Migrant women who are pregnant may have complex experiences before, during and after migration because of political, demographic, socioeconomic and environmental factors, which increases the risk of developing a new or recurrent perinatal mental illness. As one in three pregnant migrant women will develop a perinatal mental illness (Fellmeth et al, 2017), it is a growing public health concern that requires focused attention. Consequently, there has been a renewed emphasis on early identification of perinatal mental illness and prompt healthcare interventions that meet the needs of migrant women (Fair et al, 2020).
Midwives must capitalise on opportunities to raise awareness about perinatal mental health. It is important to offer guidance on accessing specialised services and support when required during all cross-cultural interactions with migrant women. However, this requires staff to have the knowledge, skills and attitudes to provide perinatal mental healthcare in culturally responsive ways. Cultural humility encourages openness, empathy and respect for cultural differences, which is critical for developing culturally responsive approaches to perinatal mental healthcare. This article proposes practical approaches to developing cultural humility as a means of providing culturally responsive perinatal mental healthcare.
Background
Migration can be influenced by political, demographic, socioeconomic and environmental factors that can result in physical and psychological stressors. This can increase migrant women's susceptibility to perinatal mental illness (Anderson et al, 2017; Fellmeth et al, 2017; Yu and Bowers, 2020).
In this context, ‘migrant women’ is used to describe women from a diverse range of cultural, ethnic and linguistic backgrounds who have migrated to a new country for any reason, and may include refugee, asylum-seeking or economic migrant women. Evidence of the difficulties migrant women experience when accessing perinatal mental healthcare services warrants urgent attention (Pangasa et al, 2019; Watson et al, 2019; Fair et al, 2020). Despite calls for increasing the cultural appropriateness of healthcare service delivery, migrant women continue to report challenges when communicating their perinatal mental health concerns (Ikhilor et al, 2019; Markey et al, 2022). They also experience insensitivity during cross-cultural encounters with healthcare professionals (Iliadou et al, 2019; Fair et al, 2021).
Early identification of perinatal mental health risks among migrant women and planning appropriate culturally responsive person-centred interventions is critical. However, this requires developing insights into how perinatal mental health support services and practices can be adapted to ensure they are culturally responsive. Gill and Babacan (2012) define culturally responsive care as quality care that respects care preferences informed by cultural beliefs and norms. These beliefs, norms and traditions play an important role in how somebody perceives perinatal mental health and how easily they can access services and support (Schmied et al, 2017). Midwives and the wider multidisciplinary team need to consider how to provide quality perinatal mental healthcare in culturally responsive ways.
Examining perinatal mental healthcare through a cultural humility lens can help midwives critically review their behaviours as a means of providing culturally responsive perinatal mental healthcare. Cultural humility was first developed as a concept by Tervalon and Murray-Garcia (1998), as a means of addressing reported limitations with the concept of cultural competence. A concept analysis of the term (Foronda et al, 2015) defined cultural humility as a continuous journey of self-reflection in developing self-awareness and openness during cross-cultural encounters and respect for cultural difference.
Flexibility in approaches to care, being respectful of cultural differences and critically reflecting on stereotypes and biases that may influence caring behaviours are all paramount to cultural humility. Masters et al (2019) and Robinson et al (2021) highlight the importance of reducing implicit biases and bringing more awareness into cross-cultural healthcare encounters, by incorporating the 5Rs of cultural humility (reflection, respect, regard, relevance, resiliency). This article proposes practical considerations for midwives when caring for migrant women experiencing perinatal mental illness, using this framework.
Reflection
Reflection in this context refers to an acknowledgement that there is always something to learn from every cross-cultural encounter, and that active listening can help support cultural humility (Masters et al, 2019). Developing cultural awareness and gaining an understanding of perinatal mental health risk factors and the importance of respecting differing perspectives of perinatal mental health is essential. Opportunities to reflect on and think about cross-cultural interactions can support cultural awareness (Lin et al, 2019) and can help develop greater understanding of a midwife's role in supporting perinatal mental health in differing contexts (Carroll et al, 2018). Although this can be an enlightening experience, at times it can also cause discomfort, as it involves recognising one's own attitudes towards cultural differences and unconscious biases.
Actively listening to migrant women's unique vulnerabilities and taking the time to understand their experiences of perinatal mental health generates new ways of thinking about differing perspectives. Markey et al (2019) highlight the importance of developing the curiosity to ask questions when unsure about cultural beliefs, as well as the commitment to providing quality care in different cultural contexts and the courage to engage in cross-cultural clinical encounters that may be new or different.
Respect
Respecting migrant women's individual experiences and perspectives of perinatal mental health and cultural norms around motherhood and help-seeking behaviour is paramount to developing cultural humility. Masters et al (2019) describe respect as acknowledging and honouring differing care preferences and providing quality care that meets the unique needs of patients in culturally responsive ways. It is essential to take the time to discuss migrant women's experiences and feelings during the perinatal period, and acknowledge and explore the cultural factors that influence their perspectives of perinatal mental healthcare and expectations of healthcare delivery.
Carrying out comprehensive, woman-centred and culturally responsive assessments that focus on understanding cultural perspectives that inform care preferences and needs is a necessity (Arefadib et al, 2021). To respect cultural differences, it is important to consider similarities in care needs, while acknowledging cultural differences and understanding the unique needs of migrant women. Midwives need to remain attentive to the potential for cultural misunderstandings during caring encounters. This requires critically reviewing sometimes narrow perceptions of cultural differences. These perceptions are informed by stereotypical assumptions and focus on differences as opposed to commonalities of perinatal mental healthcare needs (Kaihlanen et al, 2019; Markey et al, 2019). For example, it is important to consider parallels in communication styles and modes, while identifying solution-focused plans, when there are communication process differences.
Regard
Regard refers to the value healthcare professionals place on individual cultural beliefs held by women, ensuring implicit biases are considered and addressed (Masters et al, 2019). This requires a commitment to becoming culturally aware, self-critiquing cultural beliefs and values and bringing forth an awareness and commitment to addressing implicit biases and stereotypes.
An implicit bias is an unconscious belief about a person from a different cultural or ethnic background, which can influence midwives' attitudes and behaviours during cross-cultural encounters (Fitzgerald and Hurst, 2017). Midwives should challenge themselves to address possible implicit biases about migrant women during the perinatal period. These biases are often subconsciously developed but have a destructive effect on behaviours and practices. Sambrook Smith et al (2019) conducted a systematic review of the culturally insensitive care migrant women experience when accessing perinatal mental healthcare services. They reported that this insensitivity deters them from seeking further help. Taking time out to sensitively think about one's own and differing perceptions of health and illness during the perinatal period is important in avoiding a ‘right or wrong’ approach to mutually negotiating perinatal mental healthcare and can help avoid cultural misunderstandings.
Relevance
Healthcare professionals need to see the relevance and necessity of integrating cultural humility into every day practices (Masters et al, 2019). This is important for every cross-cultural caring encounter, but particularly when supporting migrant women experiencing perinatal mental illness. Ikhilor et al (2019) and Sambrook Smith et al (2019) reported on the difficulties experienced for migrant women experiencing perinatal mental illness, many of which arose from a lack of intercultural understanding on the part of the healthcare professional. Midwives need to understand the particular vulnerabilities migrant women experience that may increase their risks of perinatal mental illness, as well as complexities when accessing support and take the initiative to plan culturally responsive interventions.
There is mounting evidence highlighting the challenges migrant women experience when accessing perinatal mental health support, such as a lack of awareness of available support and how to access it (Ellul et al, 2020; Markey et al, 2022), and differing expectations of healthcare services (Maxwell et al, 2019). There can also be challenges when communicating sensitive experiences and feelings when there are language barriers. Although there are policy recommendations for the use of professionally trained interpreters, Ikhilor et al (2019) identified that migrant women experience difficulties when there are language barriers. Developing culturally responsive perinatal mental health information resources that use various modalities of communication and are available in many languages is recommended (Dossett et al, 2018; Markey et al, 2022).
Communicating cross-culturally requires excellent communication skills in order to respond appropriately when there are differences in language and communication styles informed by cultural norms. Midwives need to appreciate that mental health is sometimes stigmatised, made taboo or ostracised within some cultural groups, highlighting the necessity for care, sensitivity and respect during any discussions on perinatal mental health with migrant women. Das and Beszlag (2021) report the negative impact perinatal mental health has among migrant women for this reason, which exacerbates challenges with communicating experiences and feelings.
Resilience
Resilience refers to self-care and to the ability of healthcare professionals to mind themselves (Masters et al, 2019). McCann et al (2013) draws attention to the importance of sustaining personal and professional wellbeing as means of nurturing resilience, which improves the ability to adapt caring behaviours in culturally responsive ways. The complexities of working in an ever-evolving and increasingly culturally diverse healthcare setting, when midwives may not feel fully prepared to provide culturally responsive care, is challenging and may exacerbate feelings of stress (Markey et al, 2017).
White et al (2019) highlight the importance of addressing work-related stressors to reduce burnout and maintain standards of care. Midwives need to feel comfortable discussing challenges providing culturally responsive perinatal mental healthcare with their peers and managers, as a means of sharing concerns and collectively planning support. However, this requires the courage to acknowledge limitations and commit to working collectively to improve perinatal mental healthcare for migrant women. Providing education and training opportunities that support culturally responsive perinatal mental health screening, treatment and referral pathways is a way of developing resilience (Dossett et al, 2018; Shepherd et al, 2019).
Conclusions
There are complexities associated with providing perinatal mental healthcare to migrant women in culturally responsive ways. It is important to examine ways of developing cultural humility, and the 5Rs framework may be useful in this regard.