Perinatal mental illness in migrant women

It is now estimated that there are 272 million intergenerational migrants, equating to approximately 3.5% of the global population, and that 48% of all migrants are female (International Organization for Migration, 2020). Reasons for migrating vary, including for economic and educational improvement; to escape violence and/or conflict, and to seek protection from adverse environmental problems in relation to climate change and natural disasters (United Nations, 2023).

Migrants are at increased risk for developing mental illness, due to various stressors and vulnerabilities experienced throughout migration (Bhugra, 2004). Refugees are at particular risk of developing psychological distress (see this Mental Elf blog for more details). Migrant women during the perinatal period also encounter specific risks to developing a mental illness, including low social support, minority ethnicity, and low socio-economic status (Anderson et al., 2017).

In this paper, Stevenson et al (2023) attempted to provide a global prevalence estimate of any common mental disorder and of substance use in the perinatal period among migrant women, updating previous systematic reviews conducted by Anderson et al., (2017) and Fellmeth, Fazel and Plugge (2017). The authors also set out to identify the risk factors for these disorders and assess the quality of the eligible studies.

It’s estimated that there are 272 million intergenerational migrants, that’s about 3.5% of the global population, and that nearly half of all migrants are women.

Methods

Stevenson et al (2023) searched for cohort, cross-sectional and interventional studies in any language, measuring the prevalence of any mental disorder (using clinically validated measures or a formal diagnosis) in migrant women during pregnancy and 1-year post-delivery. Seven databases were searched, and reference lists of previous relevant systematic reviews were hand searched. Two authors independently screened the abstracts and full text papers. Study quality was appraised using adapted CASP checklists (CASP, 2023) and the JBI checklist for prevalence studies (Munn et al 2020).

The primary outcomes were prevalence estimates for perinatal depression, psychosis, anxiety, post-traumatic stress disorder (PTSD) and substance use in pregnancy among migrant women. Pooled prevalence estimates were provided, along with subgroup analyses based on study location (high-, middle- or low-income country), women’s migration status (forced or economic migrant) if data were available and perinatal period (antenatal and postnatal). In this blog, the subgroup analysis will be discussed in relation to women’s migration status as this was a novel part of the review. Sensitivity analyses were presented for perinatal depression outcomes only.

Results

135 studies were included, which presented data from 621,995 participants. Most women had migrated from South America, the Middle East, or North Africa. Most (91%) studies were conducted in high-income countries; 8% and 1% were conducted in middle-income and low-income countries (LMIC) respectively.

Perinatal depression in migrant women

• The pooled prevalence for perinatal depression was 24.2% (95% CI 22.21 to 26.09%; I² 98.8)
• Difference in findings according to study quality did not meet the threshold for significance
• For forced migrant women, prevalence was 32.5% (95% CI 24.56 to 40.40%; I²­=98.65%)
• This more than halved among economic migrants where the prevalence was 13.7% (95% CI 9.64 to 17.81%; I²­=91.48).

Perinatal anxiety disorder in migrant women

• The pooled prevalence for anxiety disorder was 19.6% (95% CI 13.23 to 25.97%; I² 96.8%)
• The pooled prevalence for forced migrant women was 11.5%, but this included data from only one study.

Perinatal PTSD in migrant women

• For perinatal PTSD, the pooled prevalence was 8.9% (95% CI 2.28 to 18.91; I² 97.4%)
• The pooled prevalence for forced migrant women was 17.1% (95% CI 1.50 to 42.99%; I² 96.63).

Perinatal substance use in migrant women

• The pooled prevalence of any alcohol use was 8.0% (95% CI 6.22 to 9.85%; I² 99.6%)
• The pooled prevalence of combined alcohol use or substance use was 5.1% (95% CI 4.58 to 5.66; I² 99.4%).

Risk factors for perinatal mental illness in migrant women

Risk factors commonly associated with perinatal depression included:

• Poor social support
• Low income
• Poor relationship with one’s partner.

Migration specific factors included:

• Being a recently arrived immigrant
• A history of trauma exposure
• Being from a minority ethnic group in the host country.

The pooled prevalence of perinatal depression among migrants was 24.2%, but this increased to nearly a third among forced migrants (32.5%).

Conclusions

The findings highlight the significant global issue of common mental disorders and substance use among migrant women in the perinatal period, with a heightened risk among forced migrant women.

The authors concluded that among migrant women in the perinatal period, “one in four experience perinatal depression, one in five perinatal anxiety, and one in eleven perinatal PTSD”.

Stevenson et al. (2023) suggest that among migrant women, “one in four experience perinatal depression, one in five perinatal anxiety, and one in eleven perinatal PTSD”.

Strengths and limitations

This is a clinically important, relevant and well-written systematic review, which adhered to PRISMA (Page et al., 2021) and Meta-analyses Of Observational Studies in Epidemiology (MOOSE) reporting guidelines. Authors included a large number of studies and these added to what we know from previous reviews (Anderson et al 2017; Fellmeth et al 2017). Another advantage, given the nature of this topic, is the inclusion of studies published in any language.

Key limitations need to be considered:

• Low quality studies included in the review. Sensitivity analyses based on study quality were only carried out for perinatal depression outcome (in which higher quality studies reported a lower prevalence of depression). As the authors acknowledge, the included evidence was generally low quality and recommend that further reviews are needed to confirm these findings.
• High heterogeneity across included studies. The authors also report that the large range of prevalence estimates across studies may be due to differences in socio-demographics, healthcare systems or methodologies and therefore the results need to be interpreted with caution. Further, the l2 (heterogeneity) statistics were very high across all results, even in the high-quality study-only sensitivity analysis, indicating significant true variation between studies, limiting our confidence in the results.
• Generally, across the included studies, more exploration of risk factors could have been conducted. For example, the review found that women who had recently arrived in the host country were at greater risk of developing depression. While useful to know, this finding needs interrogating further in order to begin disentangling the complex interplay of factors involved; for example, the increased risk may be due to not knowing where to access support and encountering structural barriers in seeking support and intervention (Ahmed et al., 2008). More complex causal analyses, such as mediation analyses, may be useful for explicitly exploring these pathways. Experiences of gender-based violence; stigma; interpersonal and structural racism; and medical mistrust were not explored, despite these factors playing a role in the development of perinatal mental illness and contributing to the barriers migrant women experience in accessing perinatal care (Collins, Zimmerman and Howard, 2011; Kim et al., 2020).

The range of prevalence estimates across studies was large, and this may be due to differences in socio-demographics, healthcare systems or methodologies and therefore the results need to be interpreted with caution.

Implications for practice

Healthcare professionals need increased awareness and knowledge of the risk of perinatal mental illnesses among migrant women, and mental health should be routinely discussed in maternity and other healthcare services that serve women who are migrants. There is some evidence that immigrant women are less likely to be screened for depression in the postpartum period than non-immigrant women (Mart-Castaner et al 2022), indicating that discriminatory practices are resulting in under-identification of mental illness, despite the increased risk for this group of women. Immigrant women, particularly refugee women are unlikely to disclose problems with their emotional and mental wellbeing if not asked by the healthcare professional in the perinatal period (Willey et al 2022), suggesting that maternity and other healthcare services should offer culturally tailored screening and care. Furthermore, women should feel safe in accessing services, which need to promote social justice and equitable power. The adoption and implementation of trauma-informed approaches, whereby women are responded to with empathy and compassion, are also relevant.

Connecting migrant women with increased social support is necessary, particularly as reduced social networks, poor relationships with one’s partner, and being a recently arrived immigrant were identified as risk factors for developing perinatal depression. Poor relationships with partners highlight the importance of exploring experiences of intimate partner violence in a culturally acceptable way, and signposting women onto culturally relevant organisations for further support.

Despite the results indicating an increased prevalence of mental illness for migrant women, we do have to be mindful of not pathologising women’s distress through a Westernised lens, which may not be culturally relevant for migrant women who have migrated to Western countries. Support interventions should not place the responsibility on women to get better. Instead, wider structural sources of oppression and hostility in the host country that may be contributing to women’s distress need to be acknowledged and addressed. For an excellent critical discussion on this topic, see Brown-Bowers et al., (2015).

The findings highlight the increased risk of mental illness that migrant women encounter in the perinatal period, particularly for immigrant women that have been forced out of their country. There are many fears and challenges that immigrant women will encounter throughout the migration experience, which can contribute to and/or exacerbate mental illness. Finally, it is important to recognise that the hostile environment towards migrants in the new country can underpin many of the associated challenges migrant women encounter in obtaining support.

Clinicians must be mindful of not pathologising women’s distress through a Westernised lens, which may not be culturally relevant for migrant women. Wider structural sources of oppression and hostility in the host country that may contribute to women’s distress need to be acknowledged and addressed.

Statement of interests

None

Links

Primary paper

Stevenson, K., Fellmeth, G., Edwards, S., Calvert, C., Bennett, P., Campbell, O. M., & Fuhr, D. C. (2023). The global burden of perinatal common mental health disorders and substance use among migrant women: a systematic review and meta-analysis. The Lancet Public Health, 8(3), e203-e216. https://doi.org/10.1016/S2468-2667(22)00342-5

Other references

Ahmed, A. et al. (2008) ‘Experiences of immigrant new mothers with symptoms of depression’, Archives of Women’s Mental Health, 11(4), pp. 295–303. doi: 10.1007/s00737-008-0025-6

Anderson, F. M. et al. (2017) ‘Prevalence and risk of mental disorders in the perinatal period among migrant women: a systematic review and meta-analysis’, Archives of Women’s Mental Health, 20(3), pp. 449–462. doi: 10.1007/s00737-017-0723-z.

Bhugra, D. (2004) ‘Review article Migration and mental health’, Acta Psychiatrica Scandinavica, 109(4), pp. 243–258. Available at: http://doi.wiley.com/10.1046/j.0001-690X.2003.00246.x

Brown-Bowers, A. et al. (2015) ‘Postpartum depression in refugee and asylum-seeking women in Canada: A critical health psychology perspective’, Health (United Kingdom), 19(3), pp. 318–335. doi: 10.1177/1363459314554315.

CASP (2023) CASP Checklists. Available at: https://casp-uk.net/casp-tools-checklists/

Collins, C. H., Zimmerman, C. and Howard, L. M. (2011) ‘Refugee, asylum seeker, immigrant women and postnatal depression: Rates and risk factors’, Archives of Women’s Mental Health, 14(1), pp. 3–11. doi: 10.1007/s00737-010-0198-7.

Fellmeth, G., Fazel, M. and Plugge, E. (2017) ‘Migration and perinatal mental health in women from low- and middle-income countries: a systematic review and meta-analysis’, BJOG: An International Journal of Obstetrics and Gynaecology, 124(5), pp. 742–752. doi: 10.1111/1471-0528.14184.

International Organization for Migration (2020) World migration report. 2020. https://publications.iom.int/system/files/pdf/wmr_2020.pdf, World Migration Report. doi: 10.1002/wom3.11.

Kim, H. G. et al. (2020) ‘Exposure to Racism and Other Adverse Childhood Experiences Among Perinatal Women with Moderate to Severe Mental Illness’, Community Mental Health Journal, 56(5), pp. 867–874. doi: 10.1007/s10597-020-00550-6.

Marti-Castaner, M., Hvidtfeldt, C., Villadsen, S. F., Laursen, B., Pedersen, T. P., & Norredam, M. (2022). Disparities in postpartum depression screening participation between immigrant and Danish-born women. European Journal of Public Health, 32(1), 41-48.

Page, M. J. et al. (2021) ‘The PRISMA 2020 statement: an updated guideline for reporting systematic reviews’, BMJ, 372(71), pp. 1–9. doi: 10.1136/bmj.n71.

United Nations (2023) Migration, Global Issues. Available at: https://www.un.org/en/global-issues/migration#:~:text=Some people move in search,disasters%2C or other environmental factors.

Willey, S. M., Blackmore, R. P., Gibson-Helm, M. E., Ali, R., Boyd, L. M., McBride, J., & Boyle, J. A. (2020). “If you don’t ask… you don’t tell”: Refugee women’s perspectives on perinatal mental health screening. Women and Birth, 33(5), e429-e437.

Zuva, D. (2021) Supporting the mental health of refugees: further evidence highlights the need for cultural awareness and competence. Mental Elf Blog. 21st Sep 2021.

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