About six weeks after she gave birth to her first son, Jaya, an immigrant from India to the United States, began to suffer feelings of inadequacy as a mother. She felt sad, helpless, useless to her newborn and husband. She imagined her death and described it to her mother over long-distance calls. "I told her that I felt reckless," she says. "I didn't feel the need to be careful about myself and my safety." Jaya (not her real name) began to cross busy intersections with less caution, hoping the universe might intervene and make her dreams a reality.
Postpartum depression affects nearly one of seven birth parents each year, according to the American Psychological Association. Postpartum obsessive-compulsive disorder and postpartum post-traumatic stress disorder affect another 5 percent and 1 percent of birth parents, respectively. While these mood disorders hit every age, race, ethnicity, and class, immigrant parents, like Jaya, are at an even greater risk—over 40 percent are affected, according to a 2017 study in the Journal of Transcultural Nursing—and face additional challenges to attaining accurate diagnosis and treatment.
But immigrant women's particularly high risk of postpartum depression has received little attention. In the limited scientific literature available, researchers have also discovered that their disorders are underreported. While many factors play a role in the scarcity of information, a mix of misogyny, racism, and xenophobia have contributed to this lack of research, suggesting the dominant culture lacks interest in examining the experiences of women, people of color, and non-American people.
I began thinking about this when writing about my own experience of postpartum depression as an American living in Asia. Although I was a migrant and experienced pregnancy, birth, and postpartum depression in a country that wasn't my own, as an "expat," the intensity of my illness and my access to support and care was mitigated by my relative wealth and temporary status overseas. But my time outside of the U.S. made me wonder about what the postpartum experience had been like for a generation of immigrant women in my community who came to the U.S. from India in the 1970s with far fewer privileges, and for the women who continue to migrate to this country.
I started collecting anecdotes, of which there are many, and research studies, of which there are few, and learned that this paucity of research can be deadly. Scientific research, with its perceived objectivity, trumps stories of lived experience like Jaya's, and governs the ways changes are made to practice and policy. How many women are dying because of this lack of data? I asked myself. While a numerical answer to that question may not exist, in the course of my reporting, as well as my own experience, I've seen that immigrant women, regardless of country of origin, share common risk factors and barriers to care, and increasing health-care providers' understanding of the meaning of postpartum mood disorders for immigrant women is key to saving lives.
"If you think about someone who's been under a lot of stress over the course of their life, then it's going to have an effect on their ability to respond to stress in a new country."
Immigration brings a sea change of transitions—in personal ties, in political or economic systems, in cultural frameworks—and a number of migration-related factors can affect mental health. Sandraluz Lara-Cinisomo, an assistant professor in the Department of Kinesiology and Community Health at the University of Illinois and author of the book Perinatal Depression Among Spanish-Speaking and Latin American Women: A Global Perspective on Detection and Treatment, underscores this "lifetime trauma" and its effect on stress response. "If you think about someone who's been under a lot of stress over the course of their life, then it's going to have an effect on their ability to respond to stress in a new country," she says.
Immigrants aren't necessarily less well-off than native-born Americans as a whole, but for those who are, financial insecurity presents a risk factor. There is strong evidence to suggest that women of low socioeconomic status (SES) have higher risk of developing a postpartum mood disorder. According to a 2010 study in Women's Health Issues, women with four SES risk factors were 11 times more likely than women with no SES risk factors to have depression three months postpartum. College-educated immigrants, specifically, are more likely to be underemployed than their native-born counterparts. This, too, takes a huge toll on mental health.
Many immigrants may have few, if any, community networks in the U.S., and disruption of familial ties is enormously traumatic. In many cultures, postpartum traditions, such as Asian confinement practices or cuarentena, play important roles in new mothers' well-being, and are nearly impossible to replicate in the absence of community or in a hyper-capitalist country that requires women go back to work, in some cases, days after giving birth. Conversely, better-off immigrants often have family members visit the U.S. to help with the transition to parenthood—but, ironically, this can also increase a mother's risk of developing a postpartum mood disorder.
Sunita Mookerjee, a community health professional in New Jersey whose work has focused on statewide initiatives to providing prenatal care through enhanced services and improved maternal and neonatal health-care systems, says that, in her experience, mothers in these situations are often railroaded by their mothers or mothers-in-law and are rarely the decision-makers in the postpartum period.
"[They] are losing their ability to make decisions independently," Mookerjee says. "I mean, things are changing, but if you have your mother-in-law taking care of you, how often are you willing to come to the phone to talk to the nurse who may have identified you at risk and needing support?"
Other sub-groups of immigrants, such as undocumented immigrants and refugees, face even more obstacles to timely diagnosis and care. Undocumented immigrants fear deportation in return for accessing public-health services. Undocumented Latina women, for example, not only fear immigration consequences for themselves should they report their mental-health concerns to a provider, but also fear that their child may be taken away by the authorities. The fear of deportation of family members can additionally impact the mental health of an expectant or new mother, Lara-Cinisomo says.
Migrants who seek refuge from war, violence, or torture are at substantially higher risk than the general population for a variety of specific psychiatric disorders, with up to 10 times the rate of post-traumatic stress disorder, as well as elevated rates of depression, according to a 2005 study in the Lancet.
This is all to say: Any one of these factors—financial insecurity, a weak support system, and a previous mental illness (whether diagnosed or not)—increases the risk of developing a postpartum mood disorder in the general population. Immigrant women's risks are compounded because of the traumas inherent to migration and life as an immigrant.
Language barriers, for example, come in many forms—from situations in which patients and providers may not share a tongue to situations in which women may not have the "right" vocabulary to discuss mental health, even if they are fluent in English. The word "depression" is rarely used in a clinical setting by immigrant women across cultures; "stress" is far more common, as are references to specific physical symptoms, such as pain in a particular part of the body, rather than emotion-based complaints.
Paige Whipps, a licensed clinical social worker with Utah Health and Human Rights, adds that clinical vocabulary itself can be stigmatizing. "We rarely use the term 'post-traumatic stress disorder' because the word 'disorder' can be triggering or off-putting," she says. "Instead, we use descriptive language, like, 'After you give birth, you might find yourself feeling really afraid for no reason,' to normalize and validate their experiences in a non-clinical way."
"We don't seek out help as fast or as well as other groups. We don't even know how to ask for it—even in our own families."
But it's not just a lack of initial health-care access: Many women do not seek mental-health care even after their health-care professional has suggested they get support. "Doctors will make referrals all day long [to immigrant mothers], and not one patient will call me," says Parijat Deshpande, a clinically trained therapist and high-risk pregnancy expert, who mostly works with Asian and South Asian immigrant families in California. "They don't want people in their family, in the community, to know they need mental-health care."
Relatedly, and maybe more importantly, there exists a persistent belief across cultures that motherhood should be difficult, and, because of this particular stigma, many women do not feel that their condition warrants seeking help.
"There are lifelong expectations about what motherhood should look like across cultures, and the disappointment that emerges from a reality that doesn't match those expectations can trigger a mood disorder," says Morgan Gross, manager of the maternal-health program at Mary's Center, a community health center in the Washington, D.C., metro area. Gross says this disappointment for new arrivals can be compounded when their expectations of life in the U.S. in general doesn't mesh with their lived experience. "It adds layers of worry to an already anxiety-ridden time. [As a culture] we don't acknowledge how traumatic the change in identity that accompanies motherhood can be."
"There is a complete lack of validation of any conflicting or negative feelings about mothering by family and society," adds Deepika Goyal, a professor of nursing at San Jose State University and co-author of a chapter on maternal mental health in Health of South Asians in the United States: An Evidence-Based Guide for Policy and Program Development, the most comprehensive summary of evidence on this topic.
Jaya ultimately got the help she needed, through a mix of family support and psychological care, although, nearly seven years and another child later, she still voices dissatisfaction about her therapist's cultural insensitivity. Jaya had to explain, for example, that some Asian families have different boundaries than the general population. "[My therapist] said that she wouldn't 'tolerate' her mother-in-law living with her. I had to tell her that this is how we function."
That's where Deshpande's non-profit, MySahana, comes in. MySahana provides training to mental-health professionals to help them provide culturally competent care to their South Asian clients. "Medical professionals need to know how to talk to women based on their culture, and know intimately what to say and what not to say to women who they are treating," Deshpande says. "Adequate care and treatment follows from that." MySahana is just one of a growing number of advocacy groups focused on immigrant women. Mookerjee, for her part, has also helped establish a number of community-based South Asian support groups throughout New Jersey.
But in order for these programs to really work, there is a fundamental misunderstanding of women's health-care preferences that must be addressed as well. For Latina women, for example, "Their first step isn't to go to a clinician; their first step is to go to friends and family," Lara-Cinisomo says. "A promotora or a lay health worker would be the next person. Someone who's entrenched in the community and who has some social capital within the community, and is trained for a specific health intervention."
"The next would be a health-care professional, but more likely a nurse practitioner," she continues. "The very last would be a therapist or a psychiatrist for medication, because trust is an important factor. Consistency in care and developing a rapport, based not just on the health-care needs of these women, but also how they're doing overall, is necessary."
"I believe we are not adequately prepared as a community to honestly, openly, and healthily address this," Mookerjee says. "Anecdotally, South Asian women don't know how to use the services available to us. We don't seek out help as fast or as well as other groups. We don't even know how to ask for it—even in our own families. It's not something to be ashamed of."