Experiences of Immigrant Women with Postpartum Depression: An Interpretive Review

The review focuses on qualitative literature describing the experiences of immigrant women with postpartum depression. Initial electronic searching was done by using Medline and CINAHL database. The references lists of related articles are also reviewed. Three articles were chosen for the review with careful consideration. The findings can be organized into three themes: differences of meanings of childbearing and postpartum practice among immigrant women, factors contributing to immigrant women’s postpartum depression, and factors aiding recovery. The results of the review can lead to instrumental and conceptual utilization. The review indicates that some further research, including research from the perspectives of health care givers, and research on immigrant cultures, is


Introduction
Migration is a global trend which affects human's health. More than 200,000 immigrants land in Canada every year; [1] most immigrant women in Canada are in their childbearing ages [2]. Research indicates that immigrant mothers are at more risk for postpartum depression and have a higher postpartum depression rate than Canadian born mothers [3]. Postpartum depression can negatively impact the health of immigrant women, decrease quality of parenting, increase family conflict, damage social relations and influence the growth and development of children [4] From my community nursing experiences, I have found that some immigrant mothers with depression are not diagnosed and have difficulty to access to community mental health programs. Nurses do not understand immigrant mothers' meaning of health and their unique experiences of depression. Institutional policies are not adjusted to reflect diverse cultures. Immigrant mothers' needs are unknown and unmet. Therefore, I suggest my research question "What are the experiences of immigrant women with postpartum depression?" The goal of my review is to explore factors contributing to, and assisting recovery from, postpartum depression of immigrant mothers, to discuss the implications of my findings, and to indicate the need of further study.
My review focuses on qualitative literature because my research question requires qualitative methodology. Immigrant mothers' experiences are situated within different cultural backgrounds and social environments. Qualitative studies can help to gain in-depth understanding and thick description of human experiences [5]. Qualitative methodology can assist comprehension of distinct group of people and their different perspectives [6]. Quantitative studies cannot answer the research question because human experiences are hard to be quantitatively measured and expressed in numbers [5].

Methodology: Searching and Sampling the Literature
Initial electronic searching was done by using Medline and CINAHL database. Different search words, including "postpartum depression", "migration", "immigrant", "postnatal", were used. The search result was then limited by publication type (peer-reviewed journals), publication year (from 1996 to 2014) and type of study (qualitative study). In order to supplement my search results, I also reviewed the references list of related articles. I chose three articles, Ahmed et al. [2] Nahas and Amasheh [7] and Ornelas et al., [8] for my review with careful consideration. The three articles were written respectively in Canada, Australia and the United States. These three countries are the most important immigrant recipient countries in the world, two of which have official policies to invite immigrants. In addition, the three articles are from different research traditions and theoretical perspectives. Ahmed et al. [2] is a qualitative research applying Glaser and Strauss' constant comparative method. Nahas and Amasheh [7] is an ethnographic study. Ornelas et al. [8] applied psychosocial theoretical framework in their study. Comparing research from different countries and perspectives on the topic of immigration is meaningful to Canadian health care practice.

Nahas and Amasheh [7]
Nahas and Amasheh [7] is an ethnographic study to explore the meanings and experiences of postpartum depression among Jordanian immigrant women in Sydney, Australia. A purposive sampling strategy was applied, and 22 Jordanian women with postpartum depression were interviewed. The study revealed three major themes: strong family support and kinship, women's traditional role, and preservation of traditional childbearing customs.
Ethnographic tradition is well carried out in the study. First, the research purpose, exploring mothers' emic perspective, is congruent with an ethnographic approach [6]. Second, the authors provided sufficient background information to help situate the study. In the study, there is a long introduction, where the ethnohistory and worldview of Jordan were described in detail. This information contextualized Jordan mothers and their experiences culturally. Third, applying ethnographic methodology, the authors provided a rich description of mothers' experiences and demonstrated that women's experiences are culturally influenced. For example, the authors found that Jordanian women, in their culture, are not supposed to be sad as new mothers. Sadness could mean that they are unable to cope and are bad mothers.
The authors applied Leininger's theory as a conceptual and theoretical guide. Leininger's theory effectively applies ethnographic tradition in nursing practice [6,7]. In this study, Leininger's theory was summarized and Leininger's Sunrise Model of Cultural Care was provided in both English and Arabic. The data analysis was guided by Leininger's four-phase analysis method. Leininger's six criteria of evaluating qualitative studies were used to evaluate findings. Leininger's three theoretical action modes, which are cultural care preservation, accommodation, and repatterning, were applied to discuss the implications of research findings. Application of Leininger's theory enhanced analytical depth, thus increasing the rigor of the study [6].
There are some weaknesses in the study. The authors did not do participant observation which is a key method of the ethnographic approach [9]. Since interviewing is the only method, I am not sure how deeply the authors were engaged with or understood Jordan culture. Another weakness is that the length of the field work was not mentioned because sufficient engagement is essential for ethnographic research [6].

Ornelas et al. [8]
Ornelas et al. [8] wanted to identify factors that caused depression and postpartum depression of Mexican immigrant mothers, as well as their coping strategies. The authors analyzed 20 semi structured interviews from low-income, Mexican-born mothers living in North Carolina. The study indicated that various economic and social stressors led to maternal depression.
The authors drew on three psychosocial theoretical frameworks, which are Family Stress Model, risk and resiliency factors, and the social network and social support theory, to guide their research and data analysis. Psychosocial theories assisted the authors to explore the relationship between social factors and mothers' mental health. For example, social network and social support theory guided the authors to identify the social stressors and mothers' coping strategies.
The authors demonstrated inductive and deductive reasoning processes during data analysis [10]. For example, from the interview data, the authors found that financial difficulties, lack of jobs, and barriers to finding proper child care contributed to the depression. This is an inductive reasoning process, which uses data to generate ideas [10]. Then, guided by Family Stress Model, the authors organized and coded financial problems, work, and child care as economic stressors. This is a deductive process using data to confirm the ideas [10]. Combining inductive and deductive reasoning, the data analysis provided rich description of the phenomenon, achieved analytical depth, and increased the rigor of the study [6].
Triangulation also enhanced the rigor of the study [6]. By interviewing participants from different families and migration backgrounds, the authors demonstrated triangulation on research sources. The triangulation of analysts and perspectives is also emphasized. In the study, at least two researchers coded each transcript, and four researchers analyzed the data. The team members came from different disciplines, such as public health, public policy and nursing. By combining different sources, analysts and perspectives, the authors reached the rigor of the study.

Ahmed et al. [2]
Ahmed et al. [2] carried out a qualitative study of the experiences of immigrant new mothers with postpartum depression in Toronto, Canada. The research goals were to understand mothers' experiences of postpartum depression, to identify contributing factors to depression and recovery, and to explore factors facilitating or hindering help-seeking. Ten new immigrant mothers were interviewed by telephone.
Ahmed et al. [2] is a Canadian local study. It reflects different immigrant status in Canada, including refugee, asylum seeking, nonrefugee and independent immigrant. It also reflects diverse cultural backgrounds, such as Chinese, Indian, Pakistan, South American and Egyptian, of Canadian immigrant mothers. In addition, it is a followup study to examine the postpartum needs of immigrant mothers and to evaluate a community service program. The research setting and the research findings are directly related to Canadian nursing practice.
The authors applied constant comparison in the process of data analysis. A constant comparative method helped the authors to explore the differences and similarities between different events, and conceptualize the possible relationship between different data [10]. For example, the authors compared women who were still depressed and women who had recovered in order to discover the factors contributing to, and helping women recover from, postpartum depression. The authors also compared mothers' experience with different health care givers, such as medical doctors, nurses, and psychologists. In contrast, mothers reported that they benefited more from nurses' visits than doctors and psychologists' services.
The major weakness of this study is that telephone interviews were the only method for data collection. Without face-to-face contact, the researchers could have missed valuable non-verbal data and the opportunities to interact with participants in order to reach deep understanding of women's experiences.

Thematic synthesis of the findings
Three articles explored the experiences of immigrant women with postpartum depression from different perspectives such as ethnographic and psychosocial traditions. The findings shared similarities, but also differences. The findings can be organized into three themes: differences of meanings of childbearing and postpartum practice among immigrant women, factors contributing to immigrant women's postpartum depression, and factors aiding recovery.
The first theme is the cultural differences of meanings of childbearing and postpartum practice among immigrant women. All three articles are consistent in that the experiences of immigrant women with postpartum depression were culturally situated. Nahas and Amasheh [7] indicated that Jordanian Australian women had to fulfill traditional roles as mother and wife to produce a family. Failing in coping were labeled as being a bad mother. This study also revealed religious and traditional beliefs about childbearing and postpartum practice. Ahmed et al. [2] indicated that in original country, most immigrant women were surrounded by family immediately after child birth, but in new country, they were left alone at home. Ornelas et al. [8] similarly indicated that Mexican women traditionally are supported by female friends and relatives, who help with household chores and child care, during forty days after a child birth.
The second theme is contributing factors to immigrant women's postpartum depression, including social isolation, lack of family support, financial difficulties, migration and acculturation. Social isolation and lack of family support are indicated as important factors of postpartum depression. Ahmed et al. [2] suggested that lack of family support, especially without the help of their mothers in a new country, contributes to postpartum depression. Immigrant mothers were left alone with the infant all day, were overwhelmed by the new baby, and did not have time for themselves, or to take care of household chores. This finding is consistent with Ornelas et al. [8], who suggested that family separation and social isolation resulted in stress, anxiety, loneliness and depression among the mothers.
Financial difficulties also caused postpartum depression. Ahmed et al. [2] found that financial pressures caused by leaving work because of the birth of a child stressed immigrant women and their family. This finding is consistent with Ornelas et al. [8] who suggested that economic stressors, such as financial difficulties, lack of work, and expenses of child care, were reasons of mothers' depression.
In addition, migration and acculturation caused depression. Ornelas et al. [8] suggested that migration impacted Mexican mothers' parenting and family relationships, causing depression. Migration also caused discrimination, which impacted on mothers' mental health. Ahmed et al. [2] stated that because of migration, language became a barrier to community service and a factor of anxiety for immigrant mothers. Nahas and Amasheh [2] indicated that Jordanian Australian women experienced two different cultures in different countries. They were expected to fulfill traditional role of a mother and wife in a new country without the necessary support.
The third theme is the factors aiding recovery from postpartum depression, including family support, community services and social support. Family support is essential for immigrant mothers to cope with depression. Ornelas et al. [8] indicated that family members, especially husbands and women's mothers, were important sources of support during mothers' recovery from depression. Husbands provided family income, assisted with child care, and provided companionship and emotional support. Women's mothers offered needed child care knowledge and gave advice and counseling about difficult situations. Ahmed et al. [2] indicated that family members offered substantial support by assisting with cooking and child care.
The role of community services to help mothers recover from postpartum depression differs among the three studies. Ornelas et al. [8] indicated that community services such as government programs and church services helped Mexican immigrant mothers cope with depression. Very different from the findings of Ornelas et al. [8] Ahmed et al. [2] indicated that very few immigrant mothers in Toronto attended community services for social and psychological support. Barriers to help-seeking included language difficulties, embarrassment, stigmatization and fear of being viewed as bad mothers. In addition, they were discouraged by the uncaring attitude of staff and health care providers, who tended to ignore mothers' depression.
The role of social networks and social support in the experiences of depressed women is controversial. Ornelas et al. [8] indicated that as a stress buffer, social support helped mothers to cope with depression. On the other hand, it can be social obligation to magnify stress and increase the risk of depression. Ahmed et al. [2] reported that friends were often too busy to offer substantive help. However, talking to other people in the same situation was helpful.

Discussion
The results of my review can lead to instrumental utilization [11]. The contributing factors of postpartum depression can be applied to develop a screening tool for early detecting of immigrant women with postpartum depression. In addition, the cultural differences of meanings of childbearing and postpartum practice among immigrant women can be utilized to synthesize a teaching tool which aims at educating health care providers about the cultural beliefs and health practices of immigrant women [12].
The results of my review can also bring conceptual utilization [11]. First, my review demonstrates that cultural differences of meanings among immigrant women. This finding helps health care givers understand how meanings and experiences are culturally contextualized, which shows the importance of providing culturally sensitive care in Canada, an ethnically diverse country. Second, my review indicates that family support is an important factor for recovery from postpartum depression. This helps health care givers understand the importance of family-centered care and indicates the need for health care organizations to accept and encourage a family-centered care model. Third, the controversial findings about the function of community services encourage health care providers to think reflectively about how to reform community services to meet immigrant mothers' needs. This finding also assists us to understand the barriers for immigrant women's access to community services.
Further research is needed in some aspects. First, while my review focuses on immigrant women's perspective, research from other perspectives, such as that of health care givers, could be meaningful to clinical practice. Qualitative research on health care givers' experience of caring for immigrant women with postpartum depression could identify the challenges perceived by healthcare workers and their coping strategies to overcome the barriers. Second, my findings highlight the need for research on immigrant cultures. Cultural differences, such as the traditional role of mother and the stigma attached to postpartum depression, are factors of postpartum depression [7]. Some mainstream perspectives of health do not respect the cultural beliefs of immigrants [13]. Ethnographic studies help to understand different meanings of health care and facilitate culturally sensitive care for immigrant mothers.