnaire and administered to mothers at twelve weeks and one year after giving birth.

Hewitt et al. (2019) explain that the EPDS is a tool that is easy to use in detecting PND. However, the tool has proved ineffective in diagnosing PND among BME populations. The tool is considered culturally insensitive. The specification of the EPDS prioritises the western culture or the whites, which makes it culturally insensitive to the minority ethnic populations. Besides, the language barrier renders the tool inapplicable to some women from the BME populations, considering that forms of translation are direct, thus not being sensitive to the local culture. Translation can pose risks of losing the actual meaning. As such, there is a need to identify the appropriate strategy that can help diagnose PND among women from BME populations other than the EPDS tool. A possible alternative is to provide a complementary diagnosis technique alongside the EPDS. This complementarity will enhance the effectiveness of EPDS by tackling and fully incorporating culturally sensitive issues from multiple dimensions.

Chapter 6: Conclusion and Recommendations

This study investigated the attitudes and perceptions of women from BME populations using a literature review perspective. PND was found to be one of the severe mental health disorders. In the United Kingdom, 23% of women die during the postnatal period, and the primary cause of death is psychological disorders. Furthermore, it was observed that culture had a significant role in the effect of postnatal depression among BME populations. Talks of PND are unheard of in some communities, and hence women fear disclosing that they are undergoing PND. Also, fear that such information might make them lose custody of their children and make them seek weakly, yet they are supposed to stand firm for the family.

Another observation was that healthcare also influences the experience of PND among mothers. A negative attitude from healthcare service providers to women from the BME population, different ethnic groups of the service provider and language barrier hinder access to mental healthcare services and diagnosis of PND. Various studies have shown that the EPDS tool recommended and mostly used in the diagnosis of PND is ineffective among women from the BME population mostly because it is considered culturally insensitive.

That said, women from the BAME groups encounter multiple obstacles towards seeking help for postnatal mental health risks. Concerns such as the prevalent stigma, wrongly tailored services, and the inappropriate behaviours by the health professionals are some of the barriers towards access to care. Interventions should seek to promote inclusivity, especially for the minority women who are vulnerable to postnatal depression. Professionals should allow minority women to access culturally appropriate spaces for the expression of their within their community settings. Besides, there is a need to provide relevant training for health professionals to support compassionate and culturally sensitive care.

The results from this research demonstrate the need for further research on the impact of PND on BAME women. Most of these women suffer from PND, and the tools available for diagnosis, mostly the EPDS, are not useful in the diagnosis of PND. The seriousness of the condition makes it necessary for the government and especially the health department in the United Kingdom to come up with the appropriate diagnosis tools that will complete the EPDS in the diagnosis of PND. The new tool should address the significant challenge currently facing the EPDS, that is, the EPDS is culturally insensitive. Furthermore, the health department should strive to ensure access to mental health services to women. Another potential solution to address the challenges associated with PND is conducting health education among the communities to address the existing myths and misconceptions associated with PND. The involvement of the gatekeepers to the various communities enhances the effectiveness of health education in breaking down barriers that hinder access to mental healthcare services. The future interventions should focus on the designing of safe spaces for postnatal women exposed to mental health issues such as digital solution, virtual networks, and peer support.