1. EXECUTIVE SUMMARY Postnatal stress and depression is a significant health issue for women of non-English speaking background (NESB) in New South Wales. The Postnatal Depression Services Review (1994) conducted by the New South Wales Health Department revealed that little was known about NESB women’s experiences of postnatal depression (PND) and their use of relevant health services. As a result, this project was initiated to consult with health workers, community representatives and NESB mothers throughout the state to gather information on their awareness of PND and NESB women’s use of services for postnatal depression (PND). The 12-month review commenced in January, 1995. The consultation process was extensive and consisted of 21 focus groups with 144 health and community workers in metropolitan Sydney, Hunter and Illawarra regions. Sixteen groups were held with 116 NESB mothers whose first language was Vietnamese, Spanish, Chinese, Tagalog, Arabic, Urdu and Macedonian. Both NESB mothers and health workers identified many factors which could increase the risk of PND for NESB women, a number of which have not been identified in previous research (NSW Health, 1994; WCC, 1994; Williams & Carmichael, 1985). Although there was some acknowledgment of chemical or biological causes of PND, participants emphasised the social and environmental factors common to many NESB women as possible risk factors for PND. These include: isolation, lack of emotional and practical support for women, the dislocation caused by migration, conflict between traditional health care practices and those advocated by Australian services, unrealistic expectations of motherhood, unemployment and financial difficulties, conflict with extended family, refugee status and gender of the baby. Discussion with health workers focused on the identification and management of PND in NESB women. There were numerous barriers to an accurate diagnosis of PND and effective management of NESB sufferers of PND. NESB women were reluctant to disclose personal concerns to practitioners because of the shame associated with not coping as a new mother. Second, there is a considerable stigma associated with depression and mental health problems in NESB communities which prevents women from speaking openly about their emotional state. Not surprisingly, many health workers from an English-speaking background said they found it difficult to recognise symptoms of distress and depression in NESB women. This situation was compounded by the lack of appropriately validated screening tools to assist practitioners in identifying these women. Effective management of NESB women with PND appeared to be problematic due to the poor awareness among NESB communities of PND and of services available to assist women and their families. In addition, cultural and communication barriers often prevented women from using services. As a result, some NESB women did not receive optimal postnatal care. Discussions with NESB mothers focused on the positive and negative aspects of pregnancy, birth and the postnatal period. In terms of health services, their experiences were mixed, but many were appreciative of the high standard of health care available to them in Australia. The primary problem area was communication between health service staff and NESB women. Language difficulties and cultural differences led to frequent misunderstandings, and sometimes distress and frustration for both parties. Women reported conflict between the advice received from health professionals and their own personal and community beliefs and practices. Another recurring theme was the circumstances common to many NESB women. Isolation, lack of support networks, poor proficiency in English and recent migration to Australia frequently placed NESB women in a ‘high risk’ situation during the postnatal period. To address the problems identified, this Review makes a number of recommendations. Three key themes (i) education and training (ii) health promotion and provision of information and (iii) service and staffing issues, underlie the preventative strategies proposed. First, health workers (both hospital and community-based) require training in the recognition and management of PND, which includes training in the use of screening methods. There was also an urgent need for staff training in cross-cultural awareness and communication skills and this needs to be built into all postnatal training areas. Second, the awareness of NESB communities could be increased by disseminating information on PND and of the services and supports available. A publicity campaign through the ethnic media is an important first step, but all services responding to PND in NESB women should ensure that their promotional material is reaching NESB communities. In addition, services which can assist health workers to provide appropriate care to NESB women, such as the Translating and Interpreting Service, must be promoted to practitioners in the private sector who are often overlooked. Third, the designation of bilingual positions in maternity units, community-based health services and postnatal facilities, such as Karitane and Tresillian Family Care Centres, is a necessary strategy to reduce the cultural and linguistic barriers experienced by NESB women. This review has highlighted the diversity of the NESB population residing in NSW. With a population stemming from various cultural backgrounds the challenge for the NSW public health system to provide appropriate care to NESB women is very great. Nevertheless, it can be met by developing a health care system that offers choices and is flexible, accommodating and sensitive to the needs of all women. regardless of their age, sex, nationality, religion or cultural background. This must surely be a high priority for health service providers and planners in New South Wales. 2. SUMMARY OF RECOMMENDATIONS EDUCATION R1Nursing staff working in maternity and early childhood services in areas with large NESB populations to receive cross-cultural and communication skills training to ensure a more empathetic service for NESB women giving birth and caring for children. R2 Health workers providing postnatal services to NESB women to receive training in (i) the recognition and management of PND, including screening methods, and (ii) cross-cultural awareness and communication skills. R3 General practitioners involved in shared-care obstetric and mental health programs receive, as part of their training and accreditation process, education regarding cross-cultural communication, postnatal distress and depression. R4 Cross-cultural training to include practice in the use of interpreters, use of bilingual workers, and ways of resolving conflict between different beliefs and practices around childbirth, neonatal and postnatal care. R5 Hospital and community-based health workers to receive training about the correct use of and services provided by interpreters and, particularly, on how to discuss sensitive issues through an interpreter HEALTH PROMOTION R6 The Mental Health Directorate of the NSW Health Department to commission a publicity campaign through the ethnic media to combat the "myths of motherhood" and to raise awareness in NESB communities of postnatal distress and depression, and of the services and supports available to women and their families. R7 The details and benefits of childbirth education classes to be promoted through the ethnic media and ethnic community organisations. This would include details of classes, times and venues. R8 Childbirth education classes to include information regarding postnatal stress and depression and how to obtain support. R9 Health workers to encourage parents to attend antenatal classes to ensure that they are prepared for the birth experience and informed of services to assist them postnatally. R10 NSW Health Department to ensure that printed information, translated into relevant languages, is available and distributed to NESB clients by staff in hospitals and Early Childhood Centres on parenting skills, PND and community-based services and support groups. R11 The Department of Immigration and Ethnic Affairs’ Translating and Interpreting Service to promote their service more widely to General Practitioners and other services in the private sector who do not have access to Health Care Interpreter Services (HCIS). R12 The Ethnic Obstetric Liaison Officer (EOLO) program to be promoted to hsoptial and community-based health service staff to ensure that they are aware of and understand the role and benefits of the program. SERVICE AND STAFFING ISSUES R13 The NSW Health Department to commission further research to investigate appropriate screening methods and effective interventions for postnatal depression in NESB women. R14 EOLO services currently funded under the National Women’s Health Program be incorporated into Area Health Service global budgets. R15 Additional EOLO teams to be established in Areas where the NESB population supports such as strategy, and existing EOLO teams to be enhanced. R16 General practitioner involvement in shared-care obstetrics to be encouraged, especially among NESB practitioners, to ensure greater continuity of care during and after pregnancy for NESB women. R17 Area Health Services to support the provision of child care so that women and their partners can attend mothers’ and parents’ support groups antenatally and postnatally. R18 Area Health Services to ensure the availability and accessibility of antenatal classes in the main community languages of women attending antenatal clinics. Some classes to be held in the community rather than in hospitals to make them more culturally appropriate and improve access for NESB women. R19 Women to be informed that (i) there are choices available to them regarding preferences for management during childbirth (position, clothing, personnel, diet, hygiene etc) and postnatally and (ii) it is the responsibility of the Health Service to respect their beliefs and choices wherever possible. R20 Hospital amenities and procedures to be flexible to ensure women from diverse cultures are able to practise their preferred birthing customs. R21 Hospitals and community services in areas with large NESB populations to ensure a certain proportion of nursing positions in maternity and early childhood services are designated as bilingual positions. R22 Community-based health services in general to employ more bilingual staff where community numbers would support such an appointment and the relevant communities consider this an appropriate strategy. Appropriate bilingual capacity should be a desirable criterion for appointment and recruitment should occur through ethnic as well as general media. R23 Assessment of the availability to each woman of positive family and community support should be intrinsic to the operation of Early Discharge Programs. R24 Area Health Services to establish and maintain cooperative working relationships with community organisations and self-help groups relevant to PND issues. Health workers to look beyond medical services for solutions to PND, for example, referring women and their partners to support networks. R25 Community-based parent support groups to be established for NESB women and their partners in areas where community numbers support this strategy. R26 A register of NESB volunteers (experienced mothers/surrogate grandmothers) to be established by health workers to provide support to NESB women. R27 Health workers to reassure women about confidentiality when using professional interpreters. The option of telephone interpreting to be provided. R28 If client numbers are sufficient, Early Childhood Centres to designate specific times or days when a bilingual worker will be present for particular language or cultural groups. R29 Day stay and residential facilities, such as Karitane and Tresillian and Family Care Cottages, to employ more bilingual staff and publicise this development to overcome problems of access. Appropriate bilingual capacity should be a desirable criterion for appointment and recruitment should occur through ethnic as well as general media. R30 Given the documented adverse effects for women, their families and the community, mental health services to address the needs of women suffering postnatal depression as a priority.