Impact of culture on refugee women’s conceptualization and experience of postpartum depression in high-income countries of resettlement: A scoping review

Background The global refugee population has reached a staggering 25.9 million. Approximately 16% of global refugees resettle in high-income countries which are often culturally very different from their home countries. This can create cross-cultural challenges when accessing health services, leading to inappropriate assessments, diagnoses and treatments if cultural background is not factored in. The impact of culture on the conceptualization and experience of postpartum depression (PPD) amongst migrant women has received growing attention in recent years, however, a specific focus on refugee and asylum-seeking women is lacking. Given the unique mental health challenges refugee women face, it is hypothesized that the interplay between culture and postpartum depression amongst refugee women may differ from other migrant women. Therefore, a scoping review was conducted to characterize what is known about the impact of culture on the conceptualization and experience of PPD in refugee women resettled in high-income countries. Methods and findings This study was conducted as a scoping review in accordance with the Joanna Briggs Institute’s Methodology for Scoping Reviews. A systematic search of studies addressing the relationship between culture and postpartum depression amongst refugee women (including asylum-seeking women) resettled in high-income countries was conducted across 6 databases including MEDLINE, PsycINFO and SOCINDEX between June 2018 and August 2019. A total of 637 articles were found. Studies were eligible if they focused on refugee women who had a pregnancy during forced migration or upon resettlement in a high-income country and focused on the impact of culture on women’s conceptualization and/or experience of PPD. Eight studies met inclusion criteria and were included in the final analysis, the majority of which were qualitatively driven. Four key themes emerged: 1) there are diverse conceptualizations and experiences of postpartum depression amongst refugee women; 2) mental health stigma has a significant impact on women’s conceptualizations and experiences of postpartum depression and help-seeking behaviors; 3) cultural traditions and social support play protective roles in postpartum mental wellbeing; and, 4) host culture has a significant influence on the pregnancy and postpartum experience of refugee women. The overall themes align with those seen in the literature on migrant women in general, however significant research gaps remain. Conclusion The studies identified through this scoping review provide a rich description of the significant impact culture has on the conceptualization and experience of postpartum depression among refugee women resettled in high-income countries. Though overall themes align with those seen in the literature on migrant women in general, further research is needed to better characterize how culture impacts refugee women’s experiences of PPD as a distinct sub-group of migrant women.


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The aims of scoping reviews as outlined by JBI include identifying types of evidence in the field, identifying knowledge gaps, clarifying key concepts, looking at how research has been done in the substantive area you speak of (ie: refugee women and the cultural conceptualizations and experiences of PPD), and to locate central characteristics related to the concepts of refugee maternal mental health. Integrating these aims into your objectives and into why you chose a JBI scoping review would help with methodological alignment.
Is there a reason why you selected a scoping review over a systematic review?
Line 128 Can you define cross-culturalism a bit more please? Where does it come from; where do you draw this concept from and how is it conceptualized within this study.
Line 148 Please include this in your introduction.

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With the history of migrant discourse being steeped in conflation of terms, I wonder if excluding studies with immigrant/migrant foci inadvertently excluded studies with refugee women experiences of PPD... Perhaps this can be discussed and elaborated on in your limitations section.
Please specify inclusion/exclusion of refugee women and their location within the PPD care provision process. For example, were refugee women who had already been diagnosed specifically with PPD included or those who had tested high on screening tools only, or...

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Were there any publication limits? (ie: date limitations) Line 211 How were disagreements (if there were any) resolved during study selection process?
Line 225 Please state how the grey literature you gathered informed or was integrated into your scoping review Line 427 Long sentence with multiple findings -please explicate to clarify and highlight these findings.
Line 534 Is this because the focus of this study was on cultural conceptualizations rather than how culture and migration status intermingle to shape conceptualizations? The unique journeys of refugees and the sociopolitical and economic determinants that shape refugee conceptualizations of PPD could be further integrated to capture the differences you hypothesized about.

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Factors not being considered here include amount of time a woman has lived in their high-income host country which impacts "cross-cultural' conceptualization, integration and assimilation. What also is not being addressed within this discussion is how refugee migration journeys include living in transition. This involves living in refugee camps or communities for several years located in low or middle income countries before they are permanently allocated a country to settle in. There is literature out there that shows how pre-migration journeys among refugees affect cultural assimilation, integration and conceptualizations of mental health. This is a huge difference between a migrant who chooses to directly move from their country of origin to a high income country. I would thus avoid extrapolating results from this scoping review to the broader migrant literature that has very different definitions and histories behind their participants. I also recommend not deducing the limited value of migration status on cultural inquiries. Although you are cautioning readers "against making the conclusion that stratification by migrant type is not of value" for a couple reasons, the idea of questioning the inextricable link of migration status to other social locations such as culture is still presented as a valid one. In doing so, unilateral understandings of human experience is being suggested along with compartmentalizing a person rather than viewing them as whole beings.

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Making final conclusions is not the aim of scoping reviews anyway, but rather recommending where the gaps are in the research you have reviewed.
Line 563 Great contribution to the interplay of culture and gender on post birth and resettlement transitions.
Line 590 Did these shortcomings include language barriers? Please elaborate.
Line 597 How is this ideology (individualism) defined within this review? It's a matter rooted in capitalism and necessary to elaborate on within the context of cultural diversity.
Line 600 Great thought and recommendation -are there any practical suggestions as to how healthcare providers can do so?
Line 616 I question generalizability as a goal of scoping reviews -take a look at what JBI says re: goals/aims/objectives of scoping reviews Line 630 To be consistent with your initial inclusion criteria, you may want to change "peripartum and postpartum period" to "of childbearing age" or vice versa... I'm now thinking the use of "childbearing age" denotes prenatal care as well -please clarify.