Postnatal Depression affects around 10-15% of mothers having their first baby. Depression during this time is seen as putting the mother at risk for the onset of a serious chronic mood disorder. Studies have indicated that women who do suffer from postnatal depression have a history of depression and psychosocial difficulties (Oates, 2004). Overall South Asians in Britain make up a total of 4% of the ethnic minority population living in the United Kingdom and 50% of the ethnic minority population (ONS 2004). Thus tackling the mental health needs of different cultures is a major public health concern for both commissioning and provider services. Overall research indicates the rates of suicide amongst South Asian women are higher than any other ethnic group (Bhugra, Desai & Baldwin,1999). Furthermore this rate is said to double for those women under the age of 30 (Bhugra, Desai & Baldwin 1999). Oates (2004) states that these factors are further exacerbated during the postnatal period. Thus the need to understand the causes and origins of depression amongst this cultural group is essential in order for health visitors to provide effective assessments and appropriate interventions.

However research looking at prevalence rates of Depression show little evidence of this illness amongst South Asians. For example this conclusion has arisen when looking at hospital admission rates. Cochrane (1977) found there to be lower admission rates for Pakistani Females and Males. This was further made evident in a follow up study conducted between 1971 -1981, which found that Pakistanis had low admission rates for all types of illness and disorders (Cochrane et al, 1989).

Similar findings have been found in G.P admission rates. Gillam et al (1989) provided more generalised findings in which he found that Asian women in general have low consultation rates for depression and various other mental disorders compared to white women. Thus it would be valid to conclude at this point that hospital admission rates suggest that Asians do not suffer from depression. However Nazroo (1997) disagrees with these findings. He points out that the instruments which are used in the study fail to accurately assess the prevalence of mental illness within Asians. Similarly Brewin (1980) found that there was no apparent difference in G.P consultation rates for Depression between Asian women and White women living in oxford. He also stated that the figures which have indicated low consultation and admission rates, do not reflect low rates of psychiatric treatments. One could therefore suggest that there are flaws in considering admission rates and identifying mental illness amongst South Asians. The consideration of prevalence rates is not the focus of the present review, however the possible causes of low admission rates amongst South Asians shall be considered throughout the review in relation to the research findings.

2.1 Role of the Health Visitor in assessing Postnatal Depression

The National Midwifery Council (2007) highlights Specialist Community Public Health Practitioner Nurses to be equipped with the skills and training to identify and assess mental health needs of mothers during the postnatal period. Furthermore, the National Institute of Clinical Excellence (2007) highlights the importance of health professionals identifying mental illness during the postnatal period and state:

“at a women’s first contact with primary care health care professionals (including midwives, obstetricians, health visitors and GP’S) should ask two questions to identify possible depression: During the past month, have you been bothered by feeling down , depressed or hopeless? During the past month have you often be bothered by having little interest or pleasure in doing things? A third question should be considered if a women answered yes to both clinical questions, such as is this something that you would want help with” .

Thus it is evident that identifying and assessing postnatal depression is pertinent to the role of the health visitor as they are in the frontline in providing early intervention and prevention. However, assessment of Postnatal Depression is challenging when faced with different cultural groups where behavioural, social, and cultural practices differ making assessment and treatments difficult.

Aim

The purpose of the present literature review is to examine the evidence regarding the causes of Postnatal Depression amongst South Asian Women. Thus through collecting and reviewing the research evidence is it proposed it will further expand our knowledge and understanding of Postnatal Depression amongst South Asian women. Furthermore, the review aims to make some recommendations for practice and identify some key areas in which the health visiting practice can further develop and propose various interventions which may be effective in addressing Postnatal depression amongst South Asian women.

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RESULTS OF THE LITERATURE REVIEW

Overall the final results included a total of 11 studies (refer to appendix) . The results indicated there to be a limit in the research on Postnatal Depression amongst South Asian Women. A total of two studies were identified within the search which had specifically looked at the origins of Postnatal Depression amongst South Asian Women . Furthermore these studies were conducted in Goa India, therefore there was question the generalisability of these findings being applied to population living in Britain. Thus it was decided to incorporate studies looking at Depression amongst South Asian women as it would contribute to understanding the origins of mental illness within this community. A number of categories emerged from the studies . These categories were further combined into a further sub categoroes (refer to figure )? categories. As a result the diagram shown (refer to Figure 1, p ) represents how the data was organised and the categories that emerged.

The origins of Depression within South Asian Women

Assessment of Depression within South Asian Women

Diagram to show the how findings were analysed

ORIGINS OF POSTNATAL DEPRESSION IN SOUTH ASIAN WOMEN

a) Research Question:

CULTURAL VUNERABILITIESb) Core Theme:

c) Higher Order:

ASSESSMENT

CULTURAL EXPECTATIONS

d) Lower order:

Extended Family Living Cultural Expression of Depression

Gender of the Newborn Stigmatisation

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Chapter 1:

THE ORIGINS OF POSTNATAL DEPRESSION IN SOUTH ASIAN WOMEN

This chapter will examine the evidence available regarding the causes or origins of depression in South Asian women. Overall the results have indicated that that the ’causes’ or ‘origins’ of depression are, due to the what the researcher describes as ‘Cultural Vulnerabilities’ which mean that they are a result of being exposed to an environment of which depression is a unavoidable response. The results are presented the following format, description of each theme along with the supporting evidence.

5.1.1 The theme of Cultural Expectations:

The theme of cultural expectations refers to those expectations formulated by the culture. Such expectations include conforming to cultural traditions. For instance living with the extended family aswell as pressures and expectations to have a male child. Living with the extended family largely refers to living with the mother and father inlaw, husbands brothers and sisters, which can lead to feeling oppressed with a number of family expectations. For example of the 11 articles reviewed the issue of extended family living occurred a total ? times within the studies as a cause of depression for South Asian Women. Shah-Sonuga-barke (2000) conducted a study looking at the relationship between the family structure and maternal mental health of two generations of Muslim and Hindu Women along with the influence this had on children’s behavioural problems. A total of 44 Muslim families and 42 Hindu families agreed to take part in the study. The mental health of the women was monitored using a Hospital Anxiety Depression Scale which is 14 item self report questionnaires. The results indicated that of 46% of the mothers and 40 % of the grandmothers scored above the scale for anxiety. Furthermore 29% of the mothers and 44 % of the grandmothers scored above the cut off point for depression, thus indicating that the majority of the randomly selected sample suffered from significant mental health issues. The findings indicated that grandmothers and children benefited from living in the extended family environment however it had detrimental effects on the maternal mother’s mental health status. Thus suggesting that the traditional extended family, amongst immigrant communities is not always of benefit to its members and in may in some circumstances contribute to the risk in mental health.

Similarly Hicks and Bhugra (2003) conducted a focus group study investigating the possible causes of suicide within South Asian women. A total of 180 South Asian women formed part of the convenience sample from 9 G.P practices and 24 South Asian community organisations in London area. The study was conducted in two parts the subjects were sent questionnaires focussing on the perceived causes of suicide and the findings from these results were formed the focus of discussion within the focus groups. The findings indicated that 90% stated a unhappy family situation to be causal factors. Thus further highlighting the family to be central in experiencing mental illness for South Asian Women.

The possible explanation for these results is that grandmothers that may have grown up in their country of origin where such traditions may have been easier to conform to as there is no exposure to the “western world”. Thus in some cases failure to understand this concept they may project the same values to a generations that is growing up and being exposed to different cultures. In contrast to this study, previous research which has looked at the benefits of extended family living have shown extended families to be a protective factor in alleviating depression in women. For example, Birchwood et al (1992) elaborates on how extended family living reduces the likelihood of suffering with depression and suggested that the support and practical advice offered in an extended family can moderate the risks associated with the development of mental illness.

Furthermore, on, Stainbrook (1954) suggested that the family structure plays a role in mediation of depression western cultures might be responsible for low levels of depression within South Asian Community . For example he stated that the frustrations and the problems which may be faced with in early life, for example marriage and new born are cushioned by the provision of many family members, who play a part in parenting within the extended family.

Tseng and Hsu (1969) identified how the extended family setting brings about low levels of depression. They conducted some research on Twianese family and found that living within the extended family creates a feeling of togetherness and stability and there is a feeling of belonging. Similarly Violtles et al (1967) stated that the role of the family is important in the sharing of loss, it reduces a sense of isolation which can result in depression.

It is acknowledged from the studies above that they were conducted on different cultural groups thus explaining the contrast in findings. However the implications of this in relation to health visiting practice and assessment of PND in South Asian women is that the perception of living with the extended family can be perceived as being positive it may be observed that these women living in a extended family setting are in a supportive environment however it is this environment which can initiate depression for South Asian women.

Furthermore previous research that has highlighted the benefits of the extended have been conducted in 50s, 60s and 70s which poses question on the historical validity of these findings to the present day. The question of whether the findings are applicable to todays population are brought to light. Further on, the research has been conducted on specific cultures therefore is not applicable to ‘all’ cultural groups, and further highlights the complexity of identifying ‘causal’ factors.

The limitations of the two studies are that they both used a small random sample thus posing questions on the generalisability of the findings. Furthermore the Hicks and Bhugra (2003) recruited only a English speaking sample thus the results are representative of those who are educated only , however recruiting from a sample that spoke little English would have increased the validity of the findings. However the validity of the study is increased as it is conducted in two parts using both a qualitative and quantitative approach thus increasing the validity of the findings.

In contrast Hussan and Cochrane (2002) conducted a qualitative study using the grounded theory approach to explore the perception and causes of depression in South Asian Women. The researchers interviewed 10 women in Punjabi, Urdu and English who were suffering from depression, along with their carers who were also interviewed about the causes of depression . The results of the study indicated that conflicting cultural expectations were initiators of depression. The women stated that moving from their country of origin had fragmented the family set up therefore there was a sense of loss and lack of support from the extended family. They stressed that the extended family provided them with support when carrying out daily activities however moving to England there was too many expectations placed upon the women to fulfil the role of the mother, and wife and carrying out all the duties to maintain the respect of the family. This finding contrasts to previous findings which highlight the extended families to be contributory in initiating depression for women. A possible explanation for these results are that migrating from their country of origin involves the individuals leaving behind their homes and their culture. It is a period of adjustment into a new environment which can inturn lead to experiencing a sense of loss and isolation. In some cases this sense of loss can be like a mourning process which can take place at least until the new culture begins to replace some of the old ties. These feelings of loss are expected to be a normal process but if a women for example emigrates from her country of origin and fails to find a substitute for what she has left behind then it interfers with the adaption process. Thus these feelings of loss can inturn result in psychological and distress and illness. Therefore the role of the extended family in this case is protective.

5.1.3. Gender of the new born

The gender of the new born has been highlighted to further initiate Depression for South women. Overall the studies indicated that there was a general preference for a male child. Being a female was considered to be a burden on the family. Thus the expectation to produce a male child places a huge expectation on the mother adding to her pressure to conform to these cultural expectations. Jambunathan (1992) studied 30 women in Madhuri India and examined social cultural factors in the development of depression. The interviews revealed that females were believed to be a curse on the family. For example one of the participants within the study stated that: “instead of being born a girl it is better to be born a free sparrow or a crow…or one should die…” (p264) . The participants within the study believed that females produced a burden on the family in relation to their marriage prospects aswell as financial stress in giving of dowries. The male was preferred as it was believed they would support them in old age and more importantly carry on the family name (Jambunathan 1992).

Furthermore, Patel et al (2002) examined the cultural specific factors such as the gender of the infant and the association with Postnatal Depression. Indian women were recruited who were mostly Hindu in origin (89%) from Goa India who participated within the study. The results of the study indicated that at 6-8 weeks 23 % of the women had postnatal depression. At 6 months a total of 22 % of the women were depressed. 14 % of the women were considered to be chronically depressed. The results indicated that gender of the newborn was significantly associated with the development of postnatal depression. The results also highlighted marital violence to be significantly higher if the infant was a girl but lower if the infant was a boy. The results suggested overall there is a preference for a male infant within this cultural group. The data was collated over a period of 6 months using two different measures. Firstly the General Health Questionniare was employed and the EPDS was used postpartum. The problem with using the two different scales were that they may both measure different aspects of depression this is not made clear within the study. Furthermore the Konki version of the scale was utilized. The validity of the scale was investigated using a two stage pilot study thus there was no confirmation this was only a pilot study. The sample was located from a hospital setting therefore it puts question on the reliability of these findings to be generalised to the population of Goa, even though thes study concludes it to be representative of the population in Goa.

Roderugues et al (2003) conducted a study which looked at the attitudes and perceptions of mothers towards childbirth. The results indicated that the poor relationships with the mother-inlaw, and husbands caused a great deal of distress for the women within the study. Furthermore the women in the study further claimed that the birth of a daughter further caused problems within their relationships with the family and the In-laws. Furthermore the gender of the infant was recognised by the fathers as being a possible cause of nerves for their wives. These findings further suggest that the cultural factors initiate depression. This study adds further strength to the previous study as the study incorporates the fathers and their perceptions. Furthermore the results are compared with depressed and non depressed women , increasing the generalisability of the findings to the general population.

In contrast to these findings Goyal et al (2005) investigated whether such cultural factors such as the gender of the infant and arranged marriages are associated with the development of Postnatal. This was a quantitative study which involved administering the PPDS a Postpartum Depression scale to 58 self selected immigrant Asian Indian women between 2 weeks and 12 months postpartum livin in the USA. The researchers attached additional 14 questions including the age ethnicity and education , occupation, marital status and whether it was arranged and the years living in the U.S. Furthermore medical information regarding the pregnancy, type and the gender of the newborn was recorded aswell as the gender of the previous children. 69 % of the women reported in having an arranged marriage. Women were well educated with at least 50% having a masters degree 43% were described as house makers. A total of 59 % gave birth to a male infant and 41% gave birth to a female infant. Previous history of depression was reported in 7% of the women. The results indicated that 24% screened positively for symptoms of depression and the results indicated that there was no statistically significant difference in the level of depression of those women that had an arranged marriage compared to those who had not had an arranged marriage. Furthermore there was no statistical significance in relation to the gender of the newborn and depression.

A possible explanation for the difference in these results are that three of the studies which have indicated gender of the offspring to be a initiator of depression were conducted in the participants country of origin, where such cultural traditions and beliefs maybe more prevalent. Whereas Goyal et al’s (1998) study was conducted on a sample of women who were educated and living in an environment where they were exposed to western beliefs and traditions thus such cultural beliefs were perhaps difficult for the participant to hold.

In relation to the practice implications of these studies suggest that if gender of the newborn is a factor then the antenatal visits perhaps should question whether there is a preference for male child and whether there are any expectations and pressures placed upon them by the extended family.

6

Chapter 2

Assessment of Postnatal Depression in South Asian Women

This chapter will examine the evidence available regarding the assessment of depression in South Asian women. Overall there is possible reasons as to why depression is difficult to assess these being the stigma surrounding the illness , the communication of distress, and the tools employed to assess depression in south asian women to be factors which can make assessment of cultural factors which have been discussed in the previous chapter difficult to detect. The results are presented the following format, description of each theme along with the supporting evidence.

5.1.1 Communication of Distress

Words that represent emotional status in many European languages have been found not exist within the South Asian culture. Wilson and McCarthy (1994) found that South Asians living in the UK express their depression somatically. The study screened a total of ? patients in G.P practices It was found that Asian patients reported having a physical problem alone rather that a mental problem compared to White patients. Thus this may lead to the indigenous population being correctly diagnosed as having depression that the Asian population. Similarly Odell et al (1997) suggested that Asian patients tended to focus much more on the physical symptoms, thus it therefore made it difficult for G.Ps to detect depression. Thus suggesting that if the G.P is unable to detect depression accurately in Asian women they are less likely to visit their G.P. This suggests a possible reason for low consultation rates between Asian patients and Health professionals. Rack (1979) found that in the Asian Culture there is no acknowledgement for the word of depression being a mental illness. It was found that in the Asian culture Asians perceived illness as being judged by the degree of social dysfunction. Therefore if a women failed in her social roles then her illness would become apparent. On the other hand if a women expresses internal distress it is not recognised.

Karaz (2005) compared depressive symptoms within two cultural groups. 36 South Asian immigrants and 37 European Americans were presented with vignette describing symptoms of depression along with a semi structured interview. The results indicated there were significant differences in the representation of depression. It was identified that depression for South Asian Women was measured through a breakdown of relationships within the family; in particular reference was made to their relationship with the extended family and husbands. In contrast European Americans characterised depression in relation to their biology and hormonal imbalances. This suggests that even if the symptoms of depression are prevalent . the recognition, and understanding and treatment of the illness is different across cultures.

Gausia et al (2009) investigated the prevalence of PND amongst South Asian Women within the sub district of Bangladesh. A total of 346 women were followed from late pregnancy to early postpartum period. The risk factors identified were formulated using a questionnaire and women were followed up and administered the EPDS scale which was validated using the BANGLA version . they identified that PND could be predicted by a number of variables these being depression in pregnancy , prenatal death, poor relationship with mother in-law or husband mother or wife.

It is evident from the literature that there are clear differences in the way in which depression is expressed within cultures. In order to diagnose the symptoms it is essential to have an understanding of the language, culture beliefs and values as it appears that these values play a part in the attitude of the sufferer. Therefore due to this in-depth knowledge of the persons culture there is question on the western diagnostic tools when interpreting illness, it is questionable whether these western diagnostic tools can be used with non western populations? Research has indicated that there are a number of problems of interpreting depression in different cultural groups, they have all concluded that there is a need to be more culturally aware and to consider social, cultural and economic aspects of a person’s life as well as their attitudes and beliefs. Furthermore it highlights why depression rates are reported to be low in this community it is because of these cultural specific factors that rates of depression within this community may be lower or higher than originally assumed.

Communication of distress

Words that represent various emotions have been found not to be present within the some languages. Another possible reason for depression within the South Asian women is the issue of stigma Attached to illness within the Asian community. The illness of the mind is perceived as being madness within the culture and believed to be incurable. Therefore those suffering from the illness will not come forward for treatment. Furthermore those suffering from depression before marriage, their chances of getting married were reduced as the community was aware of this. I f the women however married and their depression arises there is pressure placed on the husband to remarry (Cochrane and Hussain 2002). Similalry Karaz (2005) further highlighted the stigma associated with the illness as South Asian women would refer to depression as being “pagal” or “crazy” which inturn affects her status within the family. These studies suggest depression is part of the living experience for these women for example migrating to a new country or family. Thus it appears that asian women have internalised these beliefs , it then acts as barrier to them seeking any treatment or making their illness known. For this reason depression is likely to be high amongst this group .

For example the role of the family again was a key instigator and asell a)s expectations placed upon the female to fufill the duties of a mother, wife and daughter -inlaw. Further areas identified to initate depression for women were migration from their country of origin

Thus it is evident at this point there is a issue of personal space when living in this environment. The women may feel their personal space is expected to be shared amongst this environment. Thus in moving away from such traditions she is forced into their way of living thus creating a conflict between the generations and cultures.

6

Assessment of Postnatal Depression in South Asian Women

Problems of measurement of depression across cultures:

It is evident from the literature that there are clear differences in the way in which depression is expressed within cultures. In order to diagnose the symptoms it is essential to have an understanding of the language, culture beliefs and values as it appears that these values play a part in the attitude of the sufferer. Therefore due to this in-depth knowledge of the persons culture, it is questionable whether these western diagnostic tools can be used with non western populations? Research has indicated that there are a number of problems of interpreting depression in different cultural groups, they have all concluded that there is a need to be more culturally aware and to consider social, cultural and economic aspects of a person’s life as well as their attitudes and beliefs. Furthermore it highlights why depression rates are reported to be low in this community it is because of these cultural specific factors that rates of depression within this community may be lower or higher than originally assumed. This Chapter will focuss on the the validity of such tools such as the EPDS in indentifying Depression amongst South Asian Women.