The refugee experience and motherhood

The refugee experience is characterised by civil war, religious and political persecution, brutal regimes and the multiple loss of home, family and community. Perinatal maternal health in refugee-background women needs to be understood in the context of the extreme and violent events (including sexual violence), which women have endured (Ministry of Health, 2012). The psychosocial stressors for refugee women associated with re-settlement include: language; socio-economic disadvantage; unfamiliarity with new systems of health; education and employment; social isolation; racism and discrimination. Additionally, there are long-term impacts from the loss and separation from family and community; fears for family safety and financial security (Ministry of Health, 2012). Many families support other family members overseas on limited incomes. Cultural displacement leads to mother’s attempts to integrate their traditional and new cultural frameworks in their new society. Life in New Zealand society means changing conceptions of gender roles and attachment in the family; intergenerational cultural conflict; changing family structures with the loss of elders and of supportive social and community networks. Refugee mothers’ status as ‘the least valued’ and powerless members in their new society is a risk factor for postnatal depression (Tummala-Narra, 2004).

Recent research indicates that women are more vulnerable to perinatal depression when they live in poor socio-economic circumstances; experience traumatic events pre-migration; and disruption to traditional maternal, social and family supports (Morrow et al 2008). Women from refugee-backgrounds are less likely to seek and receive appropriate assistance due to the language barriers they face and the stigma associated with mental health (Anstiss, Ziaian, Procter, Warland & Baghurst, 2009). Many women are not aware of the maternity services and childbirth education services available to them. Many have ‘psychological immunisation’ as the result of the repeated trauma experienced over many years, which may prevent women and their families from approaching services (Lingam, 2003).

Commonly, women from refugee backgrounds will have experienced (beyondblue, 2007: Ministry of Health, 2012):

• Multiple bereavements.
• Adopting the children of deceased relatives.
• Trauma and torture, including psychological, physical and sexual violence.
• FGM (practiced in countries in the Horn of Africa and in the Middle East).
• Inadequate medical care during previous pregnancies, traumatic birthing experiences, death of babies and/or older children.
• Separation from family members who may have provided support during pregnancy and childbirth and with neonatal care.
• Poor general health, including nutritional deficiencies and infectious diseases.
• Dangerous migration journeys.
• Limited access to and knowledge of family planning services.
• Minimal exposure to formal hospital-based antenatal care.
• Limited educational and work opportunities in New Zealand.
• Continual fear for the safety of family members.

Many refugee women will have had minimal or no experience of antenatal care. Previous births will most often have taken place at home, often with the assistance of a traditional birthing assistant. Members of the extended family will have played a pivotal role in the postnatal care of mother and baby.

Refugee women may have complex health and social needs and may require additional support during pregnancy. This section addresses the care of women from refugee backgrounds and strategies that LMCs and other health professionals can use to promote early engagement with maternity services and to provide effective support.

Women from refugee backgrounds, arriving in the last three decades, come mainly from the countries of: East Africa , Somalia, Eritrea, Ethiopia, South Sudan, Rwanda and Burundi; the Middle East and West Asia, Afghanistan, Iraq, Syria and Iran; as well as Myanmar , Sri Lanka, Bhutan and Colombia (Ministry of Health, 2012).

Postnatal period

The experience of postnatal care for many women from refugee backgrounds in New Zealand is very different to that in their countries of origin. In many traditional societies women and their babies have a period of postnatal rest at home after the birth (commonly 40 days) in which they are cared for by their families. Many women from refugee backgrounds do not have family members in New Zealand to provide this level of support. Consequently, they are at high risk of postnatal depression. Be alert to your women’s expressions of isolation and depression (Ministry of Health, 2012).