Participants.

Our study population of interest was women identified as refugees, refugee claimants or asylum seekers who had a pregnancy during forced migration or upon resettlement. The UNHCR define refugees as people “who have fled war, violence, conflict or persecution and have crossed an international border to find safety in another country”, while asylum seekers (also known as refugee claimants) are people who have made in-country claims for asylum that have yet to be processed [2,3]. Refugee claimants and asylum seekers are classified as undocumented migrants [22]. Undocumented migrants also include those who overstay their visas, and those who are not seeking refugee status but stay within a country without permission–these individuals were not included in the scoping review [22]. For the purposes of this study, the term “refugee” will refer to refugee, refugee claimant and asylum-seeking women. There were no restrictions on women’s age, parity, country of origin or time from resettlement to study involvement. The definition of PPD diagnosis was inclusive to women who had a previous diagnosis of PPD confirmed by screening tools or clinical depression. We also included studies where women with previous pregnancies discussed their understanding of PPD if the study included women with PPD symptomatology. Studies with immigrant or migrant women as the sole focus or studies in which the analysis did not include a sub-analysis on refugee women were excluded.

Concept.

The phenomena of interest were the impacts refugee women’s native culture, as well as the host country’s culture (i.e. the cross-cultural impacts), have on refugee women’s conceptualization and experience of PPD in their country of resettlement. Here, we define cross-culturalism drawing from the definition used in the discipline of cross-cultural psychology whereby cross-culturalism is the “similarities and differences in behavior among individuals who have developed in different cultures.” [23]. Cultural factors may be seen as harmful, protective or neutral in relation to their impact on refugee women’s mental health and wellbeing in the postpartum period. Therefore, studies that addressed cultural factors in the postpartum period were included, using the World Health Organization definition of culture: “the set of distinctive spiritual, material, intellectual and emotional features of society or a social group … [which] encompasses, in addition to art and literature, lifestyles, ways of living together, value systems and traditions and beliefs.” [24]. Studies that focused only on the prevalence of PPD in certain ethnic groups were excluded. The outcome measure for our research question was the refugee woman’s conceptualization and/or experience of PPD.

Context.

The specific context of interest was refugee women resettled in high-income countries as defined by the World Bank Atlas method [25]. No restrictions were placed on health care setting of the study (i.e. acute care, primary care of the community).

Study sources.

Primary research, review articles and grey literature including policy documents, government reports, conference proceedings, abstracts, dissertations/theses, and clinical practice guidelines were included in the scoping review. Clinical practice guidelines from the last 5 years were considered. Excluded sources included books, opinion articles, and informal communications. Refer to Table 1 for a summary of eligibility criteria.

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Table 1. Eligibility criteria overview.

https://doi.org/10.1371/journal.pone.0238109.t001

Study selection.

All literature identified through the search was uploaded to Covidence, an online systematic review management program. In Covidence, all articles were subject to a title and abstract review based on the predefined eligibility criteria. This was followed by a full text review of eligible studies. Disagreements were resolved through discussion between both reviewers (SH, MM). Each step was conducted in parallel by two independent reviewers (SH, MM). Studies that met eligibility criteria following the full-text review were included in the final scoping review and subject to data extraction.

Data extraction.

Relevant data were extracted from each included study by two independent reviewers (SH, MM) using a predefined data extraction form (S2 Table). This form was revised throughout the literature review process as authors became more familiar with search results, adding further data extraction fields when appropriate.

Quality assessment.

As per agreed upon scoping review methodology, no rating of quality or level of evidence for included studies was conducted [21].

1. Diversity in cultural conceptualizations and experiences of postpartum depression.

Among the various studies that focused on the cultural conceptualizations of postpartum depression in resettled refugee and asylum-seeking women, a diversity of views were found, ranging from women having no cultural concept of postpartum depression to expressing an understanding of the condition and disclosing their own experiences with PPD [29, 30].

In Ahmed et al. (2017), Syrian refugee women in Canada endorsed having heard of postpartum depression but reserved the term “depression” for extreme cases as it means “being sick and requiring treatment” [26]. They themselves did not endorse any depressive symptoms, sharing a belief that Syrians experience less PPD than other women due to their cultural view of birth as a celebratory time [26].

Alternatively, in the study by Davey (2013), Bhutanese refugee women lacked a cultural conceptualization of postpartum mental distress altogether [30]. This is attributed to the socially determined concept of wellness in Bhutanese culture whereby one’s sense of health is a reflection of the quality of one’s social relationships [30]. Therefore, it is taboo to outwardly express personal distress as it is unacceptable to burden other members of the community with personal issues [30]. Further, study participants explained that suffering is perceived as a normal part of life in Bhutan and therefore, women are expected to endure hardships associated with birth and motherhood without complaint [30].

Ussher et al. (2012), in studying both Karen and Assyrian refugee women resettled in Australia, found contrasting cultural conceptualizations of PPD amongst these two culturally distinct groups [29]. While Karen refugee women described PPD as an “alien experience” for women who had a healthy baby, Assyrian women had a clear understanding of PPD with some participants even disclosing their own experiences with severe depression after birth [29]. Two Assyrian study participants further described having spoken to their husbands and family about their depressive symptoms in the postpartum period [29].

Stapleton et al. (2013) also note that cross-cultural differences in understandings of emotional states will influence not only how postpartum emotions are described but also how symptoms are reported [28]. This is further addressed in the review by Asif et al. (2015) in which it is noted that somatic symptoms such as headaches, non-specific chest pain and abdominal pain are common presentations for underlying emotional distress amongst refugee and asylum-seeking women in the UK [31].

In Stapleton et al. (2013), study participants postulated that PPD was essentially a Western illness, suggesting that refugee women from non-Western cultures may lack a framework for understanding the rationale behind administering a tool like the Edinburgh Postnatal Depression Scale, for example [28]. Authors then go on to provide a compelling overview on this theme stating that despite the internationalization of the term “depression” it is unlikely that meanings across cultures will be shared [28]. This view is clearly exemplified by the diversity of cultural conceptualizations of PPD held amongst the refugee and asylum-seeking women who participated in the studies included in this review.

2. The impact of mental health stigma on women’s experience of postpartum depression and help-seeking behaviors.

The stigma that surrounds mental illness amongst refugee and asylum-seeking women from diverse cultural backgrounds was a prominent theme that emerged across 7 of the 8 included studies (all except Nakash et al, 2016). Refugee and asylum-seeking women in these studies commonly expressed how stigma of mental illness impacted their willingness to disclose emotional problems or seek help from family, community members or health care providers in the postpartum period.

In Ahmed et al. (2017), it was found that mental illness is perceived negatively in Syrian culture leading women to describe their postpartum emotional states as being “bored” or “tired” but not “depressed” [26]. It was further identified that stigma and related privacy concerns (i.e. concerns that members of their family or community would find out about their depressive symptoms if they disclosed them in a health care setting) were significant barriers to accessing mental health care amongst Syrian refugee women. Authors also found that due to this stigma, husbands may prevent their wives from disclosing depressive symptoms, further impeding help-seeking for mental health concerns in the postpartum period [26]. Given the cultural stigma around the term “depression”, study participants suggested using the term “wellness” rather than “depression” when naming support programs or suggesting possible treatments [26].

Similarly, Afghan refugee women in the study by Russo et al. (2015) described the stigma in Afghan culture towards mental illness resulting in a reluctance to disclose mental health concerns to healthcare professionals [27]. This perception resulted in Afghan refugee women assuming that healthcare professionals would respond poorly to mental health issues (“think they were crazy”) [27]. In this study, it was apparent that shame, stigma and an unwillingness to disclose emotional distress to healthcare professionals contribute to a delayed diagnosis of PPD, a significant concern also highlighted by Ussher et al. (2012), amongst Assyrian women, as well as by Asif et al. (2015) in their review of obstetric care of refugee and asylum-seeking women in the UK [27,29,31].

Stapleton et al.’s study (2013) which included refugee women from Somali, Sudan, Burundi, Afghanistan, and Liberia, further supported this view, finding that that traditional cultural beliefs linking mental illness to “sorcery, unavenged spirits, or curses” deter refugee women from disclosing pertinent information and seeking help [28]. For many women, disclosure of negative feelings is suppressed due to fears of causing marital discord and bringing shame to the family. Wanting to maintain strong social relations within family and community was therefore prioritized over disclosing or seeking help for mental health problems [28].

Davey (2013), in her examination of Bhutanese women’s experience of PPD identified an interesting and unique paradox surrounding the stigmatization of mental illness in Bhutanese culture [30]. Although the term “mental illness” was stigmatized, the term “depression” was not [30]. This paradox was thought to arise from the distinction made in Bhutanese culture between brain-heart problems (where worries, anxiety, and depression are grounded) and brain-mind problems (in which mental illness is grounded) [30]. Brain-heart problems are seen as commonplace and normal, whereas brain-mind problems are stigmatized and rarely communicated [30].

3. Protective role of cultural traditions and social support.

Another prominent theme that emerged is the important role cultural traditions and intact social supports play in the lives of refugee and asylum-seeking women particularly during the peripartum period. During forced migration and upon resettlement, there is a marked shift in access and exposure to the traditions and practices of one’s native culture, as well as a significant disruption in social networks that are traditionally present around the time of childbirth. As described in several studies, practicing cultural traditions and having intact social supports in their host country are significantly protective for postpartum emotional wellbeing.

In many cultures, it is tradition to be surrounded by social support from female kin in the perinatal period [26,27]. This social support is completely disrupted by forced migration (28). In Ahmed et al’s study, strong support provided around the time of birth was protective against depressive feelings and a lack of family support was a stressor in the postpartum period for several Syrian refugee women (2017) [26]. Afghan refugee women in Russo et al.’s study (2015) shared how a lack of connection to female kin and strong family bonds results in distress, loneliness and feelings of isolation in the postpartum period [27]. Refugee women in Stapleton et al.’s study (2013) reported the absence of close kin coupled with the loss of social supports contribute to PPD [28]. In support of this notion, Asif et al. (2015) highlighted that PPD tends to be more common in women who are both physically and culturally removed from their support systems [31].

Further, in the study by Ahmed et al. (2017), Syrian refugee women described the key role of engaging in other traditions and spiritual practices such as reading holy texts, like the Quran and praying in their new countries of resettlement [26]. Russo et al. (2015) highlighted that religion is intricately connected to culture for Afghan refugee mothers [27]. The importance of remaining connected to traditions, rituals and religion was described in several studies to protect women from experiencing PPD.

Davey (2013) reported how Bhutanese women shared the importance of maintaining traditions and rituals in the postpartum period along with having intact social support (30). In Bhutan, wellness is defined in the context of social ties and relationships and migration can dismantle these ties [30]. For instance, Bhutanese refugee women described a 1-month rest post-birth as a tradition in their culture [30]. During this time, women are considered “unclean” and are thus forbidden from partaking in their homemaking tasks. This gives the mother time to rest and recover in the postpartum period as well as an opportunity to connect with her baby [30].

Russo et al. (2015) described a similar cultural tradition for Afghan women of a 10 to 40-day postpartum rest period which includes assistance from a local birth attendant and female kin [27]. It concludes with ritual celebrations with traditional food. An absence of these traditional practices in their countries of resettlement was a source of tension and isolation for women in both studies [26,30]. Stapleton et al. (2013) reported similar findings in terms of rituals and ceremonies to welcome the newborn and celebrate the mother which are lacking when a pregnancy takes place in a new country of resettlement [28].

A few studies alluded to the supportive role of the spouse in the peripartum period that may differ in the country of resettlement from the spousal role in one’s native culture [26,27,32]. In Russo et al. (2015), Afghan refugee women described the shifting role of their spouses during pregnancy and the peripartum period in their country of resettlement [27]. Without the typical female kin to support mothers in the postpartum period, husbands have to take on a greater role in providing emotional support for their wives compared to when they lived in Afghanistan [27]. In Ahmed et al. (2017), Syrian refugee women wondered whether their spouses would be prepared to take on the role of primary supporter in the perinatal period as they had not previously had such responsibility [26]. Nakash et al. (2016) provide another angle on this topic in their study examining the association between PPD, acculturation and the mother-infant bond among Eritrean asylum seekers in Israel [32]. As part of this study they asked women to rate the status of their current romantic relationship (using a 5-point Likert scale ranging from 1 “unhappy/unstable” to 5 “loving and stable”) and also had women complete the Maternal Postnatal Attachment Scale (MPAS), a self-reported measure of mother-to-infant boding during the infant’s first year of life [32]. What they found was that higher quality of current romantic relationship predicted a higher self-reported mother-to-infant bond [32]. This finding supports the notion that having a romantic partner that is perceived as loving and supportive is beneficial for refugee mothers and babies in their countries of resettlement and highlights the important role partners play in the peripartum period of refugee women at a time when social supports, including female kinship, are often lacking [32].

4. Influence of host culture on the experience of pregnancy and postpartum depression.

Several articles discussed the significant impact the host culture has on the experience of pregnancy and postpartum depression in refugee women from diverse cultures, much of which stems from the Western biomedical model of care which tends to medicalize pregnancy and emphasize the individual when diagnosing and treating PPD.

The study by Brown-Bowers et al. (2015) explores this theme at length. The paper supports the view that the Western biomedical model of PPD, in which individual biological and psychological factors are emphasized, is particularly flawed when applied to refugee and asylum-seeking women from distinct cultures as it fails to account for the social, political and economic context of their symptoms and places responsibility on the individual to help or cure herself [12]. For example, depending on the political, economic and social climate of the host country during the time of resettlement, refugees may be “valorized or demonized” by the larger society. When refugees are positioned in particularly negative ways in their host countries, this creates an aversive environment for refugee women which may contribute to feelings of alienation, displacement, and despair [12].

Brown-Bowers et al. (2015) further discuss that the prevailing birth paradigm in Canada (which applies to most high-income countries) is dominated by technology and biomedicine where birth is a medical event controlled by highly trained medical specialists [12]. This paradigm may be jarring for women from different cultural backgrounds in which rich social networks, often led by experienced women from the community, guide and support women through pregnancy, birth, and the transition to motherhood. This can create a significant disconnect between the expectations of women’s perinatal experience, informed by their native culture and past experiences, and their actual experience of care in their host country [12].

The shift to an individualistic culture was detrimental to Afghan refugee women in Russo et al.’s study (2015) [27]. Women in this study describe the feelings of isolation and loneliness in the postpartum period while highlighting the cultural hindrances to participating in activities that could alleviate social isolation. In Ahmed et al.’s study (2017), the Muslim refugee women were unable to partake in wellness activities that were open to both genders because they needed to cover their hair and body in the presence of men [26]. In this study, women also described that non-pharmacological strategies (e.g. meditation, yoga) that are often proposed in Western culture to manage depression, are not well known or understood in Syrian culture serving as a barrier to participation and identifying an opportunity for more culturally-informed wellness interventions [26].

Davey (2013) provided a different perspective. One participant in this study shared that exposure to Canadian culture causes a shift from the collectivist concept of health present in Bhutanese culture to an individualistic view [30]. Davey describes that this shift may actually help women improve their ability to recognize individual feelings and express distress in the postpartum period in their new country of resettlement.

Nakash et al.’s study (2016) focused on the association between PPD, acculturation and the mother-infant bond among a group of Eritrean asylum-seekers using validated instruments including the Edinburgh Postnatal Depression Scale (EPDS), bicultural involvement, and adjustment scale and Maternal Postnatal Attachment Scale [32]. What they found was that higher levels of acculturation (to Israeli culture in this context) predicted both lower mother-infant attachment and higher EPDS scores. This highlights the potential for assimilation in one’s host culture to negatively impact the emotional wellbeing of new mothers and their infants if it is done alongside limited involvement in one’s own cultural practices.

A lack of experience of healthcare professionals was described as a hindrance to achieving care in the postpartum period by refugee women. Asif et al. (2015) recommended that healthcare providers must be educated in order to recognize that asylum-seeking women are high risk for the development of PPD [31]. Asif et al. (2015) identified both language and cultural differences as complicating the present lack of experience of healthcare providers. In contrast, Afghan refugee women in Russo et al.’s study (2015) were satisfied with the level of education and advice from maternal healthcare professionals [27]. They describe being happy with the maternity care received and highlighted the healthcare professionals as a source of emotional support. Brown-Bowers et al. (2015) add to this view stating that qualities like sympathy and friendliness, kindness, and support may be more important than having a care provider who has specific knowledge about a woman’s cultural background [12].

Stapleton et al. (2013) provide a unique perspective on this topic, providing an in-depth exploration of the cross-cultural application of the EPDS, arguing that significant problems arise when it is applied as the standard screening tool for PPD in refugee women given its basis in a Western biomedical model of disease [28]. Refugee women from diverse cultures may not understand the concepts included in items on the EPDS, even with appropriate translation, as the transferability of many of the culturally specific concepts employed in the EPDS may be quite limited [28]. The variability in applications and interpretations of the EPDS in refugee women is highlighted by the fact that two studies included in this review used the EPDS with varying cut-off levels for a positive screen, and with distinct interpretations of the scale (e.g. in Ahmed et al. (2017), the EPDS was applied as a screening tool with a cut-off of 10 or more defined as a positive screen for being at risk for developing PPD [26]; in Nakash et al. (2016) the EPDS is applied with cut-off of 13 which is said to differentiate between minor and major depression [32], whereas Stapleton et al. (2013) outlines that an elevated score is 12 or more or a positive response to Item 10—self harm) [28].