This research was contracted by the Northern Region District Health Boards to provide understandings of the factors driving Asian women’s low access rates into maternal mental health services and to identify actions to improve access and maternal mental health outcomes for Asian women during the perinatal period (from pregnancy to the first year after childbirth). The research questions were:
a) What are Asian women’s emotional health and wellbeing and their experiences of help-seeking when they have experienced mental distress during the perinatal period?
b) What are the barriers to accessing mental health and support services experienced by Asian women in relation to perinatal mental ill health?
c) What are Asian women’s perceptions and acceptability of perinatal mental health services in New Zealand?
d) What actions can be identified to improve access and maternal mental health outcomes for Asian women in the perinatal period?
The study used a qualitative inductive thematic research design. A total of 48 interviews were completed between November 2020 and February 2021. They included 17 women during the perinatal period from five Asian sub-groups (six Chinese, four Japanese, three Indian, three Korean, and one woman of a refugee background), nine family members (seven husbands/partners and two mothers of women), six community group representatives (e.g. mothers’ group facilitators, parent support group coordinators), and 16 healthcare providers (Asian or non-Asian) involved in the care of Asian women during pregnancy and postnatally (e.g. general practitioners (GPs), midwives, Plunket nurses, social workers, counsellors, psychologists, psychiatrists). The use of triangulation, or obtaining information from multiple data sources, helped to bring forth different points of view and perspectives of the participants and promote a more comprehensive understanding of the phenomenon under study.
The research identified a range of challenges encountered by Asian women and families during the perinatal period. The key cultural challenges are related to Asian women’s traditional roles as homemakers and mothers. Hence, compared with women from more individualist cultural backgrounds, Asian women tend to feel a huge amount of responsibility about their babies, and often put the needs of their children and husbands before themselves. Asian women’s cultural background makes it challenging for them to seek help from outside of the family. Many Asian women also face migration-related challenges, which have intensified during the COVID-19 pandemic when border closures keep them separated from their extended families overseas. With no immediate family support in New Zealand except their husbands, many Asian women are solely responsible for caring their babies at home most of the time. Feelings of exhaustion, loneliness and emotional isolation can impact on their relationship with their husband, other older adults in the family as well as their own mental wellbeing.
Our research explored Asian women’s experiences of help-seeking for their mental health concerns during the perinatal period. There were substantial variations in Asian women’s emotional states during the perinatal period, their help-seeking intentions and sources and their experiences of using or not using mental health services and other support. Of the 17 Asian women interviewed, only two had ever used specialist maternal mental health services in New Zealand. One woman sought telephone counselling, and five sought help from GPs, midwives and Plunket nurses for their mental health difficulties. For these participants, the support provided by family was a major factor for seeking help. GPs, midwives and Plunket nurses were also important. They helped to identify and provide support for early-stage mental health issues, and made referrals to specialist mental health services if needed. Henceforth, having family support, and having trust and confidence in health professionals are important factors affecting Asian women’s utilisation of perinatal mental health services. Moreover, having culturally- and linguistically-matched practitioners, assurance of confidentiality and provision of free or low-cost services would also improve the effectiveness and acceptability of services.
Multiple barriers to access mental health services and support were identified. The biggest barriers are the social stigma attached to mental ill health and the harmful effects of discrimination, followed by language difficulties, lack of access to appropriate interpreters, poor understanding of perinatal mental health problems and Western treatment approaches, and lack of awareness of the New Zealand health system and services. Other practical issues that may impact on Asian women’s access to perinatal mental health support include limited financial capacity, domestic responsibilities and lack of transport.
There are also systemic barriers preventing Asian women from receiving mental health services across primary, secondary and tertiary levels. GPs, midwives and Plunket nurses are the first point of contact for health advice and services by the majority of Asian women during pregnancy and postnatally, however failure to recognise somatic presentations of mental health problems can result in missed opportunities to identify Asian women’s perinatal mental health problems at an early stage. The under-recognition of mental health problems at the primary care level can delay treatment and referral to secondary and tertiary mental health care. Furthermore, the triage of referrals is done by a referral management team. The problems of the triage process may include insufficient information provided in the referrals, and under-diagnosis due to a lack of recognition of cultural elements in psychiatric diagnosis. This may result in under-treatment of some Asian patients.
Based on the study findings, recommendations for actions to improve access and maternal mental health outcomes for Asian women in the perinatal period are made.
1. Actions to enhance health literacy and promote early help-seeking.
• Promote perinatal mental health of Asian women through incorporating a focus on perinatal mental health within existing antenatal and parenting classes, and supporting Asian women to join mothers’ groups to develop social networks and reduce isolation.
• Promote mental health and wellbeing of fathers and other members of the extended family through delivering fathers’ programmes to promote positive parenting for men and providing parenting education for grandparents. The programmes will also help to raise awareness about perinatal mental health and promote the mental health and wellbeing of families.
• Develop culturally appropriate resources to de-stigmatise mental illness and promote early help-seeking.
2. Actions to improve early identification and intervention at primary care level.
• Upskill GPs, midwives and Plunket nurses to identify warning signs and possible risk factors for perinatal emotional issues, equip them with skills to support Asian women and their families, and provide early intervention or make referrals if necessary.
3. Actions to strengthen referral pathways to maternal mental health services.
• Improve primary-secondary care interface through improving the quality of referrals from primary care and referral management at secondary level.
4. Actions to foster growth of ethnic-specific counselling and support services.
• Improve Asian families’ access to services through providing culturally responsive, holistic care by practitioners who share the same cultural and language backgrounds. Areas of service include: empowering Asian women and families to manage their stress and mental health difficulties, providing cultural, psychological, social and practical support, assistance with navigating systems, and provision of education, information and resources.
• Improve timely access to professional interpreters.
• Promote better inter-agency referrals and communication.
5. Workforce development.
• Provide CALD cultural competency training and resources in health and social service sectors to improve understanding of cultural differences in the way different Asian groups may present with mental distress, their help-seeking patterns and cultural methods of supporting women’s wellbeing during pregnancy and postnatally.
• Peer review groups for clinicians for continuing professional development.
6. Future research.
• Potential areas of future research include: the experiences of fathers and families affected by perinatal mental ill health, and the services and support they need; interventions to improve the quality of referrals from primary care to specialist mental health services; and the effectiveness of using screening tools to detect depression among pregnant and postpartum women.
We have attached the full report below, also a summary of the report in Chinese, Korean and Japanese.
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