Participant characteristics
Participant demographics are described in Table 1. Slightly fewer than half of the participants were from an Asian background, a quarter were African/Afro-Caribbean and almost a third were from mixed or “other” heritage (e.g., Chinese, Italian, Filipino and Polish). Approximately half of the participants were first-generation immigrants, with 20% having been in the UK for less than five years. None of the study participants required an interpreting service. Less than half of the participants attempted to seek help for their mental health difficulties, though they ultimately did not access formal mental health care.
Table 1
Participant’s ethnicity information (n = 28)
| | | n (%) |
Ethnicity |
| Black/ Black British | Caribbean | 2 (7.1) |
| African | 5 (17.8%) |
Total Black ethnicities | 7 (24.8%) |
| Asian/ Asian British | British Pakistani | 6 (21.4%) |
British Indian | 6 21.4%) |
| British Bangladesh | 1 (3.6%) |
Total Asian ethnicities | 13 (46.3%) |
| Mixed ethnicities | 2 (7.1%) |
Other ethnicities (e.g., White non-British) | 6 (21.4%) |
Age (Mean = 32, range 25–44) |
| 25–29 | | 7 (25.0%) |
| 30–34 | | 13 (46.4%) |
| 35–39 | | 6 (21.4%) |
| 40–44 | | 2 (7.1%) |
Employment status |
| Employed (including self-employed) | 19 (77.9%) |
| Unemployed | 9 (32.1%) |
Length of stay in the UK. |
| UK Born | | 16 (57.1%) |
| 1–5 years | | 6 (21.4%) |
| 5–10 years | | 3 (10.7%) |
| 10–20 years | | 2 (7.1%) |
| 20–30 years | | 1 (3.5%0 |
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Overview of themes
Many women reported feeling reluctant about seeking help for their mental health problems because of their uncertainty about what problems were considered normal within the perinatal period. However, these feelings were compounded by ethnicity-related barriers for most ethnic minority women in this study. These were grouped under three themes: Cultural beliefs and expectations, Help-seeking patterns, and Accessibility barriers (see Fig. 1). The main themes were further characterised by subthemes; Within the cultural beliefs and expectations theme, there were three subthemes. The first subtheme was beliefs and perceptions of PMH, where women described their ethnic group’s view of mental health. The second sub-theme was the expectation of motherhood, characterised by women’s descriptions of their expectations of motherhood within their culture, and how these conceptions could prevent families from recognising symptoms of perinatal mental health issues. The final subtheme within this theme was the inability of participants to name perinatal mental health problems in their language thus making it difficult to ascribe meanings to their symptoms and communicate their symptoms to health professionals.
The second theme of the study was the various patterns of help-seeking which differed across the ethnic groups reported by ethnicity. The final theme was accessibility barriers, which captured the problems women faced when accessing care for their mental health problems. There were two subthemes: firstly, women’s experiences with health professionals (e.g., midwives, general practitioners, health visitors) and how these experiences affected their ability to seek the required help. Secondly, women described finding safe and trusted support from peer-peer support groups.
Because women from ethnic minority groups have emphasized the uniqueness of their different cultural backgrounds and communities on their experiences, we report the results by different groupings: Black/African; South Asian, and “other.” We recognise considerable variability within these communities but hope to begin to detail some of the nuances of difference within these cultures while also highlighting commonalities with this approach.
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Cultural beliefs and expectations
Beliefs and perceptions on perinatal mental health
Most women in the study demonstrated good knowledge of perinatal mental health. Some had acquired awareness of perinatal mental health through experiences from work, social-media, and past mental health experiences. Despite this awareness, participants discussed how perinatal mental health problems within their communities remains a “taboo” topic, one that is largely unrecognised by older generations in their communities. Views from different ethnicities are provided below.
Women from Black ethnic groups reported that mental health problems were largely unrecognised in their community and more emphasis was placed on physical wellbeing by the community.
“Mental health is still not really recognised, and people are still on the darker side. It is believed that it is normal for people to go through some stages in life.” 005
“I think in my culture it’s not everybody that understands that there is something called mental health, it's possible for you to look well on the outside but on the inside, you don't look well.” 003
Women from South Asian communities expressed a similar view to the women of Black ethnicity, however there was a subtle difference in that mental health was seen as stigmatizing in their community. They described how mental health is not spoken of and is yet to be recognised, hence little importance is placed on mental health wellbeing.
“I come from an Indian community, it’s not very good. [laughs] Mental health, they think it’s not very important, and it's almost frowned upon. It's like, "Oh, well, what's wrong with her?" It's about tough love. You have to be strong all the time. You can't cry, and you can't have a bad day. You're a mom now, you have to get on with it.” 023
The quotes from women from the ‘other ethnicities’ depict some awareness of mental health; however, it is mostly ignored as it is taboo subject or people interpret it as weakness and would not wish to draw attention to it.
“In Latin America, mental health is not something you discuss. It's something that is taboo.” 012
“In Italy, if you talk about Mental health it is perceived as weakness; people wouldn’t really want to talk about their own weakness.” 002
Little variation was noted in perceptions of mental health between ethnicities and across each group; symptoms were mostly ignored and not prioritised as much as physical health needs. In some cases, mental health symptoms were normalised and seen as normal phases in life. It is also re-interpreted by others in their community as being due primarily to physical causes. Women reported these beliefs were passed down from older generations, thus impacting the confidence of most women to seek help for their mental health needs. While they were aware of the symptoms, they were torn between interpreting them as normal life processes, which affected their decision making and timing in seeking help.
Expectations of motherhood
Women discussed their perceptions of expectations placed on motherhood by broader society. A key theme that emerged was how women struggled with compound expectations: balancing British mainstream motherhood expectations with the motherhood expectations of their community. These expectations were further complicated by their community’s beliefs and perceptions of perinatal mental health problems.
Women from Black ethnicity discussed community beliefs about being a “strong Black woman,” and how these built-up expectations that one could not admit to any “weakness” (i.e., mental health problems).
“You are a strong Black woman, which will mean you are going to be a strong Black mom. I feel like that coat is a very dangerous one to wear because you are allowed to be vulnerable and because you’ve been given that coat, that very strong responsibility, you feel like you can’t let that down and that can contribute very much back to Mental health.” 15
Women from South Asian backgrounds expressed a sense of responsibility in training their children according to cultural norms. The pressure was especially felt by women who strove to instil religious beliefs in their children. They found it challenging to meet this expectation due to the perception of the broader UK environment as non-religious or conflicting with their religious values.
“Being a Muslim mother, I need to teach every single thing like our values what we need to do. I am doing the best what I can do. Look we are in western country, so we are in between at the moment. We need to teach them our values and culture as well.” 006 (S. Asian)
“I’m trying not to put too much pressure on myself or my children, but I know that I'm just doing things which I observed with my mom, she was never stopping. I can't stop because I feel guilty, and I push my children because they have to do the same. Even if I don't want to follow that pattern, I'm already on it.” 023
Within the Italian community, the role of a mother was compared to that of the Virgin Mary, known for her sacrificial nature. As a result, motherhood was seen as a responsibility centred around selflessness and setting a positive example for one's children.
“The mother is very much a Christian model of motherhood, Virgin Mary, all sacrificial. You give it all for your kids and for your family. Also, that means that if you feel low or anything, it's something that you have to work on yourself because you have to give your everything to your kids. You have to give everything to your family.” 002 (‘Other’ ethnicity)
In this study, all the women expressed their identification with the challenges of motherhood and the aspiration to follow examples set by others. They aimed to avoid being seen as inadequate in their role or criticized as ungrateful mothers when they encountered obstacles, and therefore prioritised efforts to meet these expectations. This struggle was especially daunting for women who desired to educate their children in religious customs because they perceived strong conflicts between aspects of UK culture and their religious customs. Additionally, they feared that failing not only in their maternal responsibilities, but also in the social environment they existed in. In some cases, these conflicts and the burden of their responsibilities could contribute problems with their mood, but admitting to their emotional health struggles could serve to confirm their failures.
Naming perinatal mental health
Across different ethnic communities, participants reported not having a term or name for perinatal mental health in their language and as a result women often lacked the terminology to describe their symptoms to families and their health professionals. The 50% of women in this study who were first generation immigrants described how challenging it was to use English, which was often not their first language, with health care providers, couples with the fact that in their cultures they frequently lacked clear names for perinatal mental health problems. This added to their suffering because they did not have a way to label and understand what was happening to them (as seen in Black ethnic groups where symptoms were perceived as stress and in Italian communities, symptoms were perceived as weaknesses).
“Even though I noticed that something was wrong, it was even difficult for me to articulate what was wrong.” 003 (Black Woman)
“Mental health is worse, if you feel pain in your body you can tell. Like I got a pain in my leg or arm, but mental health is worse.” 006 (S. Asian woman)
In other circumstances, the lack of cultural terms to accurately describe their experiences impacted their ability to discuss their experiences with health care providers, sometimes leading to misunderstandings with others that felt threatening to the women.
“I remember one day saying to the health visitor that– like saying to her that–she [the baby] was crying and I just found myself like I couldn't cope almost. I just got really frustrated and she [the health visitor] immediately took it the other way. Like, "Oh, what did you do when you got frustrated? Oh, okay, when you get frustrated?" I said, "No, no, no, no. I didn't get frustrated with her. I got frustrated with the situation because it's 4:00 AM and I'm tired, my body's aching and I'm trying to feed her. She's not going to sleep.” 002 (Italian woman)
In this instance the woman felt that the health visitor was beginning to worry that she might respond inappropriately to her infant when tired and overwhelmed, whereas the woman was attempting to describe how exhausting and challenging crying could be, especially late at night.
Help-seeking patterns
Women discussed how their perceptions of mental health and expectations of motherhood impacted on their decisions to seek formal perinatal mental health support. Variations in ethnic help-seeking patterns were identified as a key barrier in this process. From women’s accounts, women from the South Asian community were more likely to seek help outside their support networks and families for fear of discrimination and judgment within their community. In contrast, most women from other ethnicities described seeking support from within their families and support networks because they felt that symptoms of mental health were either initially misinterpreted by others (e.g., health professionals) or because they had strong family orientations and despite fearing family might struggle to understand, saw them as their first and safest place to find support. Views across different ethnicities are presented below.
Women reported that they faced culturally reinforced responsibilities to be “strong” mothers and mental health problems were cast as “stress from adjusting to motherhood” or a ‘spiritual attack’ (demon possessed). They felt deterred from seeking formal help for their mental health needs and instead focussed primarily on seeking support within their own support networks (church members or friends) and with their families. However, women said they often failed to find adequate support from within their families and friend’s networks because of limited knowledge of perinatal mental health existing within the community,
“When I asked my mom, she just believed it was just because of the pressure of the baby, so the baby is crying, and you can’t sleep at night. My mom just feels like it is just stress. She believes that it is more of physical stress, much more than mental stress.” 029
“When I start talking about my mental, I'm not feeling right, a lot of my relatives did say to me, "Pray about it. You'll be fine.” 015
Several women from this community also described utilizing their faith as a coping strategy and means of healing.
“I’m a Christian, so I take everything to God in prayers. [laughs] If I'm feeling down, sometimes I talk to God exactly about how I'm feeling, and it helps me get better.” 003
“I would pray because I'm Muslim, I would pray, I would– Thankfully, I had my mom, but moms have other commitments too.” 023
In this study, most of the Black women initially sought support from their close family and friends. However, two women from this ethnic group sought support from peer support groups as they did not receive adequate support from their family.
Women from Asian communities were more likely to describe facing stigma and judgment from their family and community for having mental health problems. As a result, they reported that they were more willing to consider external support for their mental health asl long as it was outside their support networks and relations. These women tended to use services from peer support groups more than those from other ethnicities.
“I think the safer option for a lot of people is just to tap into somebody that's not someone they know because with mental health and wellbeing, sometimes it's a very sensitive topic and people can misinterpret it and it's just not something that's always understood. I feel like then that's why people tap into maybe mainly other sources.” 016
“If you go to your own community or mosque, they judge you. They ask you so many questions.” 006
Many South Asian women were afraid to share their experiences with their family members because they feared being judged as a bad mother and facing discrimination and stigma. These moms also believed that seeking help within their community might not yield positive results as most people do not have knowledge about perinatal mental health and how to provide support during this period. As a result, seeking assistance from parent groups or children play centres where they could find other moms and peer support groups (both physical and online) was a common trend among the South Asian community or instead they would just keep it to themselves. However, one participant expressed a desire to seek help from her family but could not be due to other issues going on within her family.
“I don't feel like I could speak to my family because they're grieving themselves and I just don't like to burden my own family with my issues. I've never talked to them about them that much.” 016
Despite variability amongst groups, most women from other ethnic communities described their communities as largely family oriented, therefore they stated they would typically seek initial support from the people who made up their support system.
“In our culture, taking care of your emotions would really boil down to that person. Because we have very good family support, everyone is there, all the grandparents and the extended family, you would have someone to talk to. Speaking with therapists or seeking mental health support or emotional health support is not as frequent, it’s more of the immediate family circle, whomever you are closest with, then that is where you get your support from.” 009
Barriers related to accessibility to perinatal mental health services
Women’s perceptions of health professionals’ attitudes
Although cultural perceptions of mental health and help-seeking were significant barriers to accessing formal perinatal mental health services, women’s willingness to seek help was also significantly impacted by their past negative experiences with health professionals. Notable amongst the narratives of women in this study were both personal and community experiences of discrimination from health professionals that resulted in cautious and at times fearful perceptions of formal mental health services. Most women in this study described their experiences with their health professionals as emotionally difficult because of unmet expectations and needs. This was especially notable within the maternity setting, with some women describing traumatic and medically neglectful birth experiences resulting from interactions with maternity health professionals. In two instances, women felt they were refused referral for mental health treatment as they felt the staff’s medical errors may be exposed. These experiences were not specific to a particular ethnic group.
“I felt like even when I made complaint to that matron who came to see me, I felt like she even judged me. There was nothing like we will investigate into this why this happened to you. There was nothing like we should do an incident form about it. There was nobody else to go to, because these are the actual professionals who can refer you to other places. If these professionals behave, have this attitude, where can a woman go”008
IR008027
I just felt I'd got to a stage where I didn't know who to keep reaching out to because I just felt I was a broken record. I kept telling everybody about how I was feeling. Everyone kept saying, wow, this is a really difficult thing that you've been through, but no one was actually helping to do anything I think I just gave up really”25
Most women in the study felt that their health professionals did not meet their expectations during their maternity experience. They believed that midwives and nurses in maternity units should be trained to identify mental health issues as many were unable to detect signs of mental health problems or ignored them when symptoms were present.
“I spoke to a lot of healthcare professionals while I was in hospital. Some I was very obvious and open with how I was feeling, and some could have asked a few more questions for me to open up. They've [health professionals] done nothing about it. If they have had the training, and I think that's the first bit is you need to have the staff or a specific person that goes around to every mother in that ward. "How are you feeling today? How is your mental health." 025
A significant number of women shared their apprehensions about seeking medical advice due to their lack of trust in healthcare professionals. They were also afraid of being reported to social services if they disclose their symptoms.
“I had this idea that if the midwife doesn't like something that they hear, they're going to take your children away from you.” 021
If women did overcome these fears and approached health professionals for their mental health needs, they reported they felt as if the health professionals were dismissive towards their needs because of their ethnicity. This was especially true for Black women. They felt as if their fears of discrimination were realised.
“I feel like it would have been different if someone from another background had come to them and say it the way it is because I couldn’t call it the way it should be called. Maybe that was why I couldn’t get the help that I needed.” 029 (Black woman)
“I feel like with Black people especially, that happens, they feel like you should be strong, and you should be to get through it. They don't really offer you– I don't know. The way I see it, if I were White, they probably would've offered me more help.”20 (Black woman)
Some women who described having mental health problems because of the trauma they experienced caused by health professionals were reluctant to pursue formal mental health support, because they perceived mental health professionals as being representative of the types of individuals who had traumatized them in the first instance.
“I was saying, they were saying that my wound is fine, but in the end, it was septic all along. Now after that I just don't trust, if I get unwell, I wouldn't think to go and get medical help. I'd try and sort it out myself.” 027
Positive experience of peer support groups
Out of the twenty-eight women who were interviewed, a little less than half of the participants sought assistance from universal mental health services but were unable to receive help from formal perinatal mental health services due to reasons such as waiting times or dismissive attitudes from health professionals. Of the total participants, thirteen (46%) utilised support provided by their local VCS support groups or online support groups, without the help of mental health services. Women described the support groups as their happy, safe havens where different forms of support were available and where their fears of motherhood were voiced and validated. Women also described their different support groups as free of judgment and discrimination, places where their cultural values and beliefs were respected.
“I couldn't open up to someone at that time. I can do that now. I couldn't open up to someone at the time that was no offense, that was a White woman, because if I was to talk to her about, I don't want to be looked like– I didn't want to say certain things because the GP or that health professional would look at me like, I'm a crazy Black woman and I don't know how to handle my emotions. She wouldn't get that, but at the minute I said that to someone else that looked like me, they got it instantly.” 015
Then she (peer support coordinator) just told me some things and they were religious, they're linked with my religion in terms of like, they make sense to me because I'm quite strongly in my beliefs in terms of religiously, and then they meant something to me.
According to women's reports, support groups led by individuals who had previously experienced perinatal mental health challenges were particularly effective in helping women during these difficult times. Participants felt represented in these groups because the coordinators shared either their ethnicity or religion, providing them with culturally sensitive support. Additionally, women felt comfortable discussing their fears openly, knowing that other mothers in the group were likely to be going through similar experiences.