Recent immigration and the misery of motherhood: A discussion of pertinent issues

Recent immigrationand the m,sery of motherhood: a discussion of pertinent issues Lesley Barclay and Diane Kent In this paper it is assumed that the high rates of misery experienced by most new mothers in contemporary Western society are socially and culturally induced. Women from non-English-speaking backgrounds (NESB) recuperate from the stress of birth, often further complicated by morbidity from intervention, frequently alone and without practical household help. They often embark on their new mothering role with little support or guidance. In a Western society which markets a romanticised Anglo image of motherhood, where happy, contented, smiling babies and glamorous mothers appear as the norm, it is not surprising that women from NESB find becoming a mother in Australia difficult. Their difficulties are exacerbated as they frequently come from cultures where women are nurtured, valued and supported at this time in their lives. These women are often socially isolated in their new country, within an alien health system and separated from their normal birth and postpartum practices. Their misery can only be imagined, as mostly it is hidden and suffered alone. Providing a diagnosis of depression in women who are unhappy, but not clinically depressed, is likely to be even less helpful and more damaging for NESB women than for Anglo-Australian women. A diagnosis of depression excuses Western society for accepting responsibility for alleviating the isolation of new mothers by labelling them as 'sick'.

INTRODUCTION

Lesley Barclay RN, RM, MEd, PhD, Professorof Family Health, University of Technology, Sydney and the South Eastern SydneyArea Health Service, Family Health Research Unit E-mail: L.Barclay@ unsw.edu.au

Diane Kent RN, RM, MN, Research Assistant, Family Health Research Unit, L2 James Laws House, St George Hospital KOGARAH NSW 2217 Australia (Correspondence to LB) Manuscript accepted 22 September 1997

This paper follows an earlier discussion paper (Barclay & Lloyd 1996) which outlined high levels of maternal distress in white, English-speaking background women (WESB) in contemporary Western society. It was argued that the high rates of misery experienced by most Western new mothers today are socially and culturally induced. Women recuperate from the stresses of delivery without practical household help or adult company. This is frequently exacerbated by morbidity attached to interventions such as caesarean section. They begin mothering and the major physical readjustments, including establishing lactation and weeks or months of sleep deprivation, with limited or no support. They undertake the intense learning and development of mothering skills with little guidance and few, if any, role models. They do so in a society that markets a romanticised image of white, middle-class motherhood where female glamour and chubby, well-behaved, smiling babies are the norm. How, then, do non-white, non-English-speaking background (NESB) women find the transition to motherhood in Western societies? In many nonMidwifery(1998) 14,4--9 © 1998HarcourtBrace& Co. Ltd

English-language cultures women are nurtured, valued and supported from pregnancy to early motherhood. Some NESB women have enough kin around them to provide these traditional supports. Many, however, are more isolated as recent arrivals in a new country, so their experiences in Western health and social systems are very different from their expectations of childbirth. The misery of these women, like their early motherhood, is usually hidden and suffered alone. Providing a diagnosis of depression is likely to be even less helpful and more damaging for NESB than for other women, because of cultural meanings surrounding mental illness. Labelling women as sick excuses society from accepting responsibility for alleviating the isolation of new mothers, particularly those who are culturally and socially dislocated.

PROBLEMS OF I M A G E R Y A N D MOTHERHOOD We are surrounded by images of motherhood created in the romantic tradition of Mills and Boon (Barclay 1995). Typical of this genre are Johnson &

Recent immigration and the misery of motherhood

Johnson advertisements and articles about the babies of the 'rich and famous' (Callaghan 1995). The image of motherhood that appears on our television sets, supermarket shelves and magazines is steeped in the white culture of North America, Europe and Anglo-Australia (Barclay & Lloyd 1996). The norm of the new mother presented by this marketing image is well dressed and sexually attractive. Her house is large, filled with modern conveniences and designer furniture. Her husband works in an office and earns enough money for the woman to stay at home by herself in the large house with excursions outside for shopping, tennis or lunch with friends. A smiling, plump, white baby waits for his/her father to arrive home. He is supportive and involved with child care and household chores. He is the only other adult involved in the household. This imagery does not represent contemporary Western societies, many of which are multi-cultural. Real experiences of being a woman and mother are derived from many different cultures. Thirty-nine thousand of the women who gave birth in Australia in 1993 were themselves born in non-English-speaking countries (Townsend & Madden 1994). Taking on motherhood in Western societies today makes many women miserable (Barclay et al 1997). Some researchers feel there is not enough evidence to determine whether the case is the same in other cultures (Kumar 1994), although anthropological researchers feel there is (Stern & Kruckman 1983). At least 10% of Western women are diagnosed as clinically depressed (Boyce & Stubbs 1994). The superhuman demands of dealing with a new, frighteningly small human being without help and limited, or no previous experience, compounds the physical exhaustion that follows labour and delivery. Many women undergo a Caesarean section - one fifth in Australia (Lancaster & Pedisich 1993) - so they arc simultaneously recuperating from major surgery. Women are unlikely to have more than a few hours solid sleep for weeks or months because of their baby's needs for regular and frequent feeding. Most women do not feel like resuming sexual activity because of the new sensations of lactation, perineal discomfort and prolonged vaginal discharge. Some partners resent this, the additional demands placed on them by the baby, and the changes that occur in household routines when women can no longer keep household standards at pre-birth levels (Lupton & Barclay 1997). Women and men who had expected to become emotionally closer, and for their relationship to strengthen, become distressed as tensions emerge. Such tensions are not easily resolved in the new family arrangements, so both men's and women's quality of life may diminish (Barclay & Lloyd 1996). If a woman does not fit the romanticised image of motherhood, or expresses disappointment or unhappiness at her new life, we frequently label her, or she labels herself as depressed. As a society and as health professionals we have, for far too long, ignored or denied the additional cultural and social

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demands, and losses, faced by recent immigrants to Western society. Loss of previous lifestyle, loss of sense of self and of control, loss of time, freedom and independence quite naturally result in women feeling miserable (Barclay 1995, Brown et al 1994). For approximately 80% of women this response is not psychiatric illness. Immigrant women also lose family and friends, familiar birthing practices, care providers and patterns of care. Our scientifically ritualised and professionally dominated alternatives may appear not only inhuman, but incorrect to NESB women. Western practices may contravene, for example, Vietnamese cultural postpartum practices, which entail dietary restrictions for the mother, prolonged rest, bathing restrictions and special clothing. Particular dietary patterns are also followed by ethnic Chinese, Thai, Malaysian, Indian, Korean and Hmong Laotian women (Rice 1993). Foods which are considered 'hot' such as pork, garlic, pepper, ginger and salty rice axe eaten to replace the heat lost in the birthing process. 'Cold' foods, such as certain types of fruits, vegetables and fish, are avoided because they are thought to increase the likelihood of 'wind' diseases, for example chest infections and arthritis (Pillsbury 1978). Women trying to follow these diets in postnatal wards in Western countries must have special food brought to them by relatives. If there are no relatives to do this they must eat hospital food, which they believe may make them sick. Women following such a diet may also have Anglo health professionals telling them they should not eat ginger, garlic and chilli because spices unsettle their babies through breast milk.

MENTAL HEALTH A N D ILLNESS AS A CULTURAL C O N S T R U C T I O N 'Soft' technology, The Edinburgh Post Natal Depression Scale (EPDS), based on psychiatric models of illness, is being proposed by some Australian Health Departments (NSW Health Department 1994) as a screening tool to tell us how unhappy (depressed) women are. Considerable efforts are going into the validation of this scale for use with NESB (Matthey & Barnett 1995, Matthey et al 1993, Small et al 1995). A preoccupation with the EPDS and trying to validate depression scales in NESB populations diverts us from dealing with the underlying problem of the social circumstances in which women from every type of background begin their mothering. We continue to challenge its suitability for use even in an Anglo-Australian population (Barclay 1994, Barclay & Lloyd 1996) and recent studies appear to bear this out (Condon & Corkindale 1997). Psychiatric depression scales are based on relatively stable, somatic experiences of persistent fatigue, problems in sleeping, sexual disinterest and eating disturbances. These symptoms, however, are part and parcel of the predictable

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adjustment to motherhood in Western society today, and are both dynamic and developmental (Affonso et al 1990). Categorising common symptoms as depression, however, denies women's experiences of unhappiness. Somatic symptoms are exacerbated as most women tackle the postnatal period alone, with little or no experience, and with unrealistic expectations (Barclay 1995, Rogan et al, 1997). Postnatal Depression (PND) is an extension of the 'medicalisation of motherhood' (Oakley 1992). By medicalising women's experiences, professionals and society at large deny that women's circumstances have changed. Continuing to deny that motherhood, for many women, is a source of misery which exacerbates cultural difference, and which will have profound and detrimental consequences for women and society at large. The mental illness approach denies the importance of culture and social context, and belittles the emotional, physical and relationship changes attached to the birth experience (Brown et al 1994, Affonso et al 1990, Raphael & Martinek 1994). Far more importantly, the approach that relies on mental illness explanations has inbuilt assumptions from Western culture about mental illness that do not translate across cultures. For example, there is still stigma attached to being labelled as mentally ill in Western society, but in other cultures the stigma can be far more powerful and have serious consequences in later life. 'The Chinese regard mental illness as a particular stigma, because it implies character flaws in an ancestor and thus shame is imputed to the whole family' (Puckett 1993, p. 311). Vietnamese women also feel shame at the prospect of admitting to mental problems following the birth of their babies (Tang et al 1995). Clinicians and researchers are beginning to address these issues. Efforts are being directed to increasing our understanding of NESB women's experiences of motherhood within cultural contexts and in culturally sensitive ways. For example, the Mothers in a New Country (MINC) project being conducted by the Centre for the Study of Mothers' and Children's Health in Melbourne, is exploring the views and experiences of Filipino, Vietnamese and Turkish mothers in order to describe the cultural constructions of motherhood and mental health (Small et al 1995). The ambiguity and stress associated with the immigration process itself, and the break in women's knowledge accompanying that cultural leap has been described and interpreted in relation to Cambodian women's experiences by Fitzgerald (1995). The transition from 'woman' to 'mother' is a major one and it can be hugely stressful when combined with the transition from 'local' to 'immigrant'. Recognition of the complexity of being a new mother in a new country will hopefully lead to greater understanding of early mothering for NESB women and will enable Anglo clinicians to resist a monolithic, blinkered approach to mothers' distresses.

Work by Australian researchers has indicated that many women feel vulnerable, lonely and confused after they have a baby, and suggests that explanations are likely to be located in the cultural and social contexts of their lives (Small et al 1994, Brown et al 1994). Brown at al (1994) found most women do not describe themselves as sick when they find themselves to be unhappy, nor do they wish to have the label 'depression' attached to their experience. Women do not want their experience to be medically managed (Brown et al 1994). Most would prefer practical help and emotional support. Our own research shows that Anglo women are exhausted, grieving for the lifestyle they have lost and feeling poorly prepared for the experience of mothering (Barclay 1995, Rogan et al, 1997). Research is urgently needed with a wide range of cultural groups in countries with large immigrant populations.

INSIGHTS FROM OTH E R DISCIPLINES In a review of cross-cultural studies, Stern and Krnckman (1983) have argued that mild postnatal depression is a 'culture-bound syndrome' (p. 1039). They draw comparisons between societies in which 'cultural patterning of postpartum emphasises rest and seclusion, instrumental assistance from relatives and explicit recognition of changed social status' (Stern & Kruckman 1983, p. 1039) and societies with no such patterning. Cultures which recognise and practice rituals associated with the postpartum period may promote mothers' mental health. In contrast, where the postpartum period is neither recognised nor celebrated as a special time, the example used is the USA, high incidences of PND are reported (Stern & Kruckman 1983). Recent work from Hmong women resettled in California seems to support this proposition (Stewart & Jambunathan 1996). NESB women may expect traditional postpartum care but are unlikely to receive it if they are new immigrants, refugees or otherwise isolated from support people who can provide this. Anglo health workers may be at best insensitive and at worst derisory about such practices. Sociologists, historians and anthropologists offer useful contributions to explanations as to why so many women in our society find motherhood miserable, but their work tends to be ignored within Western health systems. This is possibly owing to the fact that psychiatry is increasingly influential in defining the unhappiness of mothers. It may be argued that the increasing involvement of psychiatrists in the mental well-being of new mothers in Australia could produce similar consequences to those following obstetricians' involvement in normal delivery. That is, increasing iatrogenesis and morbidity for individual women, and escalating costs for the health system. Removing expert status from experienced women in society, and replacing this with the formal education

Recent immigration and the misery of motherhood

and qualifications of health workers requires sociological explanation because it is historically (Reiger 1986) and culturally (Stern & Kruckman 1983) unique. For many women from non-Anglo cultures the exclusion of older, wiser women, and the location of birth in male dominated hospital systems, is aberrant and difficult to comprehend. This model of care has been argued to be dehumanising and expensive (Department of Health UK 1993). Labelling new mothers' unhappiness as 'depression' legitimizes medical involvement in postpartum mental health in the same way locating birth in hospitals legitimizes medical involvement in birthing. In addition, this may irretrievably stigmatise a new mother within her family and culture. New motherhood has entered 'professional' territory. This territory is based on a model of family formation that is preoccupied with illness and crisis, not growth and the development of health. In the Western world, we have publicly acknowledged that many women are unhappy following birth. This has occurred at a time in history when, arguably, there is a greater involvement of health professionals than at any time previously. Will increasing the number of health professionals caring for NESB women reduce their unhappiness after childbirth? Will testing all of them with a translated depression scale significantly improve their lot? Alternatives which involve larger social changes in attitudes and practices are likely to be of far greater importance. These include: increasing English language learning oppommities for NESB women; improving accessibility to reasonably paid and regular employment for at least one adult in the family; acknowledging that white Australian models of care are no less a creation of culture than any other model of care; - - revaluing and increasing knowledge of AngloAustralian health workers of the variety of cultural practices that surround birth and new mothering; fostering both informal and formal social support which would enable women to have choices in birthing and postpartum support; - - flexible social arrangements that would allow women to rest, to receive practical help and support, and to celebrate the transition to motherhood in the weeks following birth. -

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Stern and Kruckman (1983) claim postnatal depression is a Western problem. We claim this misery is too often carelessly labelled as 'depression'. This label implies a mental illness in the mother, when the misery is actually a normal response to a worsening of social circumstances and the experience of unexpected loss. As we said in our earlier paper: We have enabled health workers to take over new motherhood through, in part, the imprecise use of language. If we define misery as depression it

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provides the health system with both a rationale and responsibility to manage it. If we define women's unhappiness as misery attached to new motherhood, it requires the community, families and society as a whole to act and accept responsibility (Barclay 1995, p. 24-25). The foreignness of one's new land and the outlandishness of many of its customs become very apparent when the hospital sends a mother home alone, to an empty house, without any help with caring for a new baby. Mother and sisters are far away and there are few neighbours or friends to help. Her husband, if he has work, is likely to be working long hours. He may come from a culture that prohibits men from helping with chores and care for the baby. Perhaps he is tired when he gets home and expects his needs to be attended. As families are split by migration or war, women can no longer count on their mothers to be with them in the weeks or months after birth. Demands on new settlers to earn quickly, and therefore to work, when this is available, as long and hard as possible are huge. We have become sensitive to the high rates of unhappiness in Anglo new mothers but the plight of NESB women, which appears in many cases to be worse, remains hidden. Awareness is an important step in acknowledging that problems exist, but if it results in women incorrectly or unnecessarily being diagnosed with depressive illness, this awareness could be even more damaging to individuals and families than for Western women. It is impoItant that the unhappiness of new mothers is validated and they receive help. If we see the misery of most new mothers, including that of NESB women, as an appropriate response to their social isolation, something can be done to improve this.

CONCLUSION If maternal unhappiness continues to be defined and 'managed' as a mental illness, the solutions to the misery of mothers, regardless of cultural origins, will continue to be seen to lie within the woman, rather than within social and cultural contexts in which they live. The problem of most women's unhappiness after childbirth is not dealt with by giving them scales to measure its intensity or by labelling women, from whatever background, as depressed. Motherhood is a social experience that is culturally defined and community supported. Problems of mental health are also culturally defined, managed and expressed. The relationship between social isolation and mental illness cannot be ignored, and it is likely to be profound in culturally dislocated groups (Matthey et al 1993). It is more profitable and humane for society to deal with the social isolation that many women experience and reserve treatment for the few distressed women who require more extensive and complex health care.

8 Midwifery

Simply transferring the problematic model we are developing for Anglo women to NESB women shows our ignorance of the pervasiveness and power of cultural constructions of experience and their implications. It also denies pure common sense by relocating this experience inappropriately within the professional system. Professionals cannot provide the sustained loving and practical nurturing that new mothers need. Our mothers received this from their own mothers, home-birth mothers seem to get it today, and traditional societies still frequently display this phenomenon. Anglo women can learn from and incorporate elements of cultural elaboration that history shows was also part of our experience of motherhood. One of us proposed that the involvement of professionals in the childbearing process has, in fact, weakened traditional social bonds and roles, and diminished the amount of assistance provided by women to other women through social networks. It has also resulted in women who are not 'sick', but who are responding appropriately to their circumstances, being labelled mentally ill and feeling they are incompetent (Barclay 1995, p. 25). How much more distressing it must be for NESB women who do not understand or necessarily accept the medical and hospital culture we have chosen to impose on childbirth in recent times. The solution to the problem of these women's unhappiness as new mothers lies, like ours, in the family, community and society networks they no longer have and find hard, if not impossible, to recreate here. The solutions will be found in supportive networks that provide practical help for new mothers and education for couples from all backgrounds that better prepares them for the reality of the experience they will face as new parents. Broad-based approaches that address social isolation, transportation, women's employment and child care, equity in partnerships where this is culturally possible and acceptable, and shared responsibility for parenting and household chores are needed by all families. Shared responsibility can come from extended family, neighbours, friends or community, and is not male dependent. No women should have to enter motherhood alone. The challenge for society and health workers who work with NESB women is arguably much greater than those who do not. First, to create a more realistic and culturally-balanced image of motherhood that does not assume women's only help will come from their husband, but makes it clear that all women require support from someone. An image, for example, which does not hide breast feeding. Women who come from other countries think that Australians do not value breast feeding and must bottle feed; they begin to lose a cultural strength and confidence, and replace it with the nutritionally inferior and more costly bottle. Certainly, the Australian health-care system needs to help recreate and promote the importance of social bonds, networks and supports for families experiencing new parenthood. These are even more important for NESB women

and it is their absence that, unsurprisingly, exacerbates unhappiness for many to almost unendurable levels. These networks will not be the same as those which existed in the past. Glimpses of new structures that can work for many women can be seen in the work of ethnic obstetric liaison workers who bring NESB women together, both before and after birth, with women of the same language group. In the southern Sydney area (covering Canterbury, St George and Sutherland municipalities), culturallyspecific services from bilingual midwives are offered to Arabic, Chinese, Korean and Vietnamese women (Kim 1995). We need alternate images of new motherhood and parenting for NESB women that create realistic expectations, and allow women and families to react to the changes in their lives without being labelled 'depressed'. These images should acknowledge the losses of early mothering, value diversity in the experience and how this is managed in different communities, and provide help as women tackle the immense task involved of becoming a mother. Then perhaps we may have new mothers in our NESB community who feel their status is valued, who are physically less drained and who find the experience more positive and enjoyable. This could result in a dramatic reduction in the intensity of misery these women experience, which we are now recognising but may respond to inappropriately. REFERENCES

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