‘We don’t see Black women here’: an exploration of the absence of Black Caribbean women from clinical and epidemiological data on perinatal depression in the UK

Abstract

Objective

to explore the factors that might account for low levels of consultation for perinatal depression among Black Caribbean women and their absence from perinatal research in the UK.

Design

qualitative study using in-depth interviews.

Setting

antenatal clinics in a large teaching hospital and community health centres in the northwest of England.

Participants

a purposive sample of 12 Black Caribbean women was selected from a larger mixed-method study involving both Black Caribbean (n=101) and White British (n=200) women.

Findings

thematic analysis of women's narratives suggested that, despite attendance at antenatal classes, Black Caribbean women experienced difficulty conceptualising perinatal depression and expressed reservations about the nature and treatability of the condition. Personal and social imperatives to minimise distress, reluctance to discuss problems, and stoicism in the face of adversity were barriers to help-seeking. Black Caribbean women were willing to counter personal barriers and fears of engaging with mental health services to seek help. When they did so, however, health professionals appeared to be unable/unwilling to diagnose perinatal depression.

Key conclusions

the absence of Black Caribbean women with perinatal depression from clinical practice and research may be because social, structural and personal barriers prevent these women from accessing the care and support they need.

Implications for practice

in order to address the needs of child bearing women in a multi-cultural context, service providers need to ensure that culturally sensitive practice is a reality and not rhetoric. Education and training (both that given to women via antenatal classes and to health professionals) may need to be reviewed in order to improve cultural sensitivity and efficacy.

Introduction

Depression among women is a serious public health issue, which is said to be the leading cause of disease-related disability worldwide (WHO, 2000; Üstün et al., 2004). Notwithstanding arguments about whether depression during pregnancy and the early postnatal period warrant separate diagnostic categories, and whether or not prevalence rates differ from depression at other times in women's lives (Nicolson, 1998; Stoppard, 2000), the construct of ‘perinatal depression’ has gained increasing clinical and academic currency. The adoption of ‘perinatal depression’ into the clinical and academic lexicon is partly an acknowledgement that ‘antenatal depression’ may be a distinct condition (Bhatia and Bhatia, 1999; Evans et al., 2001) and that ‘postnatal depression’ might well originate during pregnancy (Green and Murray, 1994; Hobfall et al., 1995; Green, 1998).

Estimates of the rates of perinatal depression vary from 5% to 25% (Gavin et al., 2005). However, Gorman et al. (2004) concluded from their meta-analysis of the international literature that postnatal depression affects around 15% of childbearing women worldwide. Estimates of depression during pregnancy tend to be higher at around 20% (Green and Murray, 1994; Evans et al., 2001; Bennett et al., 2004). However, these aggregated figures might mask significant national and ethnic variations since, as Gaynes et al. (2005, p. 5) commented in their systematic review of the literature, the absence of information on populations other than the white population was dramatic.

Where research has been undertaken in non-Western countries, findings suggest that there may be important but under-researched associations between ethnicity and onset of perinatal depression, and that being poor and Black significantly increases the likelihood of developing perinatal depression.

For example, 43% of low-income Brazilian women of mostly African descent experienced at least one episode of depression during the first 6 months following delivery (Da-Silva et al., 1998). In one US study, more than half (51%) the sample of Black and Hispanic women was categorised as having significant levels of depression (McKee et al., 2001). In their international study into postnatal depression, Affonso et al. (2000) reported that women from Asia and South America recorded higher symptom scores than European and Australian women, thus adding to the growing body of evidence for a link between ethnicity, deprivation and increased susceptibility to perinatal depression.

Whether it is ethnicity per se or associated social factors, such as social isolation and lone parenthood (Baker and North, 1999), which increase the risk of perinatal depression is unclear. However, there does appear to be a strong and consistent link between the onset of perinatal depression, living in disadvantaged circumstances, and being from a Black or minority ethnic group. For example, in 1995, Hobfoll et al. screened 192 financially impoverished, inner-city women for depression during and after pregnancy. They found levels of antenatal (28%) and postnatal depression (23%) which were twice those recorded by middle-class women, with particularly heightened rates among single women. In their study among rural Black South African women, Lawrie et al. (1998) reported that almost one-quarter (24.5%) of their sample fulfilled clinical criteria for diagnosis with postnatal depression.

In light of these findings, anecdotal evidence from clinical practice in the UK suggesting that Black Caribbean women are less likely than either White or South Asian women to consult with symptoms of perinatal depression is intriguing. Given that Black Caribbean women are disproportionately located in areas of highest deprivation; have rates of lone parenthood which are twice the national average (National Statistics, 2001), and are more likely to experience social exclusion compounded by racism (Karlsen and Nazroo, 2002), their absence from clinical practice appears to be a paradox.

The invisibility of Black women in clinical practice is also reflected in the research literature. In the UK, perinatal research has been conducted predominantly among White (Brown and Harris, 1978; Murray et al., 2003; Oates et al., 2004) and South Asian women (see, for example, Bostock et al., 1996; Fenton and Sadiq-Sangster, 1996; Asten et al., 2004). There are a number of factors which might account for Black Caribbean women's apparent absence from clinical and epidemiological data.

In relation to research, it may be that as Black Caribbeans represent less than 1% of the UK population (National Statistics, 2002), methodological difficulties hinder recruitment of sufficiently large samples to enable researchers to calculate prevalence levels accurately. Additionally, relatively small numbers coupled with perceptions that Black Caribbeans are not significantly different from the host population might lead researchers to aggregate their data with those of White British women and use them as comparators for South Asian women (see, for example, Onozawa et al., 2003).

It has also been suggested that persistent stereotypes in psychiatric practice places Black Caribbean men and South Asian women in a binary position where the former are seen as being out of control and the latter as private and too controlled (Littlewood et al., 2001, p. 217). This led Ahmad (1993, p. 26) to conclude that, among Black Caribbeans, the genetic basis of schizophrenia…is much more likely to be both proposed and funded than…studies of black women's experiences of pregnancy and maternity care. If that is the case, it might go some way towards explaining the lack of perinatal research among Black Caribbean women.

From a clinical standpoint, Shaw et al. (1999) suggest that, despite being English speakers, subtle language differences and cultural variation in reporting style might reduce the likelihood of Black Caribbeans receiving diagnoses for mental health problems in primary care. Alternatively, intrinsic and/or structural factors within this ethnic group might protect them from onset of perinatal depression. For example, Halpern and Nazroo (1999) have suggested that the ‘ethnic density effect’ of high concentrations of ethnic minorities living in the same area might provide social cohesiveness and strong social support, which has the potential to preserve individuals’ mental health in otherwise hostile environments.

Perhaps Black women are also less likely to receive diagnoses because they are less likely to recognise and/or to consult with depressive symptoms. This may be because structural inequalities in provision mean that Black women experience poorer access to services. This may be compounded by the fact that Black people are more likely than the rest of the population to report negative outcomes of contact with mental health services (Lloyd, 1993; Keating et al., 2002). Fears of unfair/unequal treatment and negative outcomes (Keating et al., 2002) might decrease the likelihood of Black Caribbean women consulting with symptoms of perinatal depression.

However, these theories have not been formally tested as there has been little research into the role of ethnic or cultural factors in the aetiology of perinatal depression among Black Caribbean women in the UK. Neither has there been exploration of their attitudes to help-seeking during and after pregnancy or their experiences of engaging with services.