Prevalence, Risk Factors, and Interventions of Postpartum Depression in Refugees and Asylum-Seeking Women: A Systematic Review and Meta-Analysis

Over the past few decades, there has been a rapid increase in the global number of migrants [1, 2]. The majority of migrants have moved from low- and middle-income countries, settling in the USA, Canada, Australia, Japan, and several European countries [3]. Among these migrants are refugees and asylum seekers – individuals who seek protection in a foreign country but have not yet gained refugee status. Many of whom are women with young families, who may be pregnant or have recently given birth [1]. Frequently, these refugees are individuals who have fled their countries to avoid violence, war, and persecution [4]. Once settled in host nations, they are often faced with the challenge of adapting to a new culture and learning a new language [5].

Additional struggles associated with refugee settlement include isolation from family and friends and discrimination in their host countries [6]. Such psychosocial stressors can adversely affect refugee’s mental health [2, 6, 7]. Several studies have shown that refugees face an increased risk for mental disorders [8, 9]. In comparison to the native population of host countries, refugees experience approximately ten times the increased risk of post-traumatic stress disorder [10]. Refugees are also at an elevated risk of developing psychotic disorders when compared to non-refugee immigrants [10]. Especially vulnerable are refugee women during and after pregnancy [11]. Studies reveal that, during the postpartum period, refugee women are twice as likely to experience depressive symptoms as non-refugee women [6].

The transition to motherhood is associated with many physical and psychological changes [1]. The extent of these changes tends to increase the likelihood of developing mental disorders [1, 12]. Postpartum depression (PPD) is a psychological condition often associated with emotional difficulties [12]. It refers to any depressive episode that occurs within the first postpartum year, and it is among the most common pregnancy-related complications [4, 13, 14]. PPD is universal, affecting individuals in low-, middle-, and high-income countries [4]. Although the global prevalence of PPD is believed to be between 5% and 25%, the prevalence among migrants is higher than that of the general birthing population [6]. In Canada specifically, refugee women are almost five times more likely to develop PPD in comparison to Canadian-born women [1, 12].

Refugees’ increased risk of developing PPD is attributed to a combination of factors, often including a lack of social support, low health literacy, cross-cultural limitations, language barriers, and lower socioeconomic status [1, 2, 7, 9, 14]. Although PPD can be treated, refugee women often lack early detection, and the delay in treatment increases their duration of PPD [14]. Untreated PPD can have long-lasting, significant effects [9, 15]. In addition to its immediate impact on mothers, PPD is associated with poor mother-infant bonding and family relationships [1, 3]. PPD is also associated with substantial economic and societal burdens in the form of productivity losses and healthcare expenses [1, 2].

Given the prevalence of PPD among refugee women and its extensive impacts, screening tools and interventions for PPD should be prioritised to improve healthcare for vulnerable populations [2, 15]. However, the stigma surrounding mental health as well as privacy and confidentiality concerns, are major barriers that prevent refugee women from seeking mental health services [1, 2, 8]. Other obstacles to accessing mental health services include a lack of knowledge about PPD and language difficulties when communicating with healthcare providers [1, 4, 11]. To promote positive health outcomes, appropriate PPD screening can be done for early detection and treatment of depressive symptoms [1, 2]. Additionally, raising awareness about PPD and implementing trauma-informed practice principles can help ensure that refugee women feel safe and supported [2].

Despite the significant impacts of PPD and the increasing number of refugees, there is a lack of information about the appropriate identification and management of PPD among refugee women [1, 9, 16]. There is a need for reliable data to understand women’s experiences during the postpartum period; however, few articles in the existing literature systematically explore the topic of PPD among refugee women [15]. This systematic review aims to delineate the prevalence of PPD among the refugee women population and identify the risk factors and interventions associated with the condition.

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [17]. The full protocol is published on PROSPERO (registration number 311910).

A comprehensive systematic search was conducted on MEDLINE, Embase, PsycINFO, CINAHL, and Core Collection (Web of Science). Key terms related to PPD and interventions were included in the search strategy; refugee-related terminology was adapted from Selvan et al. [18]. The searches were completed in August 2022. Search strategies for each database are available in the online supplementary material (for all online suppl. material, see https://doi.org/10.1159/000535719) (full strategy in online suppl. File 1, Table S1). The PRISMA report for this study is illustrated in Figure 1.

Articles were identified from the databases and were imported onto the Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia; www.covidence.org), which automatically removed the duplicates. Studies that focused on PPD among refugee women were included. Studies included quantitative, qualitative, and mixed-method study designs. K.H. and L.M. discussed the inclusion and exclusion criteria and screened the titles, abstracts, and full text of the articles. H.A. mediated conflict resolution of articles until consensus was reached. Cohen’s Kappa statistic was used to calculate the inter-rater agreement. The remaining were assessed for their methodological quality. All PRISMA systematic review guidelines were followed including checklist, flowchart, and article tables.

H.A. assessed the quality of the included articles. The Critical Appraisal Checklist for Qualitative Research was utilised to assess the risk of bias and conduct quality assessment of qualitative and mixed-method studies [19]. The Downs and Black checklist was utilised to assess quality assessment of quantitative studies [20]. K.S. evaluated the risk and bias assessment process.

Data were collected and analysed by K.H. and H.A. using Microsoft Excel. K.S. evaluated the extracted data and resolved conflicts between reviewers. The extracted data from the articles considered study description (e.g., demographics, study setting, type of study – qualitative or quantitative), methods used to recruit participants, reported interventions that refugee women used to cope with PPD, reported risk factors associated with PPD among refugee women. Due to the nature of the review’s question, a meta-narrative analysis of the extracted data was conducted. The question “what are the reported interventions in the literature that refugee women use to cope with postpartum depression” was investigated through qualitative analysis by K.H. As such, the extracted data were based on different categories/themes that defined different barriers for refugee mothers and different intervention strategies to cope with PPD.

Applying the search strategies in various databases yielded 1,678 articles, and after two levels of screening, 22 studies were included in the review (Fig. 1). In total, 6,998 participants were identified across 20 of the 22 articles. Some articles were not included as they had overlapping patients (n = 2) or because they were not a population-based study (n = 5). Additionally, some studies (n = 5) contained information that did not differentiate between immigrants and refugees, so these participants were not included in the final prevalence count. After applying exclusion criteria, 5,207 refugee, asylum-seeking, and immigrant women were included as participants across 20 studies. Eight studies were deemed appropriate for prevalence calculation with 2,922 refugees and asylum seekers. These studies mainly used the Edinburgh Postnatal Depression Scale (EPDS) diagnostic tool to screen for PPD; however, the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-5 (SCID-5) and Refugee Health Screener-15 (RHS-15) screener methods were also utilised. A score above 4 typically indicates PPD on the EPDS, while on the SCID-5, a score above 10 is indicative of PPD [1]. Only 1 out of the 8 included studies determined prevalence using SCID-5 as a diagnostic tool; the rest used EPDS [9]. RHS-15 was used in a study to determine its efficacy; however, researchers determined that the tool was unreliable, and so the results were excluded from that study [9]. An overview of the characteristics of the included studies is provided in Table 1.

The included studies comprised qualitative studies (n = 5), mixed-method studies (n = 4), and quantitative studies (n = 13). The included qualitative and mixed-method studies were of high quality (online suppl. File 1, Table S2). Their scores ranged from 8 to 10 points out of 10 as evaluated by the Oxford-based Critical Appraisal Skills Program checklist (online suppl. File 1, Table S3). The included quantitative studies were of moderate quality. Using Downs and Black checklist, their scores ranged from 15 to 19 points out of 27. Due to limited evidence, all studies were included despite their quality.

Eight studies (n = 8/22) were selected to calculate prevalence as they contained relevant info regarding the number of refugees, asylum seekers, and immigrants, as well as the number of individuals who screened positive for PPD. The total number of individuals pooled from the 8 studies is 5,207. Of the 5,207 patients, 2,922 were refugees/asylum seekers (56.1%). Out of the 2,922 individuals, 657 were diagnosed with PPD (n = 657/2,922; 22.5% prevalence of PPD). 2,285 people were non-refugees/asylum seekers immigrants (42.9%), of which 400 had PPD (n = 400/2,285; 17.5% prevalence of PPD). EPDS scores range from 0 to 30 with a score of 0–6 indicating no depression or minimal depression, 7–13 indicates mild depression, 14–19 is found in individuals with moderate depression, 19–30 is indicative of severe depression [30]. Participants were diagnosed based on the cut-off used by the researchers in each study. A pooled mean score of EPDS was not calculated as some studies did not differentiate between migrant and refugee women. Pooling the mean EPDS scores of the few studies that did differentiate between migrant groups would have been inaccurate due to the small sample size.

Risk factors that refugee and asylum-seeking women face include domestic abuse, separation and lack of support, stress, pre-migrational experiences, prior history of mental illness, low income, and discrimination (Table 2). All 22 articles had important information about the risk factors that are associated with PPD.

Multiple studies suggested that refugee and asylum-seeking mothers may be more likely to develop PPD due to pre-migration experiences [4]. Refugees and asylum seekers go through an arduous journey to relocate. During their migration, they may experience serious trauma that can increase their risk for PPD and other mental health conditions. Further, after successfully leaving their home countries, refugees and asylum seekers may face stress due to separation from family members, domestic violence, discrimination, and financial difficulties [13].

One study looked at 250 refugees on the Thai-Myanmar border. It was found that some of the main contributors associated with PPD were interpersonal violence (OR 4.5), past trauma (OR 2.4), past depression (OR 2.3), and perceived lack of social support (OR 2.1) [15]. Another study done in Lebanon found that Syrian refugee women were more likely to score higher on the EPDS when married at a young age, when exposed to domestic violence, and when having prior history of other mental illnesses [25].

These results were also observed in qualitative studies where refugees talked about their feelings to researchers. The studies on the Thai-Myanmar border showed that refugee women there experience social stressors that may impact their mental health [7, 9, 15, 21, 23]. Many of these women with PPD expressed that they dealt with stress that was endogenous as well as caused by society. A Canadian study found the refugee status of their participants impacted their mental well-being [14]. Many women felt that they were discriminated against in the healthcare system, citing instances of hostile behaviour and negligence from healthcare professionals at hospitals and clinics [14].

Domestic violence was a common theme observed across some studies [6, 14, 16, 24, 25]. Women described their toxic relationships and how they caused them anxiety, immense stress, and depression – three major symptoms of PPD [14]. Women also cited that being away from their family hindered their ability to cope with their stress and trauma [6, 11, 13–16]. They stated that their family back home would provide support and that being away from them contributed to feelings of isolation and hopelessness. In contrast, some studies mentioned that some women were reluctant to reveal their feelings due to discrimination from family or community members [4, 14, 16, 27, 28]. Financial burden may also have a role in PPD as two studies mentioned that refugees may feel stressed when having to deal with expenses [24, 27]. However, one study found that financial problems were not correlated with EPDS scores [6].

Reported interventions for PPD recovery included support groups, individual support, self-coping mechanisms, and familial support (Table 3). Two studies focused on interventions, while six briefly highlighted coping mechanisms/preventative measures to reduce PPD. The qualitative studies that discussed interventions mentioned how the social determinants of health play a key role in PPD [1, 4, 5, 7, 11, 14, 16, 22]. The two studies emphasise clearing language barriers and being culturally sensitive as interventions to reduce PPD [1, 11, 14]. For instance, Muslim women may be reluctant to seek help from male healthcare professionals as it may be against their personal beliefs [1]. It was found that regular screening for refugees is important as PPD diagnosed early is found to have better outcomes in the long term [16]. Further, language barriers should be considered in diagnostic tests as interpreters must accurately transcribe questions and answers to ensure an accurate diagnosis [4, 11, 13, 14, 27, 29]. Bilingual healthcare providers would be more suitable as some patients feel uncomfortable with the presence of an interpreter [14]. Individual therapy or community-based interventions are recommended as they can be tailored to a patient’s cultural needs. It was found in the study by O’Mahony et al. [14] that refugee women face a unique set of issues, and they may prefer care that is attentive and culturally sensitive. Education is also important as women reported that they felt supported when their loved ones understood their struggles [11, 16]. Across the studies, support was given significant emphasis. Refugee women often felt lonely as they describe how in their home countries, they would have the support of friends and family [1, 4, 5, 7, 11, 14, 16, 22, 26]. In one study, they found that some women felt less isolated when given telephone support, community-based therapy, and individual therapy [11]. Refugee and asylum-seeking women also had their own ways of coping with PPD such as maintaining faith in their religion, spending time with family, self-reflection, keeping busy with work, educating themselves on PPD, and staying active [11, 16, 22, 26].

Based on the prevalence of PPD reported in the literature, PPD is more common in refugees and asylum seekers compared to other migrant groups. The results of this review support previous data that refugee and asylum-seeking women are at a higher risk for PPD than non-migrant women. Approximately 1 in 4 mothers fleeing a country may suffer from mild to severe PPD. Refugees and asylum seekers face stressful circumstances that may make them more likely to develop PPD [4, 11]. In addition, when arriving in a foreign country, separation from family, burden of finances, and dealing with discrimination may exacerbate the development of PPD [11]. The evidence across the included studies indicates that social isolation, domestic violence, and past trauma are issues that refugees and asylum seekers face. These issues may be associated with an increased risk of developing PPD. Due to the stigma associated with mental illness, as well as familial pressure, partner abuse, and language barriers, refugee women with PPD may be less inclined to seek help.

This review indicates that there are a limited number of studies on interventions for refugee and asylum-seeking women with PPD. The studies that did mention interventions had little information on the various components of psychiatric care for migrant women with PPD. Further, based on this review, it has become evident that there are limited data on the effectiveness of interventions for refugees with PPD (reviewer 3). This gap in knowledge needs to be further investigated, as novel treatments are needed to help women who are suffering from PPD. Diagnostic tools need to be further developed, as translations may make scores unreliable and can result in higher false negatives [2, 24]. In addition, increasing cultural awareness can help healthcare providers build rapport, facilitating an environment that allows this patient population to be more open to care [11, 12].

The purpose of this systematic review was to report the prevalence of PPD among refugee women as well as the related risk factors and interventions. A limitation of this review includes heterogeneity in the population. Some studies were not included because their population had overlapping refugee and migrant patients. This limited the sample size and the reliability of the prevalence statistics, making the strength of the effectiveness of these interventions uncertain. Despite this, reports of PPD prevalence, risk factors, and interventions were consistent among the included studies. Therefore, more long-term studies are required to strengthen the understanding of risk factors associated with PPD in refugee and asylum seeker populations. Further, the studies did not specify the details regarding birth order of children and its implications on PPD in refugee women, warranting a need for additional research. Another limitation was the lack of specificity for the rates of PPD in refugees in various host countries, making it difficult to draw conclusions regarding the relationship between PPD and access to care. Although many interventions were reported, their efficacy is yet to be established by randomised controlled trials and observational studies with larger sample sizes. In addition, many predictors and symptoms of PPD found in diagnostic guides were not indicated in the collected studies, highlighting a need for further investigation. To evaluate the efficacy of interventions in treating PPD depression among refugee women and asylum seekers, a meta-analysis can be conducted. This can result in the development of effective maternal programs tailored to improve the mental health and well-being of refugee women.

Given the influx of refugees arriving in developed countries, it is crucial that the implications of PPD are understood. This systematic review has shown that refugee populations have a greater prevalence of PPD relative to non-immigrant mothers. Further, evidence demonstrates that refugee women face a greater number of unique challenges that may predispose them to PPD. Language barriers, isolation, financial issues, and discrimination are some of the problems arriving mothers face. Government agencies need to recognise these problems and come up with novel methods to try and assist refugee women with their mental health. A number of testimonials found in qualitative research suggested that adequate support from family, friends, midwives, and healthcare workers improve symptoms of PPD. It is worth mentioning that some studies consisted of testimonials, and unfortunately, anecdotes are not reliable sources of scientific evidence, so future research should further investigate the benefits of social support in refugee women at risk of PPD. Overall, this review has shown that the social determinants of health play a necessary role in the prognosis of PPD, and it is imperative that healthcare professionals recognise and value the sociological aspects of refugee women’s health.

An ethics statement is not applicable as this review is based on published literature. This systematic review and meta-analysis are based on published research, which complies with internationally accepted standards for research practice and reporting.

The authors have no conflicts of interest to declare.

The authors report that there is no funding associated with the work featured in this article.

K.H. conceived the review, designed the search strategy, and prepared the manuscript. K.H. and L.M. selected the studies. H.A. and K.S. coordinated the contributors. H.A. resolved study selection conflicts and, with M.S.M.-M., designed the analysis. K.H., A.L., K.S., and H.A. contributed to the first draft, data extraction, and data analysis. All authors revised drafts of the manuscript and approved the final manuscript. The corresponding author had full access to all the data in the study and final responsibility for the decision to submit for publication.

There are no data to deposit on a repository. All data produced or analysed in this study are encompassed within this article. Any enquiries can be directed to the corresponding author.