Jane Yelland

Cross-cultural experiences of maternal depression: associations and contributing factors for Vietnamese, Turkish and Filipino immigrant women in Victoria, Australia

Objectives. To investigate in an Australian study of immigrant women conducted 6–9 months following childbirth (a) the associations of a range of demographic, obstetric, health and social context variables with maternal depression, and (b) womens views of contributing factors in their experiences of depression. Design. Three hundred and eighteen Vietnamese, Turkish and Filipino women participated in personal interviews conducted by three bicultural interviewers in the language of the womens choice. Utilising three approaches to the assessment of maternal depression, the consistency of associations on the different measures is examined. Womens views of contributing factors are compared with previous research with largely English-speaking Australian-born women. Results. Analysis of the associations of maternal depression revealed considerable consistency in associations among the three approaches to assessing depression. Significant associations with depression on at least two of the measures were seen for: mothers under 25 years, shorter residence in Australia, speaking little or no English, migrating for marriage, having no relatives in Melbourne, or no friends to confide in, physical health problems, or a baby with feeding problems. There were no consistent associations found with family income or maternal education, method of delivery and a range of other birth events, or womens views about maternity care. The issues most commonly identified by women in this study as contributing to depression are similar to those found previously for Australian-born women: isolation (in this study, including being homesick)—29%; lack of support and marital issues—25%; physical ill-health and exhaustion—23%; family problems—19%, and baby-related issues—17%. There were some differences in the importance of these among the three country-of-birth groups, but all except family issues were in the top four contributing factors mentioned by women in all groups. Conclusions. These findings support the evidence for quite marked cross-cultural similarity in the associations of maternal depression and in womens views about their experiences.

Cross-cultural research: trying to do it better. 2. Enhancing data quality.

Objective: To discuss a range of strategies to address the methodological and practical challenges in designing cross‐cultural public health studies.

Support, sensitivity, satisfaction: Filipino, Turkish and Vietnamese women's experiences of postnatal hospital stay

OBJECTIVE To assess Filipino, Turkish and Vietnamese womens views about their care during the postnatal hospital stay. DESIGN Interviews were conducted with recent mothers in the language of the womens choice, 6-9 months after birth, by three bilingual interviewers. PARTICIPANTS Three hundred and eighteen women born in the Philippines (107), Turkey (107) and Vietnam (104) who had migrated to Australia. SETTING Women were recruited from the postnatal wards of three maternity teaching hospitals in Melbourne, Australia, and interviewed at home. FINDINGS Overall satisfaction with care was low, and one in three women left hospital feeling that they required more support and assistance with both baby care and their own personal needs. The method of baby feeding varied between the groups, with women giving some insight into the reason for their choice. A significant minority wanted more help with feeding, irrespective of the method. The need for rest was a recurrent theme, with women stating that staffs attitudes to individual preferences, coupled with lack of assistance, made this difficult. The majority of comments women made regarding their postnatal stay focused on the attitude and behaviour of staff and about routine aspects of care. Issues related to culture and cultural practices were not of primary concern to women. CONCLUSION Maternity services need to consider ways in which care can focus on the individual needs and preferences of women.

In-Hospital Formula Supplementation of Breastfed Babies: A Population-Based Survey

BACKGROUND   In-hospital formula supplementation of breastfed newborns is commonplace despite its negative association with breastfeeding duration. Although several studies have described the use of formula supplementation, few have explored the factors that may be associated with its use. The aim of this study was to explore factors associated with in-hospital formula supplementation using data from a large Australian population-based survey. METHODS   All women who gave birth in September and October 2007 in two Australian states were mailed questionnaires 6 months after the birth. Women were asked how they fed their baby while in hospital after the birth. Multivariable logistic regression was used to explore specified a priori factors associated with in-hospital formula supplementation. RESULTS   Of 4,085 women who initiated breastfeeding, 23 percent reported their babies receiving formula supplementation. Breastfed babies had greater odds of receiving formula supplementation if their mother was primiparous (adj. OR=2.16; 95% CI: 1.76-2.66); born overseas and of non-English-speaking background (adj. OR=2.03; 95% CI: 1.56-2.64); had a body mass index more than 30 (adj. OR=2.27; 95% CI: 1.76-2.95); had an emergency cesarean section (adj. OR=1.72; 95% CI: 1.3-2.28); or the baby was admitted to a special care nursery (adj. OR=2.72; 95% CI: 2.19-3.4); had a birthweight less than 2,500 g (adj. OR=2.02; 95% CI: 1.3-3.15) or was born in a hospital not accredited with Baby-Friendly Hospital Initiative (BFHI) (adj. OR=1.53; 95% CI: 1.2-1.94). CONCLUSIONS   The number of factors associated with in-hospital formula supplementation suggests that this practice is complex. Some results, however, point to an opportunity for intervention, with the BFHI appearing to be an effective strategy for supporting exclusive breastfeeding.

Bridging the Gap: using an interrupted time series design to evaluate systems reform addressing refugee maternal and child health inequalities

BackgroundThe risk of poor maternal and perinatal outcomes in high-income countries such as Australia is greatest for those experiencing extreme social and economic disadvantage. Australian data show that women of refugee background have higher rates of stillbirth, fetal death in utero and perinatal mortality compared with Australian born women. Policy and health system responses to such inequities have been slow and poorly integrated. This protocol describes an innovative programme of quality improvement and reform in publically funded universal health services in Melbourne, Australia, that aims to address refugee maternal and child health inequalities.Methods/designA partnership of 11 organisations spanning health services, government and research is working to achieve change in the way that maternity and early childhood health services support families of refugee background. The aims of the programme are to improve access to universal health care for families of refugee background and build organisational and system capacity to address modifiable risk factors for poor maternal and child health outcomes. Quality improvement initiatives are iterative, co-designed by partners and implemented using the Plan Do Study Act framework in four maternity hospitals and two local government maternal and child health services.Bridging the Gap is designed as a multi-phase, quasi-experimental study. Evaluation methods include use of interrupted time series design to examine health service use and maternal and child health outcomes over a 3-year period of implementation. Process measures will examine refugee families’ experiences of specific initiatives and service providers’ views and experiences of innovation and change.DiscussionIt is envisaged that the Bridging the Gap program will provide essential evidence to support service and policy innovation and knowledge about what it takes to implement sustainable improvements in the way that health services support vulnerable populations, within the constraints of existing resources.

How do Australian maternity and early childhood health services identify and respond to the settlement experience and social context of refugee background families

BackgroundRefugees have poor mental, social and physical health related to experiences of trauma and stresses associated with settlement, however little is known about how refugee families experience maternity and early childhood services. The aim of this study was to explore the responsiveness of health services to the social and mental health of Afghan women and men at the time of having a baby.MethodParticipatory methods including community engagement and consultation with the Afghan community and service providers in Melbourne, Australia. Bicultural researchers conducted interviews with Afghan women and men who had recently had a baby. Interviews and focus groups were also conducted with health professionals working in the region.ResultsThirty interviews were conducted with Afghan women and men who had recently had a baby. Thirty-four health professionals participated in an interview or focus group.Afghan women and men reported significant social hardship during the period before and after having a baby in Australia, but were rarely asked about their social health by maternity and early childhood services.Most health professionals recognised that knowledge and understanding of their client’s migration history and social circumstances was relevant to the provision of high quality care. However, inquiring about refugee background, and responding to non-clinical needs of refugee families was challenging for many health professionals. Factors that made it more difficult for health professionals to engage with Afghan families in pregnancy included limited understanding of the context of migration, dependency of many Afghan women on their husband for interpreting, short appointments, and the high likelihood of seeing different health professionals at each antenatal visit. Community-based maternal and child health nurses had more scope to work with interpreters, and build relationships with families, providing a stronger foundation for identifying and responding to complex social circumstances.ConclusionThere are significant challenges in providing comprehensive, high quality primary health care for Afghan families accessing Australian maternity and early childhood services. The limited capacity of public maternity services to identify families of refugee background and provide tailored service responses are contributing to inequitable maternal and child health outcomes for families of refugee background.

Women's Experience of Discrimination in Australian Perinatal Care: The Double Disadvantage of Social Adversity and Unequal Care

BACKGROUND Discrimination in womens health care, particularly perinatal care, has received minimal attention. The aim of this study is to describe womens experience of discrimination in different models of maternity care and to examine the relationship between maternal social characteristics and perceived discrimination in perinatal care. METHODS A population-based postal survey was mailed 6 months postpartum to all women who gave birth in two Australian states in September and October 2007. Perceived discrimination was assessed using a five-item measure designed to elicit information about experiences of unequal treatment by health professionals. RESULTS A total of 4,366 eligible women completed the survey. Women attending public models of maternity care were significantly more likely to report perceived discrimination compared with women attending a private obstetrician (30.7% vs 19.7%, OR 1.79, 95% CI 1.5-2.1). Compared with women reporting no stressful life events or social health issues in pregnancy, those reporting three or more stressful life events or social health issues had a twofold increase in adjusted odds of perceived discrimination (41.1% vs 20.4%, adj OR 2.27, 95% CI 1.8-2.8). Young women (< 25 yr) and women who were smoking in pregnancy were also at increased risk of experiencing perceived discrimination. CONCLUSIONS Discrimination is an unexplored factor in how women experience perinatal care. Developing approaches to perinatal care that incorporate the capacity to respond to the needs of vulnerable women and families requires far-reaching changes to the organization and provision of care.

Applying a social disparities lens to obesity in pregnancy to inform efforts to intervene

OBJECTIVE to examine the social correlates of pre-pregnancy overweight and obesity in an Australian population-based sample and consider implications for intervention effectiveness during pregnancy. DESIGN population-based survey distributed by hospitals to women 6 months after birth. SETTING two states of Australia. PARTICIPANTS women who gave birth in Victoria and South Australia in September/October 2007. MEASUREMENTS AND FINDINGS surveys were completed by 4,366 women. Pre-pregnancy body mass index (BMI) was calculated from womens self-reported weight in kilograms/(height in metres)(2). Results showed high rates of overweight (22%) and obesity (14%) among Australian women entering pregnancy. After adjusting for other factors in the model, pre-pregnancy obesity was significantly associated with lower household income levels, less education, the experience of financial stress in pregnancy and increasing parity. KEY CONCLUSIONS to date, there is little evidence to support the efficacy of interventions to manage problematic weight in pregnancy. Applying a social disparities lens to obesity in pregnancy challenges us to consider social factors that may seem distal to obesity but are highly relevant to efficacious intervention. IMPLICATIONS FOR PRACTICE pregnancy care offers an opportunity to address social issues on the pathway to obesity. Current clinical care guidelines on maternal overweight and obesity in pregnancy rarely consider social contexts that place some women at risk and are a likely impediment to efficacious intervention.

Compromised communication: a qualitative study exploring Afghan families and health professionals’ experience of interpreting support in Australian maternity care

Introduction Difficulties associated with communication are thought to contribute to adverse perinatal outcomes experienced by refugee background women living in developed countries. This study explored Afghan women and mens experience of language support during pregnancy, labour and birth, and health professionals’ experiences of communicating with clients of refugee background with low English proficiency. Methods Interviews were conducted with (1) Afghan women and men in the first year after having a baby in Australia, by multilingual, bicultural researchers and (2) midwives and medical practitioners providing care to families of refugee background. Analysis was conducted thematically. Results Sixteen Afghan women, 14 Afghan men, 10 midwives, five medical practitioners and 19 community-based health professionals (refugee health nurses, bicultural workers, counsellors) providing maternity or early postnatal care participated. Midwife and medical informants concurred that accredited interpreters are generally booked for the first pregnancy visit, but not routinely used for other appointments. Very few Afghan participants reported access to on-site interpreters. Men commonly interpreted for their wives. There was minimal professional interpreting support for imaging and pathology screening appointments or during labour and birth. Health professionals noted challenges in negotiating interpreting services when men were insistent on providing language support for their wives and difficulties in managing interpreter-mediated visits within standard appointment times. Failure to engage interpreters was apparent even when accredited interpreters were available and at no cost to the client or provider. Conclusions Improving identification of language needs at point of entry into healthcare, developing innovative ways to engage interpreters as integral members of multidisciplinary healthcare teams and building health professionals’ capacity to respond to language needs are critical to reducing social inequalities in maternal and child health outcomes for refugee and other migrant populations.

Asking Women about Mental Health and Social Adversity in Pregnancy: Results of an Australian Population‐Based Survey

BACKGROUND Social adversity undermines health in pregnancy. The objective of this study was to examine the extent to which pregnant women were asked about their mental health and life circumstances in pregnancy checkups. METHOD Population-based postal survey of recent mothers in two Australian states. FINDINGS Around half of the 4,366 participants reported being asked about depression (45.9%) and whether they were anxious or worried about things happening in their life (49.6%); fewer reported being asked about relationship issues (29.6%), financial problems (16.6%), or family violence (14.1%). One in five women (18%) reported significant social adversity. These women were more likely to recall being asked about their mental health and broader social health issues. Far higher levels of inquiry were reported by women in the public maternity system with midwives more likely than doctors to ask about mental health, family violence, and other social hardships. CONCLUSIONS Routine pregnancy visits afford a window of opportunity for identifying and supporting women experiencing mental health problems and social adversity. Changing practice to take advantage of this opportunity will require concerted and coordinated efforts by practitioners and policy makers to build systems to support public health approaches to antenatal care.