Tag: cultural safety

First published in Mindnet  Issue 6 – Winter 2006

When my family arrived in New Zealand in 1975 there were very few people from Goa living here. We quickly got know every Goan in the country and, in hindsight, this connection provided me with an early interest in and focus on both maternal mental health and migrant mental health. Two Goan women we knew developed mental health problems that were devastating for themselves and their families. For one, it led to suicide and for another a lifelong history of mental illness and loss. Hardly good outcomes! This was a time when it was hard to maintain our culture. Thankfully, the more recent shift in focus to encompass settlement rather than just immigration will further enhance the well-being of ethnic communities in New Zealand.

There are still large research, policy and practice gaps in the area of migrant motherhood, which I’d like to address in this article. I’d like to start by highlighting the significance of migrant motherhood, which has potentially long term and wide ranging impacts on members of a family. I’ll then talk about the changing demographics of New Zealand society and suggest that health workers need to broaden their focus for working with New Zealand’s increasing diversity and develop culturally safe ways of working with migrants and their families. Lastly, I’ll share my experiences of research with migrant mothers from different ethno-cultural communities.

When migrants “cross borders they also cross emotional and behavioural boundaries. Becoming a member of a new society stretches the boundaries of what is possible because one’s life and roles change, and with them, identities change as well. Boundaries are crossed when new identities and roles are incorporated into life” (Espín, 1997, p.445). Border crossing can involve trauma related to migration and a psychic split (Mohamed & Smith, 1999).

Migration policies favour women (and families) of childbearing age, so it is no surprise that having a baby is a common aspect of a woman’s settlement experience. Motherhood and migration are both major life events. They present opportunities but incur the risk of mental health problems, more so when they are combined. Many cultures and societies have developed special perinatal customs that can include diet, isolation, rest and household help. But these traditional and specific practices and beliefs that assist in the maintenance of mental health can be lost in migration (Kruckman, 1992). Women are separated from their social networks through migration and must find new ways to recreate these rituals or lose them (DeSouza, 2002). Research suggests that the loss of support, protective rituals and supportive networks compounded by a move to a nuclear family-model can result in isolation and postnatal depression (PND) (Barclay & Kent, 1998; Liamputtong, 1994).

Access to help and support can be impeded if the mother has language and communication problems.

Migrant mothers sometimes face additional cultural and social demands and losses that include the loss of lifestyle, control, sense of self and independence, family and friends, familiar birthing practices and care providers.

Women are more likely to develop emotional problems after childbirth than at any other time in their lives and the life time prevalence of major depression in women is almost twice that of men (Kohen, 2001). According to Lumley et al. (2004), one out of every six women experiences a depressive illness in the first year after giving birth. Thirty per cent of those women will still be depressed when their child is two years old. Of those women, 94% report experiencing a related health problem. Women who experience problems in the early stages of motherhood also report problems with their relationships, their own physical health and well-being. Women report that a lack of support, isolation, and exhaustion are common experiences.

In a study of 119 pregnant immigrant women in Canada, Zelkowitz et al., (2004) found that the transitions associated with migration placed women at higher risk of depression. Forty-two percent of participants scored above the cut-off for depression. Depressive symptoms were associated with poorer functional status and more somatic symptoms. Depressed women reported a lack of social support, more stressful life events and poorer marital adjustment. In Australia, Liamputtong and Naksook (2003) found that Thai women who became mothers in Australia had several main concerns, including social isolation, different childrearing and child disciplinary practices, and the desire to preserve their culture. Findings of isolation, loneliness and negotiating between traditional and Western childbirth rituals are common in these studies and were significant issues in my own New Zealand research (DeSouza, 2006c). This research strongly suggests that migrant mothers, regardless of origin, benefit significantly from effective and familiar social support networks.

Psychiatric illness occurring at this time can have an adverse effect not only on the woman herself but also on her relationships, family, and the future development of her infant. The impact on a child of a mother’s depression can include behavioural problems, relationship problems and cognitive deficits. Research shows that infants who had a mother who was depressed in its first year of life are more likely to develop cognitive deficits and behavioural problems than infants whose mothers were not depressed in that first year (Beck, 1998).
A review by Goodman (2004) of literature from 1980 to 2002 found 20 research studies that included incidence rates of paternal depression during the first year postpartum. During the first postpartum year, the incidence of paternal depression ranged from 1.2% to 25.5% in community samples, and from 24% to 50% among men whose partners were experiencing postpartum depression. Maternal depression was identified as the strongest predictor of paternal depression during the postpartum period.

Changing demographics

Many societies are grappling with issues of citizenship and participation in the context of globalisation, increased migration and increasing diversity. In Europe, one in every fifteen people was born overseas, in the US it rises to one in eight and in New Zealand it is one in five (DeSouza, 2006a). This presents unique challenges and opportunities for service providers to develop skills and competence for working with this diversity, especially as migration is going to be a key source of population increase. Census projections to 2021 suggest that Māori, Pacific and Asian populations will grow at faster rates than the European population but for different reasons. The Asian population is expected to more than double mainly due to net migration gains while Māori and Pacific people’s increases will be due to their higher fertility rates (Statistics New Zealand, 2005).

The Asian community has the highest proportion of women (54%), followed by Māori and Pacific (53% each) and European (52%) (Scragg & Maitra, 2005). Asian women are most highly concentrated in the working age group of 15-64 years compared to other ethnic groups and to some degree this is a reflection of migration policy with Asian women using the opportunity to study or work. It is thought that 23% of New Zealand females were born overseas, predominantly in the UK and Ireland, Asia and the Pacific Islands (Statistics New Zealand, 2005). The 2001 Census revealed growing numbers of Māori (14.5%), Pacific Island people (5.6%), Chinese (2.2%) and Indian (1.2%), despite the dominance of the European/Pākehā who make up 79.6% of the population. In the period between 1991-2001, women originating from the Republic of Korea have increased 23 times from 408 to 9,354, women from China have quadrupled from 4,620 to 20,457 and women from South Asia have doubled in the same time period. Women from Africa (primarily South Africa, Zimbabwe and Somalia) have quadrupled in number (Statistics New Zealand, 2005). This has significant implications for the development and delivery of health services to women.

Cultural competence?

Working on a postnatal ward of a women’s hospital several years ago led me to question whether cultural safety had prepared the nursing and midwifery workforce for working with ethnic diversity1. Cultural safety, which refers to the experiences of the client, and cultural competence, which focuses on the practitioner and their capacity to improve health status by integrating culture into the clinical context, have been gaining prominence, but what do they actually mean?

The introduction of the Health Practitioners Competence Assurance Act 2003 has meant an additional responsibility to ensure the cultural competence of health practitioners. Cultural competence can be defined as “the ability of systems to provide care to patients with diverse values, beliefs and behaviours, including tailoring delivery to meet patients’ social, cultural, and linguistic needs (Betancourt, Green, & Carrillo, 2002). Cultural competence includes not only the interpersonal relationship (for example, training and client education) but also the organisational (for example, involving community representatives) and the systemic (for example, providing health information in the appropriate language, collecting ethnicity data).

The New Zealand Medical Council recently consulted its members on cultural competence (The New Zealand Medical Council, 2005). The consultation document includes a proposed framework and says that cross-cultural doctor-patient interactions are common, and doctors need to be competent in dealing with patients whose cultures differ from their own.

It cites the benefits of cultural competence as:

• Developing a trusting relationship;
• helping to get more information from patients;
• improving communication with patients;
• helping to resolve any differences;
• increasing concordance with treatment and ensuring better patient outcomes; and
• improved patient satisfaction.

For cultural competence to occur there is a need for the voices of ethnic communities to be considered in service development, policy and research. Despite the long histories of migration to New Zealand, ethnic communities have been absent from discussions of nation building and health care policy (DeSouza, 2006b). This has in part been due to the relatively small numbers of migrants from non-traditional source countries until the early 1990s, which meant that that the concerns of a relatively homogenous Pākehā people were reflected in policy (Bartley & Spoonley, 2004). This monoculturalism continues to be challenged by the increased prominence of Māori concerns since the 1970’s and increasing attention to biculturalism and health outcomes for Māori. Developments have also occurred with regard to Pacific peoples, largely around health disparities, but this concern has not been extended to ethnic communities despite their increasing visibility in long and short-term migration statistics. This is partly due to an assumption of a ‘health advantage’ of immigrants on the basis of current migration policy, which selects healthy people. However, evidence is growing that this advantage declines with increasing length of residence in a receiving country (Johnstone & Kanitsaki, 2005).

Cultural safety

When Britain assumed governance of its new colony in 1840, it signed a treaty with Māori tribes. Te Tiriti O Waitangi/The Treaty of Waitangi is today recognised as New Zealand’s founding document and its importance is strongly evident in health care and social policy. As an historical accord between the Crown and Māori, the treaty defines the relationship between Māori and Pākehā (non-Māori) and forms the basis for biculturalism.

Durie (1994) suggests that the contemporary application of the Treaty of Waitangi involves the concepts of biculturalism and cultural safety, which are at the forefront of delivery of mental health services. This means incorporating “principles of partnership, participation, protection and equity” (Cooney, 1994, p.9) into the care that is delivered. There is an expectation that mental health staff in New Zealand ensure care is culturally safe for Māori (Mental Health Commission, 2001). Simply put, “unsafe practitioners diminish, demean or disempower those of other cultures, whilst safe practitioners recognise, respect and acknowledge the rights of others” (Cooney, 1994, p.6). The support and strengthening of identity are seen as crucial for recovery for Māori along with ensuring services meet Māori needs and expectations (Mental Health Commission, 2001). Cultural safety goes beyond learning about such things as the dietary or religious needs of different ethnic groups; it also involves engaging with the socio-political context (DeSouza, 2004; McPherson, Harwood, & McNaughton, 2003). However, critics suggest that cultural safety needs to encompass new and growing ethnic communities. Whilst in theory cultural safety has been expanded to apply to any person or group of people who may differ from the health professionals because of socio-economic status, age, gender, sexual orientation, ethnic origin, migrant/refugee status, religious belief or disability (Ramsden, 1997), in practice the focus remains on the relationship between Pākehā and Māori, rather than migrants (DeSouza, 2004) and other communities (Giddings, 2005).

Expanding the bicultural to a multi-cultural framework is necessary without removing the special status of tangata whenua. New Zealand’s reluctance to encompass multiculturalism as a social policy framework has been shaped by two key factors, according to Bartley and Spoonley (2004). The first is the location of historical migration source countries such as the United Kingdom and Ireland, which shaped the development of activities and concerns (as they argue, racist and Anglo centric assumptions of a colonial New Zealand) and, secondly the rise in concerns over indigenous rights and the Treaty of Waitangi, which have precluded discussion around nation and nationality. Thus while countries such as Canada and Australia were developing multicultural policies, New Zealand was debating issues of indigeneity and the relationship with tangata whenua. As a result, New Zealand has yet to develop a locally relevant response to cultural diversity (multiculturalism) that complements or expands on bicultural and Treaty of Waitangi initiatives (Bartley & Spoonley, 2004).

Need for a migrant health agenda

It is, I hope, clear by now that there is a need to develop a migrant mental health agenda, yet much of the previous New Zealand research has omitted the experiences of migrant mothers. The Centre for Asian and Migrant Health Research at AUT University and Plunket have begun a collaborative project with funding from the Families Commission and Plunket volunteers to understand the experiences of migrant mothers from the United Kingdom, the United States, South Africa, Palestine, Iraq, China, India and Korea, which it is hoped will assist in the development of services and policy.

There is a misguided view that migrants do not experience compromises in their health status despite the changes in income and social support and the new stressors they encounter, which can lead to cumulative negative effects and the need to access mental health services. The neo-liberal trajectory that our society has taken has precluded an interest in the wellbeing of migrants who often face culture-related barriers in using mental health care services. Other than a literature review produced by the Mental Health Commission (Mental Health Commission, 2003), which recommended that mental health services become more responsive to Asian people, there has been little in the way of strategic or long term planning with most of the developments in this area coming from the community and voluntary sector.

Conclusion

Migrants face additional stressors that can increase their need for mental health services. Migration can be a traumatic life event. Becoming a mother in an unfamiliar country adds to this already traumatic event, leading migrant mothers to be more at risk of experiencing depression or other mental health issues. Yet, research on the migrant experience in New Zealand is limited and studies on postnatal depression have excluded migrants in the past.

As the number and diversity of migrants increase, their well-being becomes an increasingly important issue for policy makers and health professionals. The time is right to begin a dialogue about how mental health services can work effectively with this diversity. Migrant mothers hold the key to a family’s future well-being and so are an important group for us to understand and support. In the absence of policy there is a need to advocate for migrant mental health service development, building on the many grassroots initiatives that are already occurring. Beyond this, further discussion is needed as to how cultural competency and cultural safety can be applied to migrant populations.

1. ‘Ethnic’ is a term devised by the Department of Ethnic Affairs and refers to people who are neither Pakeha, Maori or Pacific).

References

Barclay, L., & Kent, D. (1998). Recent immigration and the misery of motherhood: a discussion of pertinent issues. Midwifery, 14, 4-9.

Bartley, A., & Spoonley, P. (2004). Constructing a workable multiculturalism in a bicultural society. In M. Belgrave, M. Kawharu & D.V. Williams (Eds.), Waitangi revisited: perspectives on the Treaty of Waitangi (2nd ed., pp. 136-148). Auckland, N.Z.: Oxford University Press.

Beck, C. T. (1998). A checklist to identify women at risk for developing postpartum depression. Journal of Obstetric, Gynecologic and Neonatal Nursing, 27(1), 43-44.

Betancourt, J. R., Green, A. R., & Carrillo, J. E. (2002). Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. Retrieved 27th April, 2005, from www.cmwf.org/usr_doc/betancourt_culturalcompetence_576.pdf

Cooney, C. (1994). A comparative analysis of transcultural nursing and cultural safety. Nursing Praxis in New Zealand, 9(1), 6-12.

DeSouza, R. (2002). Walking upright here: Countering prevailing discourses through reflexivity and methodological pluralism. Massey University, Albany, New Zealand.

DeSouza, R. (2004). Working with refugees and migrants. In D. Wepa (Ed.), Cultural safety (pp. 122-133). Auckland: Pearson Education New Zealand.

DeSouza, R. (2006a, May 26th). Cultural Diversity and Context: Responding to the needs of ‘This Child” in “This Family”. Paper presented at the 5th Annual Child Law Conference, Lexis Nexis, Auckland.

DeSouza, R. (2006b). Researching the health needs of elderly Indian migrants in New Zealand. Indian Journal of Gerontology, In press.

DeSouza, R. (2006c). Walking upright here: Countering prevailing discourses through reflexivity and methodological pluralism. Auckland, NZ: Muddy Creek Press.

Durie, M. (1994). Whaiora: Maori health development. Auckland; Oxford: Oxford University Press.

Espin, O. M. (1997). The role of gender and emotion in women’s experience of migration. Innovation: The European Journal of Social Sciences, 10(4), 445-455.

Goodman, J. H. (2004). Paternal postpartum depression, its relationship to maternal postpartum depression, and implications for family health. Journal of Advanced Nursing, 45(1), 2-35.

Johnstone, M.-J., & Kanitsaki, O. (2005). Cultural safety and cultural competence in health care and nursing: An Australian study. Melbourne: RMIT University.

Kohen, D. (2001). Psychiatric services for women. Advances in Psychiatric Treatment, 7, 328-334.

Kruckman, L. D. (1992). Rituals and support: An anthropological view of postpartum depression. In J. A. Hamilton & P. N. Harberger (Eds.), Postpartum psychiatric illness: a picture puzzle (pp. 137-148). Philadelphia: University of Pennsylvania Press.

Liamputtong, P. (1994). Asian mothers, Australian birth: pregnancy, childbirth, and childrearing: the Asian experience in an English-speaking country. Melbourne: Ausmed Publications.

Liamputtong, P., & Naksook, C. (2003). Life as mothers in a new land: The experience of motherhood among Thai women in Australia. Health Care Women International, 24(7), 650-668.

McPherson, K. M., Harwood, M., & McNaughton, H. K. (2003). Ethnicity, equity and quality: Lessons from New Zealand. Quality & Safety in Health Care, 12(4), 237-238.

Mental Health Commission. (2001). Cultural Assessment Processes for Maori – Guidance for Mainstream Health Services. Wellington: Mental health commission.

Mental Health Commission. (2003). Mental Health Issues for Asians in New Zealand: A Literature Review. Wellington: Mental health commission.

Mohamed, C., & Smith, R. (1999). Race in the therapy relationship. In M. Lawrence, M. Maguire & J. Campling (Eds.), Psychotherapy with women: feminist perspectives (pp. 134-159). New York: Routledge.

Ramsden, I. (1997). Cultural Safety: Implementing the concept – The Social Force of Nursing and Midwifery. In P. T. Whaiti, M. McCarthy & A. Durie (Eds.), Mai i rangiatea (pp. 113-125). Auckland, NZ: Auckland University Press and Bridget Williams Books.

Statistics New Zealand. (2005). Focusing on women. Retrieved 25th January, 2005, from www.stats.govt.nz/analytical-reports/children-in-nz/growing-ethnic-diversity.htm

The New Zealand Medical Council. (2005). Assuring Medical Practitioners’ Cultural Competence (draft document for consultation). Retrieved 3rd May, 2005, from www.mcnz.org.nz/portals/1/news/culturalcompetence.pdf

Zelkowitz, P., Schinazi, J., Katofsky, L., Saucier, J. F., Valenzuela, M., Westreich, R., et al. (2004). Factors Associated with Depression in Pregnant Immigrant Women. Transcultural Psychiatry, 41(4), 445-464.