Immigrant Women's Mental Health in Canada in the Antenatal and Postpartum Period

Abstract

Immigrant women constitute a relatively large sector of Canadian society. In 2011, immigrant women made up a fifth of Canada's female population, the highest proportion in 100 years; based on the current trends of immigration, this proportion is expected to grow over the next 20 years. As women immigrate and find themselves simultaneously experiencing an unfamiliar environment, being unacquainted with societal norms, and lacking vital social networks, they become vulnerable to mental health problems. This article aims to undertake a narrative review of the literature on immigrant women's mental health in Canada during antenatal and postpartum care by employing the transnational theory as a theoretical framework. The article starts with an overview of the theoretical framework, followed by a discussion on a literature review that particularly talks about culture, isolation and social support network, social determinants of health, and access to health care as elements to consider in avoiding mental health problem among immigrant women in antenatal and postpartum care. The literature shows a high number of depression among immigrant women, and mental health problems are higher among visible minorities than Caucasians. The highest antenatal and postpartum depression recorded are 42% and 13%, respectively. As Canada has long been and continues to be the land of immigrants, addressing the multiple factors affecting immigrant women's mental health is paramount to Canada truly achieving “health for all.”

Keywords

Immigrant women mental health depression antenatal postpartum transnational

Immigrant women constitute a relatively large sector of Canadian society. In 2011, immigrant women made up a fifth of Canada's female population, the highest proportion in 100 years; based on the current trends of immigration, this proportion is expected to grow over the next 20 years (Hudon, 2015). As women immigrate and find themselves simultaneously experiencing an unfamiliar environment, being unacquainted with societal norms, and lacking vital social networks, they become vulnerable to mental health problems (Mamisachvili et al., 2013). A study by Kirmayer et al. (2011) shows a prevalence of depression among immigrants of 10.7%; however, antenatal prevalence of depression was 32% among immigrant women and it can even reach 42% (Miszkurka, Goulet, & Zunzunegui, 2012; Zelkowitz et al., 2004), and almost 10% to 13% of women present postpartum depression (Leahy-Warren, McCarthy, & Corcoran, 2011). Consequently, health-care professionals need to establish appropriate strategies to meet immigrant women's psychosocial problems and needs (Khoo & Renwick, 2008).

Immigrant women often experience a disproportionate share of mental health concerns and mental illness linked to social determinants of health including employment, violence, socioeconomic status, race, and gender. As immigrants to Canada, women often carry a large amount of the stress and burdens of relocating and settling into a new country (MacDonnell et al., 2015). Key risk factors affecting the mental health of immigrant mothers include discrimination, lowered socioeconomic status, lack of social support, child care, transportation, housing, and food insecurity (Bodolai, Celmins, & Viloria-Tan, 2014). In a recent population-based study of postpartum mental health conducted by Vigod, Sultana, Fung, Hussain-Shamsy, and Dennis (2016), the reasons for observed higher rates of mental disorders among immigrant women were related to social risk factors, including low income, unemployment, intimate partner violence, and poor social support networks. This article aims to undertake a narrative review of the literature on immigrant women's mental health in Canada during antenatal and postpartum care by employing the transnational theory as a theoretical framework. Antenatal care is a regular check-up that a pregnant woman receives from midwife or doctor once she becomes aware that she is pregnant up to the delivery day. The postpartum period in this article will be considered as six weeks from the day a woman gives birth (World Health Organization, 2013; Women's and Children's Health Network, 2016). The article starts with an overview of the theoretical framework, followed by a discussion on a literature review that particularly talks about culture, isolation and social support network, social determinants of health, and access to health care as elements to consider in avoiding mental health problem among immigrant women in antenatal and postpartum care.

Theoretical framework

The transnational theory is primarily concerned with political and economic interconnectedness that immigrants maintained with their home countries (Remennick, 2003). Transnationalism, as defined by Basch, Schiller, and Blanc (1994), is a process by which immigrants, through their daily life activities, create social fields that cross national boundaries. Many social scientists agree that transnationalism broadly refers to multiple ties and interactions linking people or institutions across the borders of nation-states. Immigrant communities do not de-link themselves from their home countries; instead, they keep and nourish their linkages to their places of origin (Itizigsohn & Giorguli-Saucedo, 2005). In addition, transnational theory shows how identity and cultural models spread, and how networks created by immigrants are not limited only to their countries of origin but extend also to communities of the same ethnic or religious backgrounds in other countries (Ozkul, 2012). Within a health-care system, immigrants tend to compare health services they receive to their origin country health-care system; consequently, when the services are not good or meet their expectations, they can be fundamental causes of mental health problems.

Within this narrative review, the author included an article if it focuses on immigrant women, their mental health in the antenatal and postpartum period, and factors contributing to immigrant women's mental health. In addition, the author limited on the review of research studies that were conducted in Canada.

Culture as a factor of mental health to immigrant women

Many immigrants have the desire to embrace Canadian culture while retaining their own values, norms, and religion (Anderson et al., 2010). This is congruent with the transnational theory where we observe immigrants keep and nourish their linkages to their places of origin (Itizigsohn & Giorguli-Saucedo, 2005), and how networks created by immigrants are not limited only to their countries of origin but extend also to communities they have settled in (Ozkul, 2012). Culture can influence immigrant women's access to the health care by influencing their interpretations and perceptions of symptoms, decision-making, and help-seeking behavior (Delara, 2016). Conversely, within the culture, many immigrant women fear stigma attach to mental illness perception within both the family and ethnic community (O'Mahony, Donnelly, Bouchal, & Este, 2013); in addition, culture can prescribe acceptable norms for behaviors associated with gender role. The engagement of women in employment outside the home, the circumstances under which caregiving is undertaken, and the reaction to domestic violence are some manifestations of the influential role of cultural norms (Delara, 2016).

Generally, societies have different moral codes; what one group expects as right, can be experienced as wrong in another society (Rachels, 1999; Shah, 2017). Immigrants may find different moral codes in the receiving country which can create challenges to integrating into the new country's established health system. For many immigrant women, traditional customs during postpartum period are geared toward providing support for a new mother. Lack of these cultural traditions in Canada, however, reduces the women's support system and as result women become more vulnerable to postpartum depression (O'Mahony et al., 2013). It is documented that some religious beliefs as a cultural stance forbid women to be seen by a male gynecologist during labor (Mckeary & Newbold, 2010). Moreover, in some cultures, newborn babies are not breastfed for some days following birth because of beliefs that the first breastmilk is impure (Well & Dietsch, 2014). This practice may affect mental health for immigrant women when those customs are not considered.

Isolation and social support network as factors of mental health to immigrant women

Social connections and networks have a powerful effect on mental health of immigrant women (Delara, 2016). Risk factors for depression include stressful life events as demonstrated by research of Jamieson (2016) which shows that postpartum depression most often is preceded by a history of depression as well as perceived stressful life events, lack of social support, isolation, physical health problems, inability to speak the language of the host country, the demands of multiple roles, and separation from family members (Kirmayer et al., 2011). Many refugee/immigrant women describe leaving behind family members in an unsettled situation as a traumatic experience (Delara, 2016; O'Mahony & Donnelly, 2013). A research study conducted by Tang, Oatley, and Toner (2007) shows that one of the most frequent negative life events among Chinese immigrant women in Canada was separation from family and community and negative public attitudes. Family relationships are likely having a major impact on the mental health of Chinese women who immigrate to Canada as they often value close family ties. Consequently, in antenatal and postpartum period, immigrant women rely on people from an ethnically similar community because of sharing the same culture and close friends. These multiple ties and interactions linking immigrants and their relatives/friends mirror transnationalism (Itizigsohn & Giorguli-Saucedo, 2005).

Unfortunately, most of the immigrant women do not have this peer support that in return impacts negatively on their mental health during antenatal and postpartum. Another support is from people outside of ethnic culture or family member. Delara (2016) purports that whatever immigrant women receive during the antenatal and postpartum period as support can influence mental well-being. In antenatal and postpartum period, immigrant women often suffer from isolation and lack of supports, specifically, if they have nobody to help them, no neighbor, no family, and no friend. Hence, the antenatal and postpartum period becomes so difficult for immigrant women; moreover, when lack of support merges with loneliness, women become confused, hopeless, and depressed without anyone to comfort them (G. M. A. Higginbottom, Vallianatos, Shankar, Osswald, & Davey, 2016). Surely, they miss the societal support of their relatives back home as in origin country a society help mothers (O'Mahony et al., 2013). The identity crisis that accompanies immigrants may take the form of loss of self-esteem and a higher risk of depression, which is even higher when a large cultural gap exists between the type of society from which immigrant women have come and that in which they have settled (Mechakra-Tahiri, Zunzunegui, & Seguin, 2008).

Social determinants of health as factors affecting mental health of immigrant women

There is a reciprocal relationship between mental health and unemployment; people who are unemployed or who lose their jobs experience a high rate of depression (Bieser, 2005). Sometimes, it is believed that Canada contributes to immigrant depression and distress due to the lengthy process of paperwork for employment (O'Mahony et al., 2013). In addition, there is lack of recognition of foreign degrees. Currently, foreign degrees cannot be translated easily into jobs, for instance, you can find foreign-trained medical doctors who are not in health-care occupations but survive by driving taxis (Fuller-Thomson, Noack, & George, 2011). Mental health also gets worse by thinking about back home opportunities immigrant women may have; moreover, they may worry excessively about the future newborn who will not receive proper care due to the unemployment situation. One participant in O'Mahony et al. (2013) study was well-educated, but her credentials were not acknowledged in Canada. The struggle that she is experiencing illustrates the transnational theory posit of economic interconnectedness that immigrants maintain with their home country (Remennick, 2003).

The most frequent negative life event among Chinese immigrant women to Canada was an employment-related and financial strain of living below the poverty line that predict the women's mental health (Tang et al., 2007). A study on the population with increased risk of poverty demonstrates that antenatal depression among women is high at 29.5% (Bowen, Stewart, Baets, & Muhajarine, 2009). Unemployment puts immigrant women in a class of socioeconomically disadvantaged group which has higher rates of symptoms of postpartum depression and poor mental health compared to socioeconomically advantaged people (Landy, Sword, & Ciliska, 2008).

In most society, immigrants have constructed a social status in their society of origin. However, being immigrant is one of the causes of losing social status (McKeary & Newbold, 2010). In their destination country, their social status often changes; it is common for newly arrived immigrants to experience unemployment; therefore, they start thinking how they will survive in their new environment. Resettlement itself is particularly challenging for women due to their lower socioeconomic status (Dona & Berry, 1999). There is a high rate of depression among visible minorities. A study comparing postpartum depression among Caucasians and visible minorities shows that women who were visible minorities faced more elevated rates of postpartum depression than Caucasians due to great life stressors such as economic factors as visible minorities are more likely to have low income, lower level of education, unemployment, bad housing conditions, and single parenting (Nelson-Peterman, Toof, Liang, & Grigg-Saito, 2015). Immigrants may have inadequate income which adds to stress and trauma of pre-resettlement and post-resettlement which make them more susceptible to depression and other mental and physical health concerns (Nelson-Peterman et al., 2015). In a comparison between Canadian-born mothers and immigrant women, findings show that 79.4% of immigrant mothers had inadequate incomes compared to 20.6% among Canadian-born mothers (Mechakra-Tahiri, et al., 2008). The findings from a study done among immigrant women from developed countries like United Kingdom, New Zealand, Australia, and United States show that postnatal depression was 8.3% (Collins, Zimmerman, & Howard, 2011).

From an African viewpoint, it is sometimes believed that women hold less powerful positions in society compared to their male counterparts (Boon, 2009). The paternalistic attitudes are observed in many societies, and Delara (2016) reports that in most societies, “women are assigned subordinate positions to men and experience systematic discrimination in access to power, prestige, as well as resources” (p. 4). Immigrant women may experience gender discrimination in their work and hold more informal or low paying jobs (Delara, 2016). In Canada as country receiving immigrants, Pollock, Newbold, Lafrenière, and Edge (2012) claim that around 65% of immigrants experienced discrimination when visiting a health-care clinic. This negative experience was highlighted by Beiser (2005) who vividly purports that the longer immigrants stay in Canada, the more likely they recognize and experience racially based discrimination that jeopardizes mental health. When discrimination increases, the impacts on health determinants are more observable. Discrimination always happens when people are perceived as being different from others, and in Canada, Fuller-Thomson et al. (2011) assert that discrimination is very high within first two years of immigrants' arrival. The immigrants are more vulnerable to violence both during immigration process and after arrival in Canada (Stewart, Gagnon, Merry, & Dennis, 2012). One immigrant woman explains how her well-being was disturbed by the discrimination against her husband at the workplace (O'Mahony et al., 2013), and she mentions the need for an immigrant to adjust to the employer. There is a type of experience that can lead to internalized racism when immigrant women accept and internalize stigmatized messages about their ability and lack of worth which in return deteriorates mental health (Delara, 2016). Even though exposure to racism and discrimination has been shown to impact on the mental health of immigrants, the research on this topic has been limited (Kirmayer et al., 2011).

Access to health care as factor affecting mental health of immigrant women

Culturally determined barriers to care for immigrant women include lack of knowledge and understanding about postpartum depression as well as the stigma associated with depression and mental illness (G. Higginbottom, Bell, Arsenault, & Pillay, 2012). For example, Hispanic immigrants were hindered seeking mental health services by stigmas associated with cultural taboos on mental health. The perinatal experience may act as a trigger for women to recall previous traumatic events, for example, women who screened positive for symptoms of postpartum depression reported that their new infant reminded them of children they had left in their native country and this evoked the feeling of sadness (G. Higginbottom et al., 2012).

In Canada, the causes for not using postpartum mental health are associated with stigma and feelings of shame of being labeled mentally ill (Bodolai et al., 2014). The fact that diagnosed mental illness was a reason for deporting immigrants can be a barrier for immigrant women to look for assistance when they face depression during antenatal and postpartum periods (Salami, Meharali, & Salami, 2015). Although mental health illness may not have been explicitly targeted in the research project by Salami et al. (2015), it was documented in some cases that immigrants were deported to their home country because they had signs and symptoms of mental health illness. Moreover, African women in Canada often face obstetric complications related to traditional practices like infibulation and female genital cutting which may be practiced among immigrants across Canada (G. Higginbottom & Liamputtong, 2015); stigmatization of female genital cutting may influence pregnant women's willingness to seek proper care. Furthermore, pre-migratory trauma combined with the experience of precarity in the Canadian context may mean that pregnant immigrants who have experienced female genital cutting feel unable to trust health-care professionals; consequently, they may prefer cesarean sections during childbirth (G. M. A. Higginbottom, Vallianatos, et al., 2016; Merry, Vangen, & Small, 2016). Health system structure can restrict immigrant women from getting into or profiting from existing antenatal and postpartum services. Immigrant women may have to cross multiple bureaucratic obstacles, fill numerous paperwork, or search for a family doctor which may last even a year (G. M. A. Higginbottom, Vallianatos, et al., 2016). Moreover, structural barriers immigrant women encounter comprises lack of confidentiality; lack of professional interpretation as well as translation services, disintegrated services, and unsatisfactory power relationships between the service providers and clients; and lack of suitable culturally sensitive and skilled personnel who outfit immigrant women's needs (Delara, 2016).

Immigrant women may be familiar with the health-care services in their home countries but are uncertain about how to navigate the Canada health system (G. M. Higginbottom, Safipour et al., 2016). This issue is associated with lack of information; thus, immigrant women may feel lost and this affects their mental health. Health-care providers must be culturally competent so that they can respond to the issue arising from cultural practices (G. M. A. Higginbottom, Vallianatos, et al., 2016). However, it is impossible for medical staff to know every culture, as culture, practice, and beliefs related to maternity care change over time (Small et al., 2014). Although we can never become truly competent in another's culture, we can demonstrate a lifelong commitment to self-evaluation and self-critique, to redress power imbalances, and to develop as well as maintain mutually respectful relationships (Minkler, 2005). The lack of awareness of cultural differences among health-care providers was documented in research study by Lassetter and Callister (2009) and Preibisch and Hennebry (2011) as barriers for immigrants to access health services in Canada. Research conducted by G. M. A. Higginbottom, Vallianatos et al. (2016) illustrates lack of cultural sensitivity among health-care providers. During their data collection, one health-care provider said, “You know, an emergency during labor, in which case we needed the obstetricians to help but they didn't want a man under no circumstances” (p. 8). The comments produced from care providers tended to be judgmental rather than affording respect for religious and cultural diversity (G. M. A. Higginbottom, Vallianatos, et al., 2016). Culture differences that immigrant women observe during health care can affect their mental health status, and as health-care providers, we need to understand cultural issues using transnational theory to meet client expectations. For example, an immigrant woman stayed at the hospital in her postpartum period and the hospital provided food as hospital custom; it was hard for her to eat that food because she was not familiar with Canadian food. This can be the difficult moment for her and can lead to cultural shock by experiencing an unexpected event (Kongnetiman & Okafor, 2011). A second example of lack of cultural sensitivity comes from Kongnetiman and Okafor's (2011) study in which an immigrant woman from China was shocked when she was served ice cream to eat and chilly water with ice after giving birth. This was not in favor of Chinese culture and belief where around after pregnancy care cold food and cold drinks are prohibited to avoid body imbalance (Kongnetiman & Okafor, 2011).

Immigrant women usually face many communication barriers as almost all of immigrant women have a native language other than English; thus, social interaction and the ability to develop relationships within health-care system become difficult; moreover, language issue becomes a major obstacle to expressing their needs (Delara, 2016). Sanghera, Wong, and Brown (2015) were interested in investigating perinatal depressive symptoms among Punjabi-speaking women, and their findings suggest that Punjabi-speaking women are at a higher risk of experiencing perinatal depressive symptoms. A receiving country's health-care system is highly challenged by how to offer comprehensive health care; the need to use interpreters causes an extra layer of complexity. Lacking interpretation service is a barrier in offering appropriate care (Shishehgar, Gholizadeh, DiGiacomo, Green, & Davidson, 2016). In contrast, interpretation service may be available but uptake may be limited because immigrants, in general, may not be willing to share their personal experiences with interpreters due to a fear of misinterpretation, exposure, long waiting times, and perceived impatience of interpreters (Casimiro, Hancock, & Northcote, 2007).

Conclusion and recommendations

In the antenatal and postpartum period, immigrant women face different issues that in return affect their mental health such as unemployment, socioeconomic factors, lack of cultural competency among health-care providers, discrimination, food insecurity, and lack of social support. Sometimes, it is believed that Canada contributes to immigrant women mental health problems such as depression and distress due to a variety of structural barriers that can range from lengthy process of paperwork for employment, nonacknowledgment of foreigner educational credentials (Fuller-Thomson et al., 2011; O'Mahony et al., 2013), and discrimination that immigrants experience when visiting a health-care clinic (Pollock et al., 2012). The literature review indicates the lack of cultural competency and safety among health-care providers, which can be the important asset for handling diversity issues. These aforesaid issues impact on mental health of immigrant women in the antenatal and postpartum period; consequently, immigrant women mental health is affected (Miszkurka et al., 2012; Zelkowitz et al., 2004).

I would end this discussion by recommending researchers to do a systematic review study on immigrant women's mental health in Canada in the antenatal than the postpartum period. From the literature review perspective, there is a research gap on immigrant women mental health in the antenatal period, as most of research studies are focusing on postpartum mental health issues. Furthermore, the provincial health-care systems in collaboration with federal immigration supports can initiate research to find out how to make interpretation service more efficient and support this service especially in antenatal and postpartum to alleviate the impact of depression.

This article contributes to existing knowledge by illuminating the status of immigrant women's mental health in the antenatal and postpartum period, highlighting the factors contributing to immigrant women's mental health. There is potential for change in antenatal and postpartum services. The author hopes that this article can trigger improvement as health-care providers and the Canadian governments may focus on mental health contributory factors for immigrant women. Finally, because Canada has long been and continues to be the land of immigrants, addressing the multiple factors affecting immigrant women's mental health is paramount to Canada truly achieving “health for all” (World Health Organization, 2017).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Desire Urindwanayo is a PhD student (Nursing) at the University of Alberta, Canada. He holds Master of Nursing degree (Community Health) from the University of KwaZulu-Natal, South Africa and has a bachelor of nursing honors degree from the University of KwaZulu-Natal. He has as well an advanced diploma in general nursing from the University of Rwanda, former Kigali Health Institute, Rwanda.

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