Family Practice Vol. 21, No. 3, 254-260
Family Practice Vol. 21, No. 3 © Oxford University Press 2004, all rights reserved.
Experiences and understandings of social and emotional distress in the postnatal period among Bangladeshi women living in Tower Hamlets
Tower Hamlets Primary Care Trust and a Department of General Practice and Primary Care, Queen Mary's School of Medicine and Dentistry, London, UK
Correspondence to Dr SA Hull, Department of General Practice and Primary Care, Barts and The London, Queen Mary's School of Medicine and Dentistry, Medical Sciences Building, Mile End Road, London E1 4NS, UK; E-mail: s.a.hull{at}qmul.ac.uk
Received 14 July 2003; Revised 10 November 2003; Accepted 7 January 2004.
Parvin A, Jones CE and Hull SA. Experiences and understandings of social and emotional distress in the postnatal period among Bangladeshi women living in Tower Hamlets. Family Practice 2004; 21: 254–260.
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionAppendix 1 Topic guide...References |
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Objective. The purpose of this study was to explore first-generation Bangladeshi women's understandings and experiences of postnatal distress, and to describe coping strategies during the postnatal period.
Methods. This was a qualitative study using focus groups. Subjects were drawn from three existing community groups in Tower Hamlets, a multiethnic, socially deprived borough in east London. Thematic content analysis was used to explore and present the data.
Results. Many women received little practical or emotional support once home from hospital with a new baby, because of the lack of extended family networks; this contrasts with the 40 day rest period common in Bangladesh. These women understood emotional distress as separate from physical symptoms or illness, and recognized that one may influence or cause the other. Distinctive language was used to describe these thoughts and feelings. The roles of health visitors, midwives and GPs were understood solely in terms of physical care. Accordingly, they did not access professionals for emotional or psychological problems. Lack of language support services contributed to the women not seeking help.
Conclusions. Information about services, and professional roles in the postnatal period should be extended to include key family members such as husbands and mothers-in-law. Dialogue with Bangladeshi women may ensure that women understand the extended roles of GPs, health visitors and midwives in providing help for emotional distress, alongside their role in physical health care. More language support and advocacy is needed if women are to access the full range of health services.
Keywords. Bangladeshi, general practice, postnatal depression.
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 Topic guide...References |
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Bangladeshi women in Tower Hamlets have the highest birth rates of any ethnic group in the UK.1,2 This community suffers grave social disadvantage and has a high burden of physical disease, both of which might be expected to contribute to higher rates of common mental health disorders, including postnatal problems.3
However, research in the primary care setting shows high rates of general practice consultations among Bangladeshis for physical symptoms, but low rates for mental health symptoms, including those in the postnatal period, and low attendance at specialist mental health services.4,5 Explanations for these findings have included the following suggestions. Apparent low prevalence may be related to difficulties in identification by GPs and other health workers; this may be due to a different mode of expression (somatization) or a lack of interpretation services hindering communication.6–8 There may also be a reluctance to consult services thought to be inappropriate.9,10 Emotional symptoms may have different attributions, such as religious or social interpretations, which may influence where, or whether, help is sought. Such attributions may also vary between recent migrants and those who have lived longer in the UK and have gained familiarity with the lifestyle and health care system.11 Furthermore, there is controversy over the adequacy of quantitative survey instruments developed in White populations to identify symptoms in South Asian groups.12
An alternative explanatory theory is the suggestion of protective factors; in particular the protective effects of social support networks within extended Bangladeshi families.
As there is very little research information on postnatal depression in Bangladeshi populations in the UK, we decided to use a series of exploratory focus groups designed to document the experiences of Bangladeshi women in the postnatal period. The emphasis in the study was on the description of emotional distress, women's own coping strategies and their perceptions of the role of primary care services.
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 Topic guide...References |
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Participants
The three focus groups included women with children from three existing community groups for Bangladeshi women based in the east London borough of Tower Hamlets during 1999–2000. Twenty-five women participated in three focus groups composed of 10, eight and seven women, respectively. All the women had been born in Bangladesh, ranged in age from 21 to 54 years, and spoke little English. The characteristics of participants are shown in Table 1.
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Preliminary consent was obtained from the group leaders, followed by informed consent from all participants before data collection.
Topic guide
The topic guide (see Appendix) was developed from the literature and refined after interviews with local health visitors, midwives and link workers (who provide support for local ethnic minority families in accessing health professionals, and are members of that community). The topic guide addressed the following broad areas:
- problems experienced in the postnatal period
- presentations of emotional distress in the postnatal period
- coping strategies
- participants understanding and use of primary care services.
Data collection
AP and CJ attended the focus groups which were conducted in Sylheti, a dialect from northern Bangladesh which all the women spoke, including AP. The discussions, each lasting 1.5 h, were held in the usual location of the community groups; they were audio-taped, then translated and transcribed by AP. A fluent Sylheti speaker, independent of the research, checked the accuracy of the translations. It is not possible to back-translate the transcripts because Sylheti does not have a written form. The results were presented back to two of the three groups involved in the study for comment (the third had disbanded).
Data analysis
Thematic content analysis was used to interpret the data. Repeated reading of the transcripts identified a number of concepts which are presented as themes.
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Results |
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The analysis is presented as four core themes, each composed of a cluster of concepts supported by the verbatim comments of individual women taken from the focus group transcripts.
Bangladeshi women's experiences of giving birth in the UK
Women's expectations and experiences of hospital services and staff.
Women only discussed childbirth in the context of hospital, and considered the hospital to be a safe place to give birth. They also expected the hospital to be a place to recuperate and be taken care of by staff after childbirth. Women felt confused by being sent home in 24 h, and having to look after the baby themselves in hospital.
"You need rest at that time, and they just send you home.""The nurse is there to help but they say ‘you do it yourself’."
A minority of women welcomed returning home early. This seemed to be related to concerns about whether their other children were being looked after properly, rather than not wanting rest in hospital:
"...Because of them, when I go to hospital I can't stay, can't sleep, just worry."
Language difficulties. Women also spoke about the problems they experienced in hospital due to interpreters not being available. Women felt unable to access information, or that health workers were not obtaining complete or accurate information. This was also stated in relation to community services received once women left hospital.
"Sometimes when you have a baby, a woman comes from the hospital. Bengali girls don't come with the midwife, we don't understand what they say, we just sit there staring at their faces."
Family circumstances after birth—problems within the home and support from the family
Women talked freely about emotional problems experienced in hospital; however, few talked about difficulties at home apart from in practical terms. On one occasion, such a conversation was censored by an older member of the group:
"You're not going to talk about that (in-law/family problems) here are you?"
Immediate resumption of role after returning from hospital. Women spoke of the difficulty of having to resume the roles of mother, wife and housewife immediately after returning from hospital, of having to ‘deal with everything’ by themselves.
"You bring the baby home. You need to eat, the family need to eat, have to clean the house, have to wash the children, take them to school, take them to Arabic reading (classes). You have to do all this work in one day, how can you get rest? Is there time?"
Lack of support at home in the UK. Contrary to popular beliefs about the nature of the extended Asian family in Britain, help from relatives was not available to many women.7 Some women only had family in Bangladesh, while for others there were practical problems preventing family members from offering assistance. This was contrasted to the 40 day rest and recuperation period women experience in Bangladesh, where her tasks are delegated to servants or to female members of the extended family. Living arrangements in Bangladesh also make this more practical.
"You can keep a workwoman. This woman can do the cooking and look after the children. Your mother-in-law and brother-in-law's wife at home, or people in side houses (neighbours) will help if you can't cook rice.""There are people there (in Bangladesh). In this country, I mean if a woman has five sons, they live in five different houses, it's not like that in Bangladesh."
Women did not spontaneously mention support from their husbands, but when prompted some said their husbands worked long hours, others said their husbands did what they could. Generally the women did not expect their husbands to provide practical help; any help forthcoming was based on his discretion. The reasons why husbands may not help were given as being shameful and ‘unmanly’ for men to get involved in childcare issues. Men who did help their wives risked being ridiculed as being weak and giving in to their wife's demands by the wider Bangladeshi community.
Responses to emotional distress and problems within the family
Emotional responses to problems.
The language used by women to express emotional or psychological distress was distinctive, and different from the psychological or psychiatric language which is more familiar to the indigenous population. Bangladeshi women talked about feeling ‘restless or without peace’ in their minds. They described this state as feeling sad, bad or angry, being tearful, as having an aching heart, or a trembling heart, or feeling pressure in the heart, and not getting any comfort from looking after their children. These feelings were attributed to practical problems, for example having little opportunity to rest, and lack of support at home.
"When people have difficulty that's when it (sadness/restlessness) impinges on their mind, before then it won't impinge.""If there is restlessness in the mind then nothing can be done, you can't care for your children or look after yourself, or anyone. It's like your head/mind becomes crazy, because I worry all the time, because in this country I don't have anyone. I am alone in this country."
Coping strategies. The way in which women coped with their problems did not seem explicit or planned. The general feeling was that ‘you do it’ rather than thinking about ‘how you would do it’. The strategies mentioned, such as praying to Allah, or ‘keeping yourself happy’, relied on the woman's ability to manage problems and emotional distress by herself.
"There's no point talking about this problem because everyone has to do it, it's what women need to do, they have to do it.""If sadness comes from inside, you have to put up with it."
A small number of women suggested it might be helpful to tell someone about their problems. Most women felt that if you did not tell someone explicitly about your problems, it would be difficult for another person to pick it up.
"If you don't tell someone about the sadness in your mind, no one will realize, it will stay inside."
There was no generally accepted pattern about whom to talk to. Some women felt it was appropriate to talk to people outside the family, others would only consider talking to relatives, others said they would never speak to anyone about their problems. There was agreement across the groups that parents were appropriate to approach; however, most women's parents were in Bangladesh. Some women felt that telling someone about practical or emotional problems may imply weakness or failure to fulfil one's role as Bangladeshi women.
Experiences of primary care services in the postnatal period
Women's expectations of primary care support were different from expectations of hospital care. Women did not expect to be looked after by primary care health professionals as they had with maternity ward nurses.
Support received from health visitors and midwives. Most women thought that the midwife visited women at home after childbirth to monitor the physical health of the mother and baby. However, when asked in more detail about the midwife's role postpartum, many women were unsure or vague in their description.
"If the midwife comes, doesn't do anything. Just checks the baby and goes. ‘Is the nappy on right? Is that OK?’ "
Health visitors were generally viewed as being ‘helpful’. Most women thought the health visitor's role was to check the physical health of the baby and, if needed, the mother. All three groups were prompted about whether they would disclose emotional problems/distress to health visitors. The general consensus was that they would not; one group found the idea funny.
Researcher: "If you have sadness would you tell the health visitor about this?""No why should we say?"
Researcher: "So you don't tell the health visitor these things?"
"No!" [Whole group starts to laugh].
Two main reasons were given for this. Most women considered this was not part of the health visitor's role, which they considered was to be about physical care. Other women felt that health visitors were not appropriate individuals to talk to about personal issues.
"The health visitor didn't ask us these things (about emotional problems) when they came to visit."Researcher: "This is your own private matter (restlessness in mind); does anyone talk about that? Did you tell your health visitor?"
"If I tell them, they can't distance (remedy) it."
Support from GPs in the postnatal period. The role of the GP was seen as being for monitoring and checking physical health and for prescribing medication. Across all three groups, most women felt that they did not have good relationships with their GPs. Women complained there was not enough time in GP consultations, they felt their problems were not taken seriously, that they were not examined properly or enough by their GPs, and they were not referred to secondary services when they should have been.
"You say what your illness is; they're not bothered to hear you out.""We don't think the doctor checks patients properly, you say ‘I have headache’, then he writes you tablets. Normally if there is a pain there, they should check it."
Women did not disclose personal or emotional problems to their GPs because they did not see it as part of the GP's role. Some women felt that emotional distress was not a proper illness, like physical illness, or that doctors did not have time or interest in such problems.
Researcher: "Why don't you tell the GP about this matter?""Well we think, I have this (emotional) pain because of my own situation. What can the doctor do about it? That's what comes to mind."
"What type of medicine can you get to have peace in your mind?"
"The doctor doesn't have time to help you. Then how are you supposed to (bring up matters)?"
Some women said they would not disclose their emotional problems, but would present the physical symptom resulting from their emotional problems.
"Well you won't tell (the GP) your innermost problems. You might say, ‘I couldn't sleep at night, because of pain, because of this and this’."
However a small number of women felt that the GP should prescribe medication for feeling ‘restless’, and should try to detect such problems.
"The GP should give her something for restlessness.... I haven't gone, but she [referring to a participant in the group] goes for that type of thing.""Your feet and arms ache, after that, you are young but you look old, because of the illness (restlessness). But the illness has not been detected."
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 Topic guide...References |
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Main findings
This study confirms previous reports that the current hospital practice of making women responsible for their own and their infant's care, and being discharged within 24 h of childbirth, conflicts with many Asian women's expectations about the need for rest after childbirth.13 Many women felt ‘rejected’ at being sent home the next day. This contrasts with modern obstetric policy, which views early discharge and early role resumption positively. Contrary to popular views of South Asian communities, many women's families in the UK were unable to offer practical support during the 40 day postpartum period as they would in Bangladesh.14 Hence an important support network was absent. Women did not expect their husbands to provide this practical support, in contrast to western notions of fatherhood. This contrasting view of the service needs around childbirth was compounded by the lack of language support both in hospital and in the community. The lack of explanation and understanding of early discharge policy may have contributed to the limited expectations this group held of postnatal primary care services.
Women in this study understood emotional distress as something different from physical illness, and that one may cause or influence the other. The descriptions fitted a psychosocial model, in that emotional distress was considered a product of social stress. The language used to describe these emotions was different from the psychological terminology common in western cultures, but appeared consistent across the three focus groups. In contrast to the common view that Bangladeshis are more likely to express emotional problems as somatic symptoms, this study suggests that women may positively choose not to present emotional problems to health professionals for a range of cultural reasons.15
Many women believed that GPs and health visitors only have a role or interest in physical health. In one group, women were concerned that disclosure of problems relating to their husbands or children would lead to health professionals contacting social services. Women were also concerned that discussion of domestic issues would give the family a ‘bad name’, with the risk of the women being seen as responsible for problems within the family. Some women did not want to disclose problems within the Bangladeshi community to a wider audience, in case this reflected badly on the community as a whole.
Choice and limitations of the study method
A qualitative study was considered most appropriate for this topic because there has been little previous research in this area.16 Focus groups are useful for exploring the meanings and understandings participants attach to given situations.17 Where English is not the first language of participants, focus group methodology allows people to use their own language and vocabulary, as was illustrated by these groups.18
Steps were taken to improve the reliability and validity of the study. Triangulation was used to inform the topic guide, using existing literature and evidence from key informants among local midwives, health visitors and link workers, who had wide experience of working with Bangladeshi women postpartum.19 The same topic guide was used across the three focus groups, and similar issues emerged in each group; this acted as a check on reliability. To improve validity, the key findings were presented back to the participating groups and the link workers. There was general agreement that the analysis was an accurate representation of the information collected.
The study only included women brought up in Bangladesh, and hence was not able to explore the views of younger second-generation women brought up in east London, who may hold rather different views. Due to the aims of the study, the topic guide was by necessity problem oriented; this may have precluded discussions about women's positive experiences in the postnatal period. Participants were not limited to the immediate postpartum period, so it is possible that recall of specific events may have faded. Kitzinger notes that in a group setting, group norms may silence dissent, and in two of the three focus groups a social hierarchy was observed.20 Older women tended to dominate the discussions, and silenced any mention of family problems. Women also tended to speak about their own personal experiences rather than consider hypothetical problems; hence issues of confidentiality may have compromised the depth of discussion due to the presence of other participants.
Policy implications
This study highlighted a need for more effective communication between service providers and users on health service provision around the time of childbirth for the Bangladeshi community. Cultural dissonance in expectations needs to be addressed explicitly. Information about services and health professional's roles may be more effective if it were aimed at husbands and mothers-in-law, as well as the pregnant women.
GPs and other health professionals need more understanding of the language of emotional distress current in the Bangladeshi community. A greater awareness of the many reasons women may not disclose emotional or psychological problems is needed, along with a range of skills in enquiring into symptoms of emotional distress in the postnatal period. Women need to be reassured about confidentiality, particularly when a health worker is from their community, or when advocates are present in consultations.
What this study adds
- Bangladeshi women may receive little practical and emotional support after returning home from hospital with a new baby.
- In the UK, many Bangladeshi women cope with emotional distress alone in the postnatal period. Emotional distress is experienced and understood as something different from physical illness, but support outside the family is rarely sought.
- Women are unclear about an extended role for primary care workers including health visitors, midwives and GPs beyond physical health concerns, and do not seek help from them for emotional or psychological problems.
- Women needed more language support to access services effectively.
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Appendix 1 Topic guide used in each of the three focus groups |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 Topic guide...References |
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Problems experienced and distress
WHAT PROBLEMS MIGHT A BANGLADESHI WOMAN FACE, AFTER HAVING A BABY (OR WITH A YOUNG BABY) IN THE UK?
Have you, or anyone you know experienced any of these problems?
Has someone else you know?
How would the mother feel (or What will come into her mind)?
HOW DO THESE PROBLEMS AFFECT EVERYDAY LIFE?
What does it stop you doing?
What does it make you do more of?
HOW CAN SOMEONE TELL IF ANY OF THESE PROBLEMS (EMOTIONALLY) UPSET WOMEN?
What do women do when they are emotionally upset?
Can you tell if a woman is emotionally upset (in the postnatal period)?
Coping strategies
HOW DO WOMEN MANAGE THESE PROBLEMS?
What do women do? What else?
WHERE WOULD WOMEN GO FOR HELP?
Where else?
IN WHAT WAY WOULD THIS HELP?
Views about service
WHO COMES TO VISIT AFTER HAVING A BABY?
Who else?
What happens?
WHAT DO YOU THINK ABOUT HEALTH VISITORS/GPs?
What do you think their role is?
What else?
Is this helpful/unhelpful? How?
HOW DO WOMEN PRESENT PROBLEMS TO GPs OR HEALTH VISITORS WHEN WOMEN WANT HELP FROM THEM?
What type of problems can health visitors or GPs help with?
What about emotional or personal problems?
WHAT DO HEALTH VISITORS OR GPs DO TO HELP WOMEN WHO HAVE THESE PROBLEMS?
WHAT CAN HEALTH VISITORS AND GPs DO TO BETTER HELP BANGLADESHI WOMEN WITH THESE PROBLEMS IN THE POSTNATAL PERIOD?
What would help?
What would happen if these services become available?
What is currently stopping Bangladeshi women using services?
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Acknowledgments |
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We thank all the interviewees and group facilitators. Mary Bird and Lisa Orpwood, psychologists with Tower Hamlets Health Care Trust gave advice and support throughout the project. AP, CJ and SH contributed to the design of the study. AP and CJ were responsible for sampling, data collection and analysis. AP transcribed and translated the focus group discussions. AP wrote the study report. CJ and SH wrote this paper. AP was employed by Tower Hamlets Health Care Trust, CJ was funded by the Department of General Practice and Primary Care, QMUL. Additional funding came from the East London Network of Researchers. Competing interests: none declared.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionAppendix 1 Topic guide...References |
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