Perinatal health and mental health inequalities are prevalent issues in the UK, disproportionately affecting ethnic minority groups. Individuals of Black, Asian and mixed background face a higher risk of maternal death in comparison to their white counterparts (Knight et al., 2023). With mental health related issues being a leading cause of maternal death (Knight et al., 2023) specialised services such as the Perinatal Mental Health Service (PMHS) provide care to prevent, detect and treat these difficulties (Royal College of Psychiatrists, 2021).
Despite increased risk of difficulties, South Asian, Black, and White Other women have less access to community PMHS (Jankovic et al., 2020), ethnic minority women are also less likely to report treatment for perinatal anxiety and depression (Moore et al., 2019). From 2018 to 2020 only 17% of women who died received good care, improvements to care could have made a difference in the outcomes of 37% of the women, including 69% who died by suicide (Knight et al., 2020).
This highlights the need for improved care access, particularly for disproportionately affected South Asian and Black communities. Recognising that differences in help seeking does not completely explain differences with care engagement (Prady et al., 2021), Conneely et al. (2023) conducted their study to better understand how Black and South Asian women experience access and receive care from Perinatal Mental Health Services (PMHS).
Ethnically minoritised women are found less likely to receive treatment for perinatal mental health difficulties.
Methods
Key sampling criteria including ethnicity, migration experience and English-speaking ability were utilised to recruit participants to the study. Through non-probability, purposive sampling, 37 Black and South Asian women with lived experience of perinatal mental illness and accessing support from Perinatal Mental Health Services (PMHS) were selected. Grouped by British census categories, participants were involved in one-on-one semi-structured interviews conducted remotely. Interviews took place over 19 months starting from January 2020. Of those interviewed, 4 participants required an interpreter.
The interview topic guide explored how and when they received treatment and whether the format of care and interview method was impactful on their experience. Women were also asked about their perception of how ethnicity and culture impact their service experience and how service acceptability and accessibility could be improved in relation to ethnicity and culture.
Interviews were analysed using framework analysis developed by a multidisciplinary team of clinicians, researchers, and people with lived experience of perinatal mental health illness. The framework was applied and adapted with the emergence of new themes.
Results
Four broad themes and their sub-themes were identified:
Self-identity, social expectations, and different attributions of distress deter help-seeking
- Seeking help affects how women see themselves
- Minimising distress and self-dismissal
- Different attributions of mental distress affect where women seek help
- Shame and discretion, suspicion and fear
- Other judgement and discrimination.
Conflict between social, personal, and cultural factors had emotional and practical impacts on help-seeking behaviour in women. Differences in self and familial expectations, perceptions of mental health and help-seeking served as barriers. Women often feared judgement from others and the removal of their children due to distrust in services. They described having to overcome these factors to prioritise their health and the health of their children.
Hidden and disorganised services impede getting support
- Not knowing what support is available
- Opaque and inconsistent services get in the way of women who are seeking help.
Practical issues affected access, engagement and receiving care. Being unaware of services was the biggest barrier, with only 5 of the 37 participants knowing about Perinatal Mental Health Services (PMHS). Lack of clarity and inconsistency in care led to women feeling unsafe; further damaging distrust in services.
The roles of curiosity, kindness and flexibility in making women feel, heard, accept and support by clinicians
- Services are nurturing
- Respected and treated equally mostly
- Flexibility and curiosity in staff inspired feeling accepted and respected.
Most women had predominantly positive experiences with services, having felt valued by their relationships with clinicians. Women appreciated the respect given to ethnicity, culture and religion, and not being treated differently because of these factors. In fact, curiosity, open-mindedness, and flexibility were essential in helping women feel supported and putting trust in services.
A shared cultural background may support or hinder a rapport
- Clinicians and patients shared cultural background is a shortcut to rapport
- Sharing ethnic background with clinicians is unimportant, and even unhelpful.
Many women expressed that their clinicians ethnic background was an unimportant factor, but rather kindness, curiosity and feeling understood were seen as more important. For some women, clinicians being of the same ethnic background was seen as a barrier as there was concern about potentially being judged. For others, shared ethnic background made it easier for them to be understood and express themselves.
Clinicians’ curiosity, kindness and flexibility towards cultural and religious traditions were appreciated by participants as a sign of respect and empathy.
Conclusions
The authors concluded that there were varying experiences of services by Black and South Asian women as the themes revealed external and internal barriers and practical issues that affected help-seeking and access. However, an important finding was that women benefited from services, with the majority of them having positive experiences due to the curiosity, kindness, flexibility, and trust built by clinicians making them feel understood. Improvements in educating women on the services available to them as well as how they could be delivered would improve services. The authors also recommended that multifaceted interventions would be useful for women due to the complex interplay of factors on help-seeking behaviour.
This research suggests that accessible information about service availability and provision for ethnic minority women could improve service use.
Strengths and limitations
Researchers conducted a study in line with COREQ guidelines for an underrepresented group in mental health research, overall deepening our current knowledge of perinatal mental health. Due to this, the result of the study can further inform future research and have practical impact. The study reveals the process that occurs before and after care, which is less well known as services only interact with women during care. Additionally, the inclusion of non-English speaking participants gave access to a group that is typically excluded from research even when conducted with minoritised communities.
Categorising participants in census groups may have led to the potential dismissal of cross-cultural and intercultural differences. For instance, the label of ‘South Asian’ is a broad term covering 8 countries, each with several cultures between them. These differences may influence outcomes, as Pakistani and Bangladeshi women experience more health inequalities than Indian women, despite all of them being labelled as ‘South Asian’ (Raleigh, 2023).
Following that, the collective grouping of Black and South Asian women does not account for differences in medical experience between both groups. As Black participants tend to report more experiences of ethnic discrimination in comparison to South Asian participants who report more experience of religious discrimination (Jaspal & Lopes, 2021). Additionally, having no Black interviewer may have hindered the reporting of these experiences (Song & Parker, 1995), which may have had an effect on results.
Researchers did not explicitly assess the strength of participants’ connection to their culture and ethnicity. This connection may have informed parts of their identity, views, and behaviour such as decision making (Yates & de Oliveira, 2016) possibly contributing to personal factors to care access. The terms ethnicity and culture being used interchangeably is also a limitation as they are different forms of identity with different functions (Loue, 2013). It is also possible that experience of accessing and receiving care may be due to factors outside of ethnicity/culture, such as location-seeking as the majority participants were from an urban area.
The findings highlight Black and South Asian women’s experience of services, however the cross-cultural and intercultural differences are yet to be explored.
Implications for practice
This study serves as an effective foundation for future research and aids in the accessibility, acceptability and receiving of services for Black and South Asian women. Following the limitations, future research should aim to consider cross cultural and intercultural differences, assess the effect of ethnic and cultural connection and other aspects of identity considering that there is often intersectionality between social characteristics. For example, perinatal inequalities and risk can also be seen in individuals with low socioeconomic status, a majority of those with this status come from ethnic minority backgrounds (Francis-Devine, 2020; Kozhimannil et al., 2011).
The results revealed that a prominent issue is the lack of knowledge that care exists. As mentioned by the authors, public health policy campaigns should help in promoting and advertising PMHS, especially in vulnerable communities. Results also highlighted the role of community influence among Black and South Asian women through family and friends in help seeking, such as seeking alternative methods through religion. Being in collaboration and promoting the services with community organisations, religious leaders and other community spaces could help in increasing knowledge, education, and stigma reduction. Education may lead to more awareness and symptom recognition, possibly allowing women to be more open in their conditions which may encourage them to go to services faster.
Due to service’s history of mistreating Black and ethnic minority women, there is distrust in communities (Horn, 2020), this distrust enforces behaviours such as avoidance as seen with other medical experiences such as vaccination (Minaya et al., 2022). Community-based outreach should be utilised to gain trust, this may allow more women from these communities to access services. The suggestions given by the women to improve services should be taken into consideration, executed, and evaluated to see if experience improves, interventions should be multifaceted, as research shows several factors contribute to service experience. As mentioned, only 17% of women who died received good care (Knight et al., 2020), services should be transparent and consistent in terms of what is offered, as well as with following up on referrals and offering future steps to help with feelings of disappointment when services end.
Coming from a Black immigrant background, I believe that active outreach is necessary to regain trust from these communities, specifically the Black community. Having known someone who died due to perinatal mental health issues, the need for this service is crucial and research serves as a foundation for driving change.
Community outreach services can rebuild trust with black and ethnic minoritised communities and raise awareness to improve access to treatment.
Statement of interests
No conflicts of interests to declare.
King’s MSc in Mental Health Studies
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Links
Primary paper
Conneely, M., Packer, K. C., Bicknell, S., Janković, J., Sihre, H. K., McCabe, R., Copello, A., Bains, K., Priebe, S., Spruce, A., & Jovanović, N. (2023). Exploring Black and South Asian women’s experiences of help-seeking and engagement in perinatal mental health services in the UK. Frontiers in Psychiatry, 14. https://doi.org/10.3389/fpsyt.2023.1119998
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