Elsevier

General Hospital Psychiatry

Volume 32, Issue 1, January–February 2010, Pages 17-25
General Hospital Psychiatry

Psychiatry and Primary Care
Falling through the net — Black and minority ethnic women and perinatal mental healthcare: health professionals' views

https://doi.org/10.1016/j.genhosppsych.2009.07.007Get rights and content

Abstract

Objectives

The objective of this study was to investigate health professionals' views about perinatal mental healthcare for Black and minority ethnic women.

Methods

Qualitative data were collected from a range of healthcare professionals (n=42) via individual interviews and focus groups. Participants were recruited from antenatal community clinics, a large teaching hospital, general practice and a specialist voluntary sector agency in the north of England, UK.

Results

Participants reported inadequacies in training and lack of confidence both for identifying the specific needs of Black women and for managing perinatal depression more generally, particularly in women with mild/moderate and ‘subthreshold’ depression. Inadequate perinatal depression management was associated with failure to screen routinely, confusion about professional roles and boundaries, and poorly defined care pathways, which increased women's likelihood of ‘falling through the net,’ thus failing to receive appropriate care and treatment.

Conclusions

Suboptimal detection and treatment of perinatal depression among ‘high-risk’ women highlight gaps between UK policy and practice. This applies to women from all ethnic groups. However, evidence suggests that Black women might be particularly vulnerable to deficiencies in provision. Effective management of perinatal depression requires a more robust implementation of existing guidelines, more effective strategies to address the full spectrum of need, improved professional training and a more coordinated multiagency approach.

Introduction

Detection and treatment of perinatal depression are important public health issues because of the condition's potentially serious consequences on women's life-long mental health and the health and well being of their children and families [1]. Perinatal depression is known to adversely affect children's physical, cognitive and psychological health [2], [3] (particularly among disadvantaged populations [4], [5], [6], [7], [8]) and is associated with family breakdown and institutionalization of children [3], [9], [10]. This suggests that suboptimal management of perinatal depression might have particularly serious ramifications for Black Caribbean women in the UK, as a high percentage are lone parents [11], [12].

Inequalities in access, care and treatment are antithetical to the core values of the UK's National Health Service (NHS), which is founded on strong social principles of providing high-quality, accessible and equitable healthcare based on solely on clinical need (rather than ability to pay). However, despite major reform [13], [14], inequalities persist. In response, a number of policies aimed at improving the health of vulnerable and underserved communities have emerged in the last decade or so. However, policies designed to ‘tackle health inequalities’ [15], bring women's mental health ‘into the mainstream’ [16], [17] and ‘deliver race equality’ in mental healthcare [18] appear to have made little impact on improving the mental health of Black and minority ethnic (BME) women [19], [20]. For example, although generally agreed psychosocial risks such as social deprivation, lone parenthood and having a personal or family history of mental illness [21], [22], [23], [24], [25] disproportionately affect BME women, anecdotal and limited research evidence suggests that relatively few Black Caribbean women in the UK access perinatal mental healthcare despite evidence of significant levels of morbidity [26].

Detection and treatment of depression [27] and perinatal depression in primary care [28], [29] are known to be universally poor. The reasons for this are not entirely clear, but evidence suggests that personal and cultural factors such as the attitudes and beliefs of practitioners and laity may be as significant as structural barriers [26], [30], [31], [32], [33], [34], [35], [36]. In relation to the mental health of minority groups in the UK, research and service delivery tend to focus on serious mental illnesses among BME men [37], [38], [39], [40]. Accordingly, relatively little attention has been paid to addressing the specific mental health needs of minority women, particularly in primary care [18], [20].

This study aimed to begin to redress this gender imbalance. To examine factors that might account for the relative invisibility of Black women in primary mental healthcare, NHS and voluntary sector practitioners were consulted about their experiences of and views on managing perinatal depression among women of Black Caribbean origin.

Section snippets

Methods

A purposive sample of healthcare professionals (n=42) and child-bearing Black Caribbean women (n=42) was interviewed (either in focus groups or individually) about their perceptions of the extent to which current services meet the perinatal mental health needs of BME women. This article reports only the views of healthcare professionals. The views of women in the study will be reported in a forthcoming article. In addition to examining barriers to receiving care, the author encouraged

Antenatal contact and missed opportunities

Participants did not appear to regard antenatal depression either as a condition warranting intervention in its own right or as a mechanism for identifying women who are at risk for postnatal depression, even when women had known histories of postnatal depression. According to practitioners, this may be because antenatal care focuses primarily on physical issues:

“Even though women may have had PND in the past, if they've got other more pressing medical problems, for example diabetes or some

Discussion

This article explored practitioners' views about managing perinatal depression in BME women. It focused on examining perceptions of the factors that might explain the low levels of consultation diagnosis and treatment for perinatal depression among Black Caribbeans — an ethnic group that is known to experience higher rates of other mental illnesses, coupled with poorer access to and outcomes from contact with mental health services in the UK [43]. However, the study has wider implications for

Conclusions

Despite remedial action at the policy and practice levels, suboptimal detection and management of depression remain persistent problems in primary care [52], [80]. Some ethnic groups may be more likely to have their symptoms overlooked [44], [81]. According to practitioners in this study, the perinatal mental healthcare of Black Caribbean women, who are at greater theoretical risk for the onset of perinatal depression but largely absent from associated clinical and research data [82], endorses

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