‘There's something in their eyes’ - Child Health Services nurses’ experiences of identifying signs of postpartum depression in non-Swedish-speaking immigrant mothers

Experiences of health professionals in screening for postpartum depressive symptoms: a qualitative systematic review

OBJECTIVE

The objective of this review is to assess and synthesize the available qualitative evidence on health professionals' experiences in screening for postpartum depression (PPD).

INTRODUCTION

PPD is a significant public health problem. Clinical screening is essential to develop appropriate interventions to meet the needs of women and their families. The findings of this review have important implications for decision-making and policy development for continuous professional development programs that promote evidence-based PPD screening.

INCLUSION CRITERIA

This review considered studies that explore the experiences of health professionals who screen for PPD in any geographic location at any health care facility, scenario, or setting. The review focused on qualitative data, including methods such as phenomenology, grounded theory, ethnography, action research, and feminist research.

METHODS

The review followed a 3-step search strategy in line with JBI methodology for systematic reviews of qualitative evidence. The databases searched included PubMed, CINAHL (EBSCOhost), Embase (Elsevier), Scopus, LILACS (BVS), ScienceDirect (Elsevier), PsycINFO (Ovid), Index Psi Journals (BVS-PSI), and PePsic (IPUSP). Unpublished studies were searched for in Google Scholar, Cybertesis, Dart-E, EthOS, and Open Access Theses and Dissertations (OATD). Two independent reviewers evaluated the included studies for methodological quality and extracted data using the JBI data extraction and synthesis tools. Studies published in English, Portuguese, and Spanish from database inception until October 2023 were included.

RESULTS

Twenty-four qualitative studies from 14 countries across 5 continents involving 392 health professionals were included. A total of 113 findings were extracted and grouped into 5 categories: i) education and training; ii) responsibility of PPD screening, referral, and follow-up: role of the job and work overload; iii) screening, referral, and follow-up; iv) disclosure, judgment, culture; v) and health system structure. Two synthesized findings evolved from these categories: i) The need for training and ongoing education, professional role, professional practice, and ways of caring in screening postpartum women for depressive symptoms; ii) External barriers, facilitating factors, and health system issues.

CONCLUSIONS

Health professionals' experiences caring for women and families concerning PPD are influenced by their culture, practices, training, and worldview. Regular workshops and practical training sessions that emphasize the development of PPD-screening skills, particularly in recognizing subtle signs of depression and conducting culturally sensitive assessments, could be highly effective for health professionals. Policymakers should collaborate with health care professionals to develop and implement policies tailored to different contexts and cultures. Providing educational subsidies and ensuring monitoring and follow-up after PPD screening are fundamental for the sustainability of PPD screening and management.

Screening instruments for antenatal and postpartum mental health disorders in migrant women: a systematic review

PURPOSE

Maternal mental health disorders are prevalent among migrant women. Due to the association of these disorders with adverse pregnancy outcomes, early recognition, and referral are important. This review aims to provide an overview of the literature on mental health screening for migrant women during pregnancy and the postpartum period.

METHODS

We systematically searched PubMed, EMBASE, and PsycINFO, covering publications before July 15th, 2024. Database searches were supplemented by a grey literature search, which included a systematic Google and Google Scholar search, hand searching of reference lists, and citation searches. Quantitative, qualitative, and mixed-method studies published in any language were included if they evaluated or validated screening methods for maternal mental health disorders in first-generation migrants. Screening for eligibility, data extraction, and quality appraisal were conducted by two independent researchers. Results were summarized narratively.

RESULTS

Among the 3035 records screened, 30 articles met the inclusion criteria. Our findings indicate that health care providers and migrant women recognize a substantial need for maternal mental health screening, especially for depression, and in a lesser quantity for anxiety and PTSD. We describe a range of barriers and facilitators that impact the quality and feasibility of mental health screening. Research on available screening instruments in migrant populations reports reasonable accuracy, reliability, and validity. However, qualitative evaluations question the screening instruments' cultural appropriateness and translatability.

CONCLUSIONS

There is an urgent need for the development and implementation of maternal mental health screening programs tailored to pregnant or postpartum migrants. Further research is essential to enhance the effectiveness and cultural sensitivity of these screening programs.

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.

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.

Experiences of nurses caring for involuntary migrant maternal women: a qualitative systematic review

OBJECTIVE

The objective of this review was to identify, critically appraise, and synthesize qualitative evidence on the experiences of nurses providing care within various health care delivery environments to involuntary migrant women who are experiencing pregnancy, birth, or post-birth.

INTRODUCTION

Nurses are central to providing care to populations experiencing inequities. These populations include forcibly displaced pregnant and/or mothering women who have migrated involuntarily. Most of these women are ethnically diverse and often experience poverty and low literacy. This review is focused on the experiences of nurses providing care to these women.

INCLUSION CRITERIA

This review considered qualitative, peer-reviewed studies published in academic journals. Studies and study abstracts that examined nurses' experiences of providing care to involuntary migrant maternal women were included. Women could be pregnant and/or mothering. All settings in which nurses practice were considered.

METHODS

Information sources that were systematically searched for this review included CINAHL (EBSCO), PsycINFO (EBSCO), MEDLINE (EBSCO), PubMed (NLM), Web of Science, and Google Scholar. A gray literature search in Google was also developed. Studies published in English from 2000 onward were considered. Final searches were conducted in January 2021 using language within database thesauruses, such as CINAHL headings and MeSH terms, as well as keywords related to qualitative inquires on experiences of nurses caring for involuntary migrant maternal women. An intersectionality lens was applied within all review methods. Study selection was conducted by two reviewers who screened titles and abstracts that aligned with the inclusion criteria. The review followed the JBI approach for critical appraisal, data extraction, and data synthesis.

RESULTS

Twenty-three qualitative studies were included in this review. Qualitative methodologies within these studies included case study, ethnography, interpretive descriptive, and grounded theory. Nine studies considered the sex of participating nurses, and three studies considered participant history of migration. A total of 115 findings were pooled into four categories and aggregated into the following two synthesized findings: i) Nurses integrate cultural and linguistic diversity within practice; and ii) Nurses assess for inequities resulting from forced migration on maternal women. Study quality was rated as moderate on ConQual scoring, with dependability rated as moderate and credibility rated as high.

CONCLUSIONS

Key implications are made within nursing education programming, nursing practice, and policy analysis. In the realm of nursing education, integration of migrant status as a health determinant will enhance nurses' skills in assessing migrant status and understanding how varying statuses contribute to barriers among involuntary migrant women accessing health services. Providing ongoing education to nurses centered on trauma and violence-informed practice is recommended. With regard to nursing practice, review findings revealed the need for creative solutions to overcome language barriers. Innovative approaches for nurses working across language barriers in acute and community health contexts when interpreter services are not available need further exploration and protocol integration. Examination of clinical care pathways is needed for inclusion of involuntary migrant women, and exploring assessment strategies targeting how migrant status contributes to limited health service accessibility. For policy, organizations need to build policies that promote examination of migrant status and its health impacts among involuntary migrant maternal women exposed to migration-related trauma and violence to support nurses in their care provision.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42019137922.

Health care professionals’ experiences of screening immigrant mothers for postpartum depression–a qualitative systematic review

Introduction

Postpartum depression is considered a major public health problem, which immigrant mothers are at particular risk of being affected by, but it can also have long-lasting traumatic effects on the child’s health and development. The Edinburgh Postnatal Depression Scale is the world’s most commonly employed screening instrument for postpartum depression, used in connection with a clinical interview to screen for symptoms of postpartum depression. The aim of this study was to synthesize health care professionals (HCPs) experiences of identifying signs of postpartum depression and performing screening on immigrant mothers, since previous research suggested that this task might be challenging.

Methods

The databases CINAHL, PubMed, PsycINFO, SocINDEX, Embase and Cochrane were searched for papers published January 2000–December 2020, reporting qualitative data on immigrants, postpartum depression and the Edinburgh Postnatal Depression Scale. Eight papers representing eight studies from four countries were included and the Critical Appraisal Skills Program was used to assess their quality. The synthesis of studies was guided by Noblit & Hare’s seven-step method based on meta-ethnography.

Findings

The synthesis resulted in two final themes: “I do my best, but I doubt that it’s enough” and “I can find no way forward”. The themes convey the fear and frustration that health care professionals experienced; fear of missing mothers with signs of postpartum depression, related to feeling uncomfortable in the cross-cultural setting and frustration in handling difficulties associated with communication, translated versions of the Edinburgh Postnatal Depression Scale and cultural implications of postpartum depression.

Conclusions and clinical implication

By supporting HCPs’ self-efficacy in handling cultural implications of postpartum depression and by developing evidence-based clinical guidelines for the use of interpreters and translated versions of the Edinburgh Postnatal Depression Scale the screening of immigrant mothers may be facilitated.

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.

Cultural competence and experiences of maternity health care providers on care for migrant women: A qualitative meta-synthesis

BACKGROUND

The United Nations Sustainable Development Goals 2030 aim to reduce health care inequity and maternal and infant mortality rates amongst marginalized populations. To provide adequate and culturally relevant maternity care for minority ethnic groups, it is imperative to examine health care providers' views on care for migrant women. We reviewed published accounts of views and experiences of maternity health care providers providing maternity care for migrant women as a way of exploring their cultural competency.

METHOD

A qualitative meta-synthesis was conducted. Systematic searches were conducted in five electronic databases from inception dates through February 2021. Qualitative data were analyzed using a framework thematic analysis based on Campinha-Bacote's five-component cultural competency model.

FINDINGS

Eleven studies were included. Findings were presented according to Campinha-Bacote's model: cultural awareness, cultural knowledge (personal responsibility, familial role and cultural influence, the influence of social and system factors, conflicting maternity care expectations), cultural encounter (language and communication), and cultural desire (establishing trust and going the extra mile, resources to boost culturally competent care).

DISCUSSION

Our findings can inform the design of high-quality behavioral change, health care management, sociological, and other relevant studies, along with reviews of what matters to service users about cultural responsiveness. Our data also suggest that health system constraints can exacerbate the lack of cultural competency. Improving the quality of care for migrant communities will necessitate a joint effort between health care organizations, health care providers, policymakers, and researchers in developing and implementing more culturally relevant maternity care policies and management interventions.

First perinatal psychiatric episode among refugee and family-reunified immigrant women compared to Danish-born women: a register-based study

PURPOSE

This study aimed at examining psychiatric morbidity in the perinatal period among refugees and family-reunified immigrants compared to Danish-born women, including predictors of psychiatric morbidity according to migration history.

METHODS

Inclusion criteria were women who had a residence permit in Denmark and gave birth to a live child between 1 April 1998 and 31 December 2014. The study included 7804 refugee women, 21,257 family-reunified women, and 245,865 Danish-born women. We estimated Odds Ratios (ORs) of having a first-time perinatal psychiatric episode (PPE) and specific risk for affective, psychotic, and neurotic disorders.

RESULTS

Compared with Danish-born women, women family-reunified with immigrants had lower (aOR 0.37, 95% CI 0.22-0.64) and refugees had higher ORs of PPE (OR 1.46, 95% CI 1.22-1.76). In fully adjusted models, refugees no longer presented increased risk of PPE (OR 1.16, 95% CI 0.95-1.42) but showed higher ORs for psychotic (aOR 4.72, 95% CI 2.18-9.84) and neurotic disorders (aOR 1.31, 95% CI 1.01-1.72). Women family-reunified with refugees and to Nordic citizens had higher ORs of psychotic disorders. Among migrants, refugees had higher ORs of PPE.

CONCLUSIONS

Results suggest that elevation in risk of PPE among refugees compared to Danish-born may be related to higher likelihood of poverty and single-parenting among refugees. Still, refugees appear to have increased risk for neurotic and psychotic disorders. In contrast, family-reunified to immigrants may have lower risk of PPE. Maternal health programs need to focus on promotion of mental health and tackle social risks that disproportionately affect immigrant women, particularly refugees.

Postnatal depression and anxiety screening and management by maternal and child health nurses in community settings: A scoping review

OBJECTIVE

To examine the range and nature of primary research evidence on postnatal depression and anxiety screening and management by maternal and child health nurses within community settings.

BACKGROUND

Maternal and child health nurses are well-placed to identify and support women at risk of, or experiencing, postnatal depression and anxiety- a prevalent public health issue which remains largely undetected.

METHODS

Scoping methodology, guided by the Arksey and O'Malley (2005) framework, was used. The following electronic databases were searched in June 2019 and again in July 2020: Cumulative Index of Nursing and Allied Health Literature, MEDLINE, PsycINFO, and COCHRANE Library. Primary studies that were published in English, between 2008 and 2020, were included. PRISMA checklist and PRISMA flow diagram were used to adhere to best practice guidelines.

RESULTS

Twenty-three articles, relating to 22 studies, met the inclusion criteria. Two principal themes were identified: 'screening for postnatal depression and anxiety' and 'factors that influence postnatal depression and anxiety management'. Subthemes in the former related to attitudes toward screening, routine screening practice, screening efficacy, and attitudes toward the Edinburgh Postnatal Depression Scale. Subthemes in the latter included availability of formal care pathways, referral options, knowledge and confidence, and multiagency collaboration.

CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE

While maternal and child health nurses value their role in identifying and supporting mothers at risk of postnatal depression and anxiety, certain individual and organisational factors contribute to a gap between best practice and clinical practice. Narrowing the gap between evidence and practice is unlikely without directly addressing these barriers. Gaps in maternal and child health nurses' knowledge, skills and confidence regarding effective screening and management of mothers experiencing, or at risk of, postnatal depression and anxiety, impacts the quality of care provided. Ongoing training and professional development which adequately addresses these gaps is required.

Language barriers between nurses and patients: A scoping review

OBJECTIVE

Global migration and linguistic diversity are at record highs, making healthcare language barriers more prevalent. Nurses, often the first contact with patients in the healthcare system, can improve outcomes including safety and satisfaction through how they manage language barriers. This review aimed to explore how research has examined the nursing workforce with respect to language barriers.

METHODS

A systematic scoping review of the literature was conducted using four databases. An iterative coding approach was used for data analysis. Study quality was appraised using the CASP checklists.

RESULTS

48 studies representing 16 countries were included. Diverse healthcare settings were represented, with the inpatient setting most commonly studied. The majority of studies were qualitative. Coding produced 4 themes: (1) Interpreter Use/Misuse, (2) Barriers to and Facilitators of Quality Care, (3) Cultural Competence, and (4) Interventions.

CONCLUSION

Generally, nurses noted like experiences and applied similar strategies regardless of setting, country, or language. Language barriers complicated care delivery while increasing stress and workload.

PRACTICE IMPLICATIONS

This review identified gaps which future research can investigate to better support nurses working through language barriers. Similarly, healthcare and government leaders have opportunities to enact policies which address bilingual proficiency, workload, and interpreter use.

The Synergistic Influence of Life Experiences and Cultural Nuances on Development of Depression: A Cognitive Behavioral Perspective

The synergistic influences of everyday life experiences, societal expectations, and cultural nuances affect a person's ability to successfully manage their life and remain mentally healthy. Persons from culturally and ethnically diverse populations may incur depression when societal expectations and cultural influences are in conflict with each other. Chronic stress, often-referred to as toxic stress, contributes to the development of depression as it is unrelenting, beginning in childhood and continuing into adulthood. This article discusses connections between societal expectations, persons' cultural perspectives as well as the role that these connections may contribute to in the development of toxic stress and depression. Beck's Cognitive Behavioral Theory provides a basis to describe the role that synergistic influences play in development of depression for culturally and ethnically diverse persons.

‘Happy that someone cared’—Non-native-speaking immigrant mothers’ experiences of participating in screening for postpartum depression in the Swedish child health services

Immigrant mothers who have immigrated during the last ten years and do not speak the language of the new country are found to be at particular risk of being affected by postpartum depression (PPD). Still they choose to participate to a lesser extent in screening for PPD and are not screened out as frequently as can be expected. In this study, non-native-speaking immigrant mothers' experiences of participating in screening for PPD in the Swedish Child Health Services were elucidated. Thirteen qualitative interviews were performed with the help of an interpreter and analysed using latent content analysis. The possibility to participate in screening was appreciated by the mothers even though the concept of PPD in general was unclear. Cultural beliefs about mental ill health, negative expectations connected to their perceived value as a woman, shame at not being grateful enough for their new life and negative experience of the interaction during the screening challenged them in speaking about their mood. To facilitate the screening procedure for this vulnerable group of mothers, it is important to be aware of possible challenges when speaking about their mood and to strive for a trusting clinical interview with the assistance of a female interpreter on-site.