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NIHR Signal New insights into how ethnicity and culture affect maternal mental health

Published on 16 April 2019

doi: 10.3310/signal-000762

Ethnicity and culture can affect how and when women seek help for mental health problems before or after having a baby. Many women avoid seeking help because they feel services are not sensitive to their beliefs. Services should ensure all women, regardless of background, can access the support they need during and after pregnancy.

This mixed methods systematic review of UK evidence found that many women are not aware of the help available to them, and those that are aware often view it negatively. Reasons for this include language barriers and fear of judgement by healthcare professionals and family members.

Tailoring services could encourage more women from ethnic minorities to seek help. Measures such as ensuring patient information is written in a range of languages and providing staff with additional diversity training may facilitate this.

Share your views on the research.

Why was this study needed?

Up to one in five women will experience mental health problems such as depression and anxiety during or after pregnancy. This can have far-reaching effects on maternal and child outcomes. Early intervention can make a big difference to both severity and recovery times.

This figure is likely to be even higher for women from ethnic minorities. The reasons for this are not clear. It may be that risk factors such as poverty and low social support are more prevalent or that mental health services are failing to meet their needs.

What is certain is that many women from ethnic minorities are not seeking professional help. This systematic review drew information from a range of studies to try and understand what women themselves want.

What did this study do?

This mixed methods systematic review pooled quantitative and qualitative data from 15 UK studies with a combined total of 4,970 participants. Most of the findings came from 14 small studies comprising focus groups and interviews of 399 women. One large postal survey of 4,571 women was used to look at access to treatment. Studies explored perceptions, experiences and help-seeking behaviours associated with mental health conditions in women from ethnic minorities during the perinatal period. The findings were grouped into themes.

The ethnicity or nationality of participants included Bangladeshi, Pakistani, Indian, South Asian, Asian, Mixed Asian/British, Pathan, Black, Black African, Nigerian, Ghanaian, Black Caribbean, Portuguese, White American, and White Australian. Although some studies included data from English or White British participants, this was excluded where possible.

Ten studies had between 6 and 33 participants so some views may not be representative of the wider ethnic-minority population. No studies were excluded because of quality, but the authors rated findings by strength of evidence.

What did it find?

  • Seven themes were identified: awareness and beliefs about mental health, the influence of culture, symptoms and coping strategies, isolation and seeking support, accessing mental health services, experiences of mental health services, and what women want.
  • Within these, the impact of cultural beliefs on how symptoms are interpreted was one of the key findings. In some cultures, conditions such as depression are not acknowledged. Stigma and the fear that their ability to be a mother will be called into question are additional barriers. This makes it difficult for women to know when to seek help and, even if they do, find the courage to do so.
  • Many women were not aware of the services available to them. Those that were, often avoided them due to bad past experiences or assumptions that care would not be sensitive to their needs. Reasons for this varied, including the language barrier and lack of female staff.
  • Emotional isolation was often mentioned, and some felt that they lacked support from partners and family due to a range of factors such as denial of their symptoms or geographical distance. Many sought solace from others who shared similar experiences either in person or online.
  • The large survey found that White women were more likely to be offered treatment than Black or Asian women.

What does current guidance say on this issue?

The 2014 NICE guideline on antenatal and postnatal mental health states that culturally relevant information about perinatal mental health problems should be provided to women taking into account the fear of stigma.

Also, NICE guidance on pregnancy and complex social factors (2010) makes several recommendations to help women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English, make full use of antenatal care services. Examples include using a variety of different ways to communicate with women, and completing training to understand the individual needs of women from these groups.

What are the implications?

Mental health services need to actively reach out to all members of the community. The barriers to service use such as perceptions of care and difficulties in accessing services highlighted in this study could be alleviated through improved communication and information provision.

If women and their families know the symptoms to look out for, they may be more likely to seek help if they need it.

The findings suggest a need for more cultural awareness and training for professionals including midwives, obstetricians and staff in specialist mother and baby units.

Citation and Funding

Watson H, Harrop D, Walton E et al. A systematic review of ethnic minority women’s experiences of perinatal mental health conditions and services in Europe. PLoS ONE. 2019;14(1):e0210587.

All authors received funding for this study from Sheffield Health and Social Care NHS Foundation Trust. Grant number Aa4344482 https://shsc.nhs.uk/.

Bibliography

Mental Health Foundation. Black, Asian and minority ethnic (BAME) communities. London: Mental Health Foundation, 2019.

NICE. Antenatal and postnatal mental health: clinical management and service guidance. CG192. London: National Institute for Health and Care Excellence; 2014.

NICE. Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors. CG110. London: National Institute for Health and Care Excellence; 2010.

Royal College of Psychiatrists. Mental health in pregnancy. London: Royal College of Psychiatrists; 2018.

WHO. Maternal mental health. Geneva: World Health Organization; 2017.

Why was this study needed?

Up to one in five women will experience mental health problems such as depression and anxiety during or after pregnancy. This can have far-reaching effects on maternal and child outcomes. Early intervention can make a big difference to both severity and recovery times.

This figure is likely to be even higher for women from ethnic minorities. The reasons for this are not clear. It may be that risk factors such as poverty and low social support are more prevalent or that mental health services are failing to meet their needs.

What is certain is that many women from ethnic minorities are not seeking professional help. This systematic review drew information from a range of studies to try and understand what women themselves want.

What did this study do?

This mixed methods systematic review pooled quantitative and qualitative data from 15 UK studies with a combined total of 4,970 participants. Most of the findings came from 14 small studies comprising focus groups and interviews of 399 women. One large postal survey of 4,571 women was used to look at access to treatment. Studies explored perceptions, experiences and help-seeking behaviours associated with mental health conditions in women from ethnic minorities during the perinatal period. The findings were grouped into themes.

The ethnicity or nationality of participants included Bangladeshi, Pakistani, Indian, South Asian, Asian, Mixed Asian/British, Pathan, Black, Black African, Nigerian, Ghanaian, Black Caribbean, Portuguese, White American, and White Australian. Although some studies included data from English or White British participants, this was excluded where possible.

Ten studies had between 6 and 33 participants so some views may not be representative of the wider ethnic-minority population. No studies were excluded because of quality, but the authors rated findings by strength of evidence.

What did it find?

  • Seven themes were identified: awareness and beliefs about mental health, the influence of culture, symptoms and coping strategies, isolation and seeking support, accessing mental health services, experiences of mental health services, and what women want.
  • Within these, the impact of cultural beliefs on how symptoms are interpreted was one of the key findings. In some cultures, conditions such as depression are not acknowledged. Stigma and the fear that their ability to be a mother will be called into question are additional barriers. This makes it difficult for women to know when to seek help and, even if they do, find the courage to do so.
  • Many women were not aware of the services available to them. Those that were, often avoided them due to bad past experiences or assumptions that care would not be sensitive to their needs. Reasons for this varied, including the language barrier and lack of female staff.
  • Emotional isolation was often mentioned, and some felt that they lacked support from partners and family due to a range of factors such as denial of their symptoms or geographical distance. Many sought solace from others who shared similar experiences either in person or online.
  • The large survey found that White women were more likely to be offered treatment than Black or Asian women.

What does current guidance say on this issue?

The 2014 NICE guideline on antenatal and postnatal mental health states that culturally relevant information about perinatal mental health problems should be provided to women taking into account the fear of stigma.

Also, NICE guidance on pregnancy and complex social factors (2010) makes several recommendations to help women who are recent migrants, asylum seekers or refugees, or who have difficulty reading or speaking English, make full use of antenatal care services. Examples include using a variety of different ways to communicate with women, and completing training to understand the individual needs of women from these groups.

What are the implications?

Mental health services need to actively reach out to all members of the community. The barriers to service use such as perceptions of care and difficulties in accessing services highlighted in this study could be alleviated through improved communication and information provision.

If women and their families know the symptoms to look out for, they may be more likely to seek help if they need it.

The findings suggest a need for more cultural awareness and training for professionals including midwives, obstetricians and staff in specialist mother and baby units.

Citation and Funding

Watson H, Harrop D, Walton E et al. A systematic review of ethnic minority women’s experiences of perinatal mental health conditions and services in Europe. PLoS ONE. 2019;14(1):e0210587.

All authors received funding for this study from Sheffield Health and Social Care NHS Foundation Trust. Grant number Aa4344482 https://shsc.nhs.uk/.

Bibliography

Mental Health Foundation. Black, Asian and minority ethnic (BAME) communities. London: Mental Health Foundation, 2019.

NICE. Antenatal and postnatal mental health: clinical management and service guidance. CG192. London: National Institute for Health and Care Excellence; 2014.

NICE. Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors. CG110. London: National Institute for Health and Care Excellence; 2010.

Royal College of Psychiatrists. Mental health in pregnancy. London: Royal College of Psychiatrists; 2018.

WHO. Maternal mental health. Geneva: World Health Organization; 2017.

A systematic review of ethnic minority women's experiences of perinatal mental health conditions and services in Europe

Published on 30 January 2019

Watson, H.,Harrop, D.,Walton, E.,Young, A.,Soltani, H.

PLoS One Volume 14 , 2019

BACKGROUND: Women from ethnic minority groups are at greater risk of developing mental health problems. Poor perinatal mental health impacts on maternal morbidity and mortality and can have a devastating impact on child and family wellbeing. It is important to ensure that services are designed to meet the unique needs of women from diverse backgrounds. AIM: The aim of the review was to explore ethnic minority women's experiences of perinatal mental ill health, help-seeking and perinatal mental health services in Europe. DATA SOURCES: Searches included CINAHL, Maternity and Infant Care, MEDLINE and PsycINFO with no language or date restrictions. Additional literature was identified by searching reference lists of relevant studies. DESIGN: This was a mixed method systematic review. Study selection, appraisal and data extraction were conducted by two researchers independently. A convergent approach was adopted for the analysis and the data were synthesised thematically. RESULTS: The 15 eligible studies included women from a range of minority ethnic backgrounds and were all undertaken in the United Kingdom (UK). Seven overarching themes were identified; awareness and beliefs about mental health, isolation and seeking support, influence of culture, symptoms and coping strategies, accessing mental health services, experiences of mental health services and what women want. CONCLUSION: Lack of awareness about mental ill health, cultural expectations, ongoing stigma, culturally insensitive and fragmented health services and interactions with culturally incompetent and dismissive health providers all impact on ethnic minority women's ability to receive adequate perinatal mental health support in the UK. Future research should focus on in-depth exploration of the experiences of these women across multiple European settings and interventions to reduce health inequalities among vulnerable mothers and families affected by perinatal mental ill health.

Expert commentary

This systematic review highlights the barriers experienced by ethnic minority women with perinatal mental illness to accessing mental healthcare in the UK. It also discusses difficulties experienced during healthcare delivery.

It emphasises that while there is a need for increased access to specialist perinatal mental health support in England (as outlined in NHS England’s Long Term Plan), an approach is required tailored to a population’s unique needs.

This may require liaison with agencies, such as the voluntary sector, with whom ethnic minority women may be more likely to engage; they can help women find a voice for their difficulties and signpost to sources of support. It also demands a culturally competent NHS workforce confident in managing the care of an increasingly diverse patient population.

Dr Claire Wilson, MRC Clinical research training Fellow; and Professor Louise Howard, NIHR Research Professor and NIHR Senior Investigator

Louise Howard is a trustee of a perinatal mental health charity, the Marcé Society, and has worked for NICE and NICE Scientific Advice on perinatal mental health.