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Addressing Postpartum Depression in Refugees: Impact on Infants and the Role of Home Visiting Programs

Periodic Reporting for period 1 - REFUDEPRE (Addressing Postpartum Depression in Refugees: Impact on Infants and the Role of Home Visiting Programs)

Reporting period: 2020-09-01 to 2022-08-31

Mental health disorders during the perinatal period, particularly perinatal depression, affect 15% of women worldwide. Forced migrant women have a higher risk of developing perinatal mental health disorders, with a pooled prevalence of 33,5%. Postpartum mental health can interfere with the mother’s ability to care for her baby and impact the development of the child. However, there is limited evidence about the effects of poor postpartum mental health on infants born to refugee mothers. Despite the importance of providing care that is culturally sensitive has been recognized, evidence of the potential of psychosocial interventions to enhance refugee mothers’ mental health after birth is scarce.

In REFUDEPRE we took a mixed methods approach to understand the burden of postpartum mental health problems on refugee women and their offspring and shed light on the role of nurse home visiting programs to support the mental health and psycho-social well-being of refugee women after giving birth.

The study was situated in Denmark. Denmark has one of the oldest universal home-visiting programs in Europe in which community health nurses (CHN) offer free home visits to all infant families. Since 2002, standardized data from CHNs records about infant development and maternal mental health are organized into a clinical database, the Child Health Database (CHD). In addition, from 2017 to 2020 an enhanced home visiting model was implemented to support the integration and well-being of refugee families in Danish society - the Health Nurses Strengthen Integration. In this enhanced program, CHNs in 15 municipalities were trained in cultural competencies and offered extra visits with a focus on parenting, child development, and Danish culture and systems (i.e. healthcare, and education).

In summary, results from REFUDEPRE demonstrate that postpartum mental health problems are associated with an increased risk of infant regulatory, motor, and communication problems regardless of mothers’ migration background and that challenges in the mother-child relationship mediate this association. Nonetheless, findings suggest that infants born to primiparous refuge mothers, independent of the mother’s length of stay in Denmark, are more likely to show infant regulatory problems at 8-11m, after adjusting for social and obstetric risk factors, and maternal mental health problems. Our qualitative study with health nurses and refugee women highlights the practices that enhance refugee mothers’ resources and psychological well-being and how health nurses navigate individual and systemic challenges to care for refugee women who experience mental health challenges.
In our quantitative study, we used data from the Child Health Database and National registries to investigate the effects of maternal mental health on infant development among refugee families in comparison to non-immigrants. First, our analysis showed that compared to Danish-born women, immigrant women, including refugees, were between 80-90% more likely to lack a postpartum depression screening using the Edinburgh postpartum depression scale (EPDS), pointing out problems in screening practices. In our subsequent analysis focused on community health nurses (CHN) records of maternal mental health problems, which were based on CHN and mothers’ conversations about mental health problems. Second, in a sample of 62964 infants (of which 3,4% had a refugee background), we showed that infants born to first-time refugee mothers had a higher risk to have late regulatory problems at 8-11 months than their counterparts. These differences in infant development were in part explained by refugee mothers’ increased postpartum mental health burden. Last, an analysis focusing on the group of refugee mothers showed that postpartum mental health problems increased infants’ odds of having regulatory, motor, and communication problems. The negative effects of postpartum mental health problems were mediated by challenges in the mother-child relationship (described as parents’ ability to respond to infants' needs).

Our phenomenological qualitative study was based on interviews with 12 health nurses and 9 refugee mothers that participated in the enhanced home visiting program. Drawing from the Resource-Based Model of refugee adaptation (Ryan et al. 2008) our thematic analysis showed how by creating a safe space for sharing about one’s life and hopes, offering respectful knowledge about parenting, focusing on families’ strengths, and ‘hand-holding’ families in interactions with Danish welfare services, health nurses facilitate mothers’ gain of new cultural, social, and psychological resources to respond to the daily challenges of mothering in exile. The emotional connection between mothers and health nurses, which often substituted lost social supports, served as the foundation of such resource gain and facilitated a process of gaining confidence and control in parenting abroad while feeling cared for and supported. These findings point towards the potential of this home-visiting model to promote the psycho-social well-being of refugee women. Whether this approach can prevent postpartum mental health problems needs to be further investigated. In our analysis of qualitative data, we also identified some of the dilemmas and challenges that health nurses experience when caring for refugee women that experience mental health challenges and the importance of taking a systems perspective to improve the mental health care of refugee women.

These findings have been disseminated at the European Public Health conference, the Nordic Marce Conference, the 21st Nordic Migration Research Conference, and the COST Action RISEUP-PPD international conference. Our first open-access article has been recently published: Marti-Castaner M at al., (2022). Disparities in postpartum depression screening participation between immigrant and Danish-born women. European journal of public health, 32(1), 41-48. More peer-review articles will follow in the upcoming months in open-access formats.

Our exploitation strategies included presenting the findings at the Danish Health Nurse Board and at the National Institute for Public Health and to stakeholders from international organizations (Danish Refugee Council, Red Cross, Danish Refugee Council). Findings have also been presented to practitioners, municipalities, and stakeholders in Denmark to plan the preparation for Ukrainian refugees arriving in Denmark.
Findings from REFUDEPRE have had societal impacts at a regional level. We have been part of the Danish expert group on postpartum depression organized by the Danish Ministry of Health and helped develop new recommendations. We have also developed an online class on perinatal mental health among immigrant and ethnic minority women, for the continued education of health nurses and midwives in Denmark.

In addition, our findings have informed a new project to develop an internet-based intervention for postpartum depression for the Danish-speaking population and explore the potential and pitfalls to develop a culturally adapted version for immigrant and refugee women.

As we continue to publish and disseminate our findings, we expect to further collaborate with the Rise-PPD COST action and improve the screening practices and psycho-social care of immigrants and refugees across Europe experiencing maternal mental health challenges.
presentation at RISEPPD COST action conference