Case studies

The following are four cases for readers to reflect on. The case studies present postnatal depression and the settlement challenges CALD women face. It is recommended that readers also read about the perinatal care and traditional practices of the cultural groups under the cultural profiles section of this resource, to increase awareness of the diverse cultural practices during the postnatal period.

Case Study 10: Postnatal depression (Chinese)

Ling, with her daughter, arrived in New Zealand a year ago from China to join her husband. Ling speaks little English. Ling’s husband has been working two jobs to support his family. After a year in New Zealand, Ling gave birth to their second child, a son. A Well Child/Tamariki Ora nurse became concerned about Ling’s exhaustion and lack of interest in the baby. The nurse, with a Mandarin speaking female interpreter assesses Ling for depression using the Patient Health Questionnaire 3 (PHQ-3) on which she scores 19. The Well Child/Tamariki Ora nurse refers her to her general practitioner who diagnoses her with postnatal depression and prescribes antidepressant medication. Ling was exhausted from the night feedings for her baby. With the full-time care and responsibility of her children, she felt socially isolated and missed the support of her family.

Case Study 11: Postnatal depression and immigration issues (Iraqi)

Safia and her husband Walid arrived from Iraq in 2003. They are refugees who were in a refugee camp in Jordan before being selected to come to New Zealand as part of the refugee quota. Safia has had her first child, a daughter. Safia speaks limited English. She desperately wants her mother, who lives in Bhagdad, to come and help her after the birth.

Safia is tearful every time the Well Child Tamariki Ora nurse visits her. She has repeatedly called her mother, telling her that she must come to stay with her. However, Safia’s application for a visitor’s visa for her mother has been declined, as her travel documents do not meet the requirements for entry to New Zealand. Safia becomes more withdrawn and depressed every time you visit. Safia’s five week old baby is breastfed. Safia is unable to sleep and requires daily support to manage her baby and household responsibilities. There is a huge strain on the level of support that Walid and friends can provide for Safia.

The Well Child/Tamariki Ora nurse has undertaken the PHQ-3 assessment which has indicates that Safia may be suffering from postnatal depression. The nurse refers Safia to her GP for a maternal mental health assessment.

Case Study 12: Postnatal depression (Indian)

Amritha is a 24 year old woman from India. After her marriage 4 years ago she moved from Mumbai to Auckland to join her husband and his family. Amritha gave birth to a baby girl, her first child, six weeks ago. She and her husband Krishna live with Krishna’s parents.

Practice Nurse Assessment

During a visit to the general practice for vaccinations for the baby, Amritha’s mother-in-law tells the practice nurse that she is concerned about her daughter-in-law as she is reluctant to get out of bed or to look after the baby, and constantly complains of pain in her stomach.

The practice nurse refers her to the GP.

GP Assessment

A physical examination does not reveal anything abnormal, or that could not be related to her recent childbirth.

During her conversation with the GP, it transpires that Amritha believes that she is worthless and that her in-laws do not like her. When she was working, she had friends to talk to but now that she is home all day she feels trapped. Amritha is disappointed that she did not have a boy child. She tells the GP that she doesn't want to spend time with her baby, and that she is reluctant to feed the baby and that she herself doesn't want to eat. She says that she doesn't have the energy to look after herself and the baby too.

The GP recommends that a blood test is taken. Amritha states that apart from having a baby she has had no previous health problems.

Case Study 13: Postnatal depression (Burmese)
(Adapted from Kokanovic et al., 2012)

Ma Sha’s family arrived in New Zealand in 2013 when she was five months pregnant with twins. Ma Sha has limited English language ability and low literacy. She has had a few years of primary education at a Christian Missionary School in Myanmar where she learned some Burmese.

Maternity Service

Ma Sha had an emergency induction performed not long after her arrival due to serious health concerns for one of the twins. Ma Sha did not fully understand why or how medical procedures were performed and she did not receive any interpreting services during the week she was in the birthing unit. Without an interpreter she said she “just used my hands and legs” to communicate. During the birth someone told her that her, “son did not have his head”. The head had disappeared. She described that her “heart was shaking” with fear. However, she delivered successfully, but had difficulties establishing breastfeeding.

Postnatal care by Midwife (immediate after birth)

When Ma Sha returned home with her babies she felt the intense loss of her grandmother who raised her, who was left behind in the refugee camp. Ma Sha tells the midwife that during the birth she had experienced extreme anxiety. On the next visit Ma Sha through an interpreter tells the midwife that she has difficulty sleeping. Her husband tells the midwife that Ma Sha is frequently in tears for no reason. She says: “I am not sure how to name this feeling in Karen but the Burmese word satedakyat (big anxiety) is how I should put it. I feel anxious about things and my heart is satepyae, sategon, (exhausted, tired). I don’t know how to explain it. I feel hurt”

The midwife suspects Ma Sha may have postnatal depression and refers her to her GP for a maternal mental health assessment.

GP postnatal depression assessment

During the GP assessment Ma Sha tells the GP that she was raised by her grandmother because her mother had been hospitalised due to an illness she referred to as meedwinyu a rarely used Burmese term meaning ‘someone who is psychologically abnormal after birth’ or sometimes defined as having postnatal madness.

Ma Sha was desperate to tell her story about giving birth to her twins alone in New Zealand without family and the extreme distress she felt throughout her pregnancy, birth and postnatal period.

Ma Sha agrees to psychological support and is referred to appropriate primary mental health services. In addition to receiving psychological support, Ma Sha also has effective personal coping strategies which have helped her and her family to survive years of violence and repression in Burma, dangerous and unsafe refugee camps, and the stress of resettlement in New Zealand. She finds great strength and comfort in spirituality. Ma Sha has a strong Christian belief in God. She says that her life is in ‘God’s hands’ and she prays several times a day (Kokanovic et al., 2012)

Maternal mental health social work support

Ma Sha was referred to Rose, a social worker in the maternal mental health service who makes a home visit with an interpreter. Ma Sha initially tells Rose that she is doing well and does not need help but later says that she feels isolated and alone. She misses her family and her husband works night shifts. Ma Sha has to cope with the twins, who are difficult to feed on her own, much of the time.

Rose is sympathetic and supportive and suggests that Ma Sha may benefit from medication. She suggests that she could link her with a Karen women’s group that she knows meets locally.

Rose leaves feeling that there are issues that she is missing. She decides to ask the interpreter for cultural advice in the post-brief session after the visit and finds out from her that the postpartum period is a very special time for Karen-Burmese women. During this time, it is expected that women are revered and treated with great care by their husbands and family. There are customary restrictions on what kind of work or movement a woman can do after childbirth, and traditionally women would rest for a month. The husband is expected to bathe and feed the mother during the first few days as she is confined to bed, and the family prepare special foods that are believed to keep her ‘warm’. Practising the right postpartum requirements is believed to be necessary, otherwise it is believed that women may become ill and possibly never recover from this.

The interpreter tells Rose that Ma Sha not only misses her family, but all the postpartum care she would expect in Myanmar. Missing this care compounds the loss of her family, and she is also concerned that her distress and not sleeping is a consequence of not receiving traditional care.

The interpreter tells Rose that in Karen-Burmese culture seeking help is considered a sign that the family is not able to take care of itself, and so Ma Sha may feel guilty and uncomfortable about accepting intervention, although she wants help. Rose decides that at the next visit she will acknowledge the loss of traditional care and support, and ask Ma Sha to explain what these would be if she was giving birth back home.

Rose makes a time to meet with Ma Sha and her husband to explore ways that they could compensate for the lack of traditional support and to include whatever rituals possible. This will help the couple to overcome the fear of spiritual harm from not performing the expected rituals.