According to NHS, Post Natal Depression (PND) is a common disorder affecting more than 1 in every 10 women. It can also affect the fathers or partners, however, less commonly occurring (NHS.UK 2018). As explained by the WHO report, the risk of PND is increased by poverty, acute stress, migration, experiencing violence (such as domestic, sexual or gender-based), emergencies, conflicts, natural disasters, and inadequate social support (WHO.int 2018). According to Edge (2006),all ethnic groups can be affected by PND; anddifferent barriers such as social, personal, economic and environmental factors can impede access to healthcare services. However some research also showsincreased prevalence of undiagnosed depression among theAfro-Caribbean community in the UK compared to their White counterparts (Berthoud and Nazroo 1997; Nazroo 1997; Shaw et al. 1999).
The objective of this systematic review is to study the factors associated with postnatal depression among the African Caribbean community in the UK. The study will include therevision of primary research studies done in the UK, and other journals that discuss the intervention, treatment, prevention and risk factors of PND in the UK.
In order to investigate the prevalence of PND among African Caribbean Community living in the UK, a systematic search of three electronic resources and catalogues was conducted for peer-reviewed articles and journals. The electronic resources used were Scopus, Web of Science, Discover based on EBSCOhost interface, UTS library and NCBI. Google Scholar was also used to search for articles and journals.
Only journals and peer-reviewed articles that studied PND among African Caribbean women in the UK was selected, in order to build a secondary literature.
Keywords used: Postnatal depression + African Caribbean women, Postnatal depression, health inequalities +African-Caribbeans, treatment + postnatal depression, health + African Caribbean, ethnic women + mental health, barrier + mental health + ethnic minorities, stigma + discrimination + mental health
The inclusion criteria for the search includes primary research on postnatal depression, perinatal depression, and included African Caribbean women in the UK as the first criteria.However, there was no consideration on the size of participants for the primary studies, and any primary paper that discussed the topic was selected regardless of the sample size.
The study excludes secondary research, studies (primary or secondary) on populations other than AfricanCaribbean communities in the UK, studies (primary or secondary) on other forms of depression and also studies (primary or secondary) outside the UK, except for the incorporation of general ideas from global perspectives.
Several important factors were identified through the systematic review of the selected articles and journals, which will be discussed thematically. The key findings accumulated throughthe systematic review of primary studies are as below:
It has been pointed out that the lack of discourse about mental health issues by Afro Caribbean women in the UK may have resulted in their unfamiliarity as well as the inability to understand the aetiology, symptoms and their management of related mental healthissues such as PND. An unwillingness shown in general by African Caribbean women, to discuss openly about mental health increases the risks. Similarly, it has been identified that the unawareness of mental health problems by the public. Consequently, understandingof the causes and treatment (as per public understanding) of mental health issues differ greatly from that of the healthcare professionals. Such challenges eventually result in the formation of misconceptions and wrong beliefs about this mental health problem by individuals suffering from it.
Almond and Lathlean (2011) studied the equity and fairness in the providence of care to women suffering from PND, and found that the lack of understanding of the diverse requirements of the different ethnic minority populations in the UK, by the healthcare visitors or nurses. They pointed that because their training did not equip them with the right skills and knowledge to assess the needs of minority women and treat them effectively, and hence did not foster the development of cultural competency. Jirwe (2008) pointed out that cultural competency is the ability of the nurses to consider factors like the cultural background of the patient, their beliefs, values and traditions in the care plan, and that it is a necessary skill expected from nurses for the treatment of all patients. The unwillingness to discuss health issues could also be related to this lack of cultural competency.
Edge et al. (2004) pointed out that the self-concept of African Caribbean women to show them as ‘strong black women’ has been identified as a powerful counter to depression. This can be reflected upon by the long history of adversity faced by them in the form of slavery and racism. To survive the adversities, the Afro-Caribbean women had to increase their tolerance to it. This could have a significant influence on their willingness to seek help, and show themselves as strong individuals (Edge et al. 2004).
Missed opportunities to identify risks or prevent the onset of PND during antenatal contact has been studied by Edge (2010). In the study, the author interviewed healthcare professionals and African Caribbean women in the antenatal stage, and found that the participants did not consider the necessity of intervention for perinatal depression, nor were it considered as a risk factor for PND. The practitioners opined that in the presence of other medical conditions (like diabetes) tends to overshadow diagnosis of PND which results in the lack of any follow-up on the flagged cases. Studies by Evans et al. (2001) have shown perinatal depression as more common than postnatal depression, and recommended early screening for depression during the perinatal stage.Chabrol and Callahan (2007) suggested that antenatal classes, postnatal debriefing, and CBT can be effective to treat mothers at risk of PND. Other suggestions included postpartum check-ups,midwife support, social support and home care support as well as psychotherapy sessions.
It has been pointed out that the healthcare professionals are often unable to recognise the symptom of PND when presented by the Afro-Caribbean women. This further reducesthe trust of African Caribbean women in primary healthcare, reinforcing the belief that they will not be able to assist them. The lack of confidence and competence to identify PND were found to be recurrent themes.Such a view was also pointed out by Smith et al. (1994) in his study he concluded that a lack of knowledge by obstetricians and midwives acted as barriers to the provision of information about prenatal screening tests. Hunter (2001) also proposed that the midwives should be able to understand emotions at work that can allow improvement in their own working lives as well as meet the care needs of a childbearing woman.
Keating and Robertson (2004) pointed out that mistrust and fear experienced by the ethnic minorities, combined with reluctance to seek help, fear of criticism is caused due to an environment of misunderstanding, prejudice and misconceptions. This fear further affects their interaction with healthcare service, cause adverse health-seeking behaviour (Keating and Robertson 2004; Keating et al. 2002). This also can result in underutilization of healthcare service by the vulnerable groups (Baker et al. 2002).McLean, Campbell and Cornish (2003) also pointed out those ethnic minorities like African Caribbean communities have a reduced likelihood to be offered counselling services. This further increases their fear to seek help and thus exert negative effect on both mental and physical health as of individuals (Baumeister, Twenge and Nuss 2002; Marmot 2005)
According to Edge et al.(2004) stigmatization associated with mental health dysfunctions often result in the women not seeking medical assistance, and moreoverthey would seek help only if their condition was affecting the well-being of their children and their family. The African Caribbean women seemed to take pride in their resilience to adversity that strengthens their collective sense of self-worth (Edge et al. 2004).Thornicroft (2008) also pointed out that prejudice against people with mental health conditions coupled with the expectations of being discriminated due to such problems increases the chances of avoiding help and treatment.
Almond and Lathlean (2011) mentioned that healthcare policies in the UK are designed to provide treatment for everyone in the same way and equally, along with the principles of horizontal equity. Currently, the services available for postnatal depression include health visitor programs and perinatal counseling for early intervention.The support also involves delivery of interpersonal therapy, cognitive behavioral therapy, and support for anxiety disorder and treatment for post-traumatic stress disorder (Gov.uk 2018). Furthermore, NHS hasalso pledged more support to be provided to women with postnatal depression who suffered stillbirth, miscarriage or death of their babies. This can provide support to the high risk group, and protect their well-being. This addresses the care needs pointed out by Chabrol and Callahan(2007).
In the UK, the prevalence of PND is mostly due to a combination of a lack of understanding of the disease and its symptoms by those suffering, which decreases their propensity to seek medical assistance (Jorm 2000). The self-construct developed during the times of slavery, when women needed to be strong for their family, which they instilled vigorously unto their children, to allow them to cope up with the disadvantages they were born into (Edge et al. 2004). In the face of socio-cultural, political and historical adversities endured by them, depression was not considered either appropriate or proportionate to the situation (Edge et al. 2004).
Also, Almond and Lathlean (2011) highlighted the lack of cultural competencies possessed by the healthcare visitors, while Edge (2010) pointed out the inability of the healthcare professionals to identify the early symptoms and risks of PND(2002) mentioned that being a member of ethnic minorities can be associated with social exclusion and social vulnerability and can cause poorer health outcomes which may increase the risks of mental health issues among these vulnerable groups. The equity policy of healthcare also fails to address the existing inequalities or prevent them, instead aiming provision of equal treatment for everyone (Almond and Lathlean 2011). Gary (2005) suggested that the combination of stigma and being a part of an ethnic minority can adversely affect the well-being of individuals suffering from mental health problems. Curtis and Lawson (2000) found a distinctive pattern in the reporting of illness among African Caribbean minorities, which is supported by the studies conducted by Edge (2006) that found these women are unlikely to consult a medical professional for perinatal depression. This further reduces the chances of the early diagnosis of PND.
Chabrol and Callahan (2007) suggested that preventative measures for PND should include antenatal classes and groups, postnatal debriefing and cognitive behavior therapy for mothers at risk. Such factors can help in the early identification of PND as well as extend support and offer follow-ups for mothers suffering from it.
Conclusion:
With an overview of the abovementioned factors, it can be concluded that an increased understanding of the symptoms and risks of PND among pregnant women can increase the chance of self-reporting. Healthcare professionals should also possess cultural competencies apart from the required clinical competency.De-stigmatisation of mental health problems is also needed, to encourage people to report their mental health conditions.The African Caribbean women should be encouraged to seek assistance for mental health issues, which with an understanding of the disease can improve their reporting. Interventions like cognitive behaviour therapy; counselling and psychotherapy can be useful for helping mother diagnosed with PND. Effective communication should be fostered between the community and health practitioners and healthcare services to ensure adequate reporting of the problem and provide the mother adequate information to understand their condition in order to help them better.
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