Recognition of Risk Factors for Postpartum Depression in Refugee and Immigrant Women: Are Current Screening Practices Adequate?

Diagnosis of Perinatal Mental Health Conditions Following Medicaid Expansion to Include Low-Income Immigrants

Importance

For some low-income people, access to care during pregnancy is not guaranteed through Medicaid, based on their immigration status. While states have the option to extend Emergency Medicaid coverage for prenatal and postpartum care, many states have not expanded coverage.

Objective

To determine whether receipt of first prenatal care services and subsequently receipt of postpartum care through extensions of Emergency Medicaid coverage were associated with increases in diagnosis and treatment of perinatal mental health conditions.

Design, Setting, and Participants

This cohort study used linked Medicaid claims and birth certificate data from 2010 to 2020 with a difference-in-difference design to compare the rollout of first prenatal care coverage in 2013 and then postpartum services in Oregon in 2018 with a comparison state, South Carolina, which did not cover prenatal or postpartum care as part of Emergency Medicaid and only covered emergent conditions and obstetric hospital admissions. Medicaid claims and birth certificate data were linked by Medicaid identification number prior to receipt by the study team. Participants included recipients of Emergency Medicaid who gave birth in Oregon or South Carolina. Data were analyzed from April 1 to October 15, 2023.

Exposure

Medicaid coverage of prenatal care and Medicaid coverage of postpartum care.

Main Outcomes and Measures

The main outcome was the diagnosis of a perinatal mental health condition within 60 days postpartum. Secondary outcomes included treatment of a mood disorder with medication or talk therapy.

Results

The study sample included 43 889 births to Emergency Medicaid recipients who were mainly aged 20 to 34 years (32 895 individuals [75.0%]), multiparous (33 887 individuals [77.2%]), and living in metropolitan areas (32 464 individuals [74.0%]). Following Oregon's policy change to offer prenatal coverage to pregnant individuals through Emergency Medicaid, there was a significant increase in diagnosis frequency (4.1 [95% CI, 1.7-6.5] percentage points) and a significant difference between states in treatment for perinatal mental health conditions (27.3 [95% CI, 13.2-41.4] percentage points). Postpartum Medicaid coverage (in addition to prenatal Medicaid coverage) was associated with an increase of 2.6 (95% CI, 0.6-4.6) percentage points in any mental health condition being diagnosed, but there was no statistically significant difference in receipt of mental health treatment.

Conclusions and Relevance

These findings suggest that changing Emergency Medicaid policy to include coverage for prenatal and 60 days of postpartum care for immigrants is foundational to improving maternal mental health. Expanded postpartum coverage length, or culturally competent interventions, may be needed to optimize receipt of postpartum treatment.

Prevalence, Risk Factors, and Interventions of Postpartum Depression in Refugees and Asylum-Seeking Women: A Systematic Review and Meta-Analysis

INTRODUCTION

Refugee women are at an increased risk of developing postpartum depression (PPD) due to a combination of various psychosocial stressors. This systematic review aimed to outline the prevalence of PPD among refugee women and explore related risk factors and interventions currently in practice.

METHODS

A search was conducted using MEDLINE, Embase, PsycINFO, CINAHL, and Core Collection (Web of Science) for articles published until August 2022, yielding 1,678 records.

RESULTS

The prevalence of refugee and asylum-seeking women was 22.5% (n = 657/2,922), while the prevalence of non-refugee/asylum-seeking women with PPD was 17.5% (n = 400/2,285). Refugee/asylum-seeking women face a unique set of issues such as domestic abuse, separation and lack of support, stress, pre-migrational experiences, prior history of mental illness, low income, and discrimination. Refugee/asylum-seeking women may benefit from support groups, individual support, self-coping mechanisms, and familial support.

CONCLUSION

This review identifies that a higher prevalence of PPD in refugee and asylum-seeking women compared to other groups can potentially be attributed to the unique risk factors they face. This warrants the need for further research as studies on interventions for this condition are limited among this population.

Postpartum depression and life experiences of mothers with an immigrant background living in the south of Sweden

PURPOSE

Postpartum Depression (PPD) -a common health problem for mothers' postpartum increases the risk of negative interaction between mothers and infants as it reduces the former's ability to respond to the latter's needs appropriately. Migrant mothers exhibit a higher prevalence of risk factors for PPD. Hence, this study aimed to investigate migrant mothers' life experiences pertaining to motherhood and PPD.

METHODS

Qualitative interviews were conducted with 10 immigrant mothers in the south of Sweden during 2021.

RESULTS

The qualitative content analysis revealed the following main themes: 1) PPD (two sub themes-psychosomatic symptoms and burden of responsibility due to feelings of loneliness); 2) mistrust of social services (one sub-theme-afraid of losing their children and Swedish social services' lack of understanding); 3) inadequate healthcare (two sub-themes-limited healthcare literacy for migrant mothers and language barrier; 4) women's coping strategy for well-being (two sub-themes-better awareness and understanding of the Swedish system and society, and freedom and independence in the new country).

CONCLUSIONS

PPD, mistrust of social services, and inadequate healthcare lacking personal continuity were common among immigrant women, thus precipitating discrimination-including lack of access to services because of limited health literacy, cultural differences, language barriers, and insufficient support.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

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

BACKGROUND

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

AIM

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

ETHICS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Screening Tools for Mental Disorders Among Female Refugees: a Systematic Review

Female refugees are particularly vulnerable to mental disorders but assessment may be complex and challenging. Various screening tools have been developed for this population, but little is known about their usefulness. The main aim is to examine the literature on the effectiveness of screening tools for mental health problems among female refugees. Systematic review of PubMed, PsycINFO and Embase to locate all published work. Comprehensive search terms were used and inclusion and exclusion criteria were formulated. The initial search yielded 877 articles, of which 757 were removed after titles and abstracts were reviewed. Then, 121 full-text versions of articles were examined and 96 excluded according to the criteria. A total of 25 articles were included in this systematic review in accordance with the PRIMSA guidelines. Twenty screening tools were evaluated. There is a lack of tools used to screen refugee women, and in particular those in emergency settings. Cultural factors may not be accounted for in the development of screening instruments. Further research in this field can help inform public health policies to address social, educational and occupational inclusion for refugee women in different contexts.

Disparities in postpartum depression screening participation between immigrant and Danish-born women

BACKGROUND

Qualitative studies suggest that immigrant women experience barriers for postpartum depression (PPD) screening. This study examines the prevalence of participation in PPD screening in the universal home-visiting programme in Denmark, in relation to migrant status and its association with acculturation factors, such as length of residence and age at migration.

METHODS

The sample consists of 77 694 births from 72 292 mothers (2015-18) that participated in the programme and were registered in the National Child Health Database. Lack of PPD screening using the Edinburgh Postpartum Depression Scale (EPDS) was examined in relation to migrant group and acculturation factors. We used Poisson regression with cluster robust standard errors to estimate crude and adjusted relative risk.

RESULTS

In total, 27.8% of Danish-born women and 54.7% of immigrant women lacked screening. Compared with Danish-born women, immigrant women in all groups were more likely to lack PPD screening (aRR ranging from 1.81 to 1.90). Women with low acculturation were more likely to lack screening. Women who migrated as adults [aRR = 1.27 (95% CI 1.16, 1.38)] and women who had resided in Demark for <5 years [aRR = 1.37 (95% CI 1.28, 1.46)] were more likely to lack screening.

CONCLUSIONS

Immigrant women in Denmark, particularly recent immigrants, are at increased risk of not being screened for PPD using the EPDS. This can lead to under-recognition of PPD among immigrant women. More work is needed to understand how health visitors recognize the mental health needs of immigrant women who are not screened, and whether this gap results in reduced use of mental health services.

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.

Immigrant Women and Mental Health Care: Findings from an Environmental Scan

Immigrant women's mental health is a growing public health policy issue. New immigrant mothers may be particularly vulnerable to less than optimal mental health following childbirth given the cultural and geographic isolation, socioeconomic factors, gender roles, and language difficulties that influence their postpartum experiences. The purpose of this environmental scan was to increase understanding of immigrant women's perinatal mental health care services within the interior of a western Canadian province. Four interrelated themes emerged to impact postpartum health of immigrant women: (i) community capacity building, (ii) facilitators of mental health support and care, (iii) barriers of mental health promotion and support, and (iv) public policy and postpartum depression. Knowledge gained from this study contributes to healthy public policy and practices that promote mental health and support among immigrant women.

Refugee and Immigrant Women's Experience of Postpartum Depression: A Meta-Synthesis

The aim of this work is to synthesize qualitative research on refugee and immigrant women's experiences of postpartum depression (PPD) to gain insight into the unique needs of this group of women. This population is more at risk of developing PPD due to a complexity of issues including pre- and postmigratory stressors; however, there is currently little research on this topic available to health care providers and policy makers. Thirteen articles met inclusion criteria, and five themes emerged from the meta-synthesis: (a) suffering in solitude, (b) the invisible illness, (c) cultural conceptualizations, (d) barriers to help seeking, and (e) facilitators of help seeking. Conclusions suggest immigrant women with PPD may lack understanding of their condition, are often isolated, are alone, fear stigmatization, and risk being considered an unfit mother. Raising awareness with health care providers of the meaning of PPD for immigrant women is key to the provision of effective care.

Postpartum Depression Screening Tools: A Review

OBJECTIVE

The purpose of this study was to analyze the accuracy of screening tools in detecting postpartum depression (PPD).

METHODS

A review of the literature was conducted using PubMed, Clinical Key, and Google Scholar from the years 2001-2016 with a modified PRISMA method. The keywords, "postnatal depression screening," "antenatal depression screening," and "maternal depression" were used in the search. Sixty-eight articles were reviewed, and 36 further analyzed.

RESULTS

The accuracy of screening tools was dependent upon a number of factors. The studies reviewed differed in the types of screening tools tested, the combination of screening tools administered, the timing in which screening tools were administered, the geographic location of patients screened, and the reference standard(s) used.

CONCLUSIONS

No tool could be deemed best at accurately detecting PPD on the basis of sensitivity and specificity. Additionally, there was no recommended time duration in which screening should be done. Thus, further research is needed to elucidate the accuracy of PPD screening tools, and the best criteria to determine this.

Detecting antepartum and postpartum depression and anxiety symptoms and disorders in immigrant women: A scoping review of the literature

A scoping review of the literature was conducted to compile existing evidence and identify gaps on detection methods and practices of antepartum and postpartum anxiety and depression symptoms and disorders in immigrant women. With the assistance of a health science librarian, four databases were searched between January and March 2016. Thirteen articles met the inclusion criteria and their findings were compiled using numerical summary and thematic analysis. No articles specifically addressing the screening of anxiety disorders or symptoms in antepartum or postpartum immigrant women were found. Some studies showed positive results for using translated tools. Other studies showed similarities in immigrant and non-immigrant assessment. However, several challenges in detection existed. Some of these challenges include cultural appropriateness of some questions and the accuracy of interpretive services and instrument translation. Limited literature was found, indicating a need to design and test targeted strategies to ensure that immigrant women are provided with appropriate antepartum and postpartum emotional support and mental health services based on appropriate policies and practices.

Systematic health screening of refugees after resettlement in recipient countries: a scoping review

CONTEXT

Health screening of refugees after settlement in a recipient country is an important tool to find and treat diseases. Currently, there are no available reviews on refugee health screening after resettlement.

METHODS

A systematic literature search was conducted using the online Medical Literature Analysis and Retrieval System ('MEDLINE') database. Data extraction and synthesis were performed according to the PRISMA statement.

RESULTS

The search retrieved 342 articles. Relevance screening was conducted on all abstracts/titles. The final 53 studies included only original scientific articles on health screening of refugees conducted after settlement in another country. The 53 studies were all from North America, Australia/New Zealand and Europe. Because of differences in country policies, the screenings were conducted differently in the various locations. The studies demonstrated great variation in who was targeted for screening and how screening was conducted. The disease most frequently screened for was tuberculosis; this was done in approximately half of the studies. Few studies included screening for mental health and non-infectious diseases like diabetes and hypertension.

CONCLUSION

Health screening of refugees after resettlement is conducted according to varying local policies and there are vast differences in which health conditions are covered in the screening and whom the screening is available to.

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.

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

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