Mental health conditions are the most prevalent disorder among women in the perinatal period, and are a global issue (Fellmeth et al, 2017). Perinatal mental health issues increase morbidity and are the major causes of direct maternal deaths in the UK (Watson et al, 2019; Knight, 2022). The phenomenon adversely effects families and the psychosocial development of offspring, leading to a socio-economic cost on British society of £8.1 billion each year (Bauer et al, 2022).
South Asian women in the UK have elevated risks of developing perinatal mental health issues (Smith et al, 2019) and this has been linked to language barriers, social stigma, isolation, differences in cultural values and poor knowledge and education on perinatal mental health issues (Smith et al, 2019). The higher birth rate among South Asian women compared to the indigenous population and a low female employment rate compared to other ethnicities in the UK have also contributed to higher levels of perinatal mental health issues (Masood et al, 2015).
Perinatal mental health has been a focus of research and policy for many decades. However, this interest has mainly centred around perinatal mental health in large populations (Howard and Khalifeh, 2020) and there has been an under-representation of the concerns and experiences of South Asian women (Sihre et al, 2019). This is specifically the case for Sri Lankan women who have migrated to the UK. The Sri Lankan population in the UK is estimated to be 146 627, and the number of Sri Lankan women with non-British nationality in the UK is estimated to be 19 000 (Office for National Statistics, 2021). The number of Sri Lankan women who give birth in the UK is not known, as this figure is not indicated in the records of live births of non-UK born mothers in the UK.
Language barriers and stigmatisation of perinatal mental health issues in specific societies may have impeded examination of South Asian women's experiences of perinatal mental health issues and their access to health services (Bandyopadhyay et al, 2010; Nilaweera et al, 2014; 2016). Studies carried out with Sri Lankan women have largely included English speaking Sinhalese women in high income countries (Lansakara et al, 2010; Navodani et al, 2019), and it is important to understand that the Sri Lankan community is multi-ethnic and includes populations that speak different languages, such as Tamil, English and Malay (David, 2012).
There is a clear gap in literature to help midwives and other healthcare professionals care for the perinatal mental health needs of English and non-English speaking Sri Lankan women in the UK. Therefore, to improve understanding of perinatal mental health issues for this population, the present study aimed to examine the views and opinions of Sri Lankan women who lived in the UK about perinatal mental health.
Methods
This mixed-methods online survey collected both quantitative and qualitative data simultaneously. These data were analysed separately and synthesised to develop the findings (Creswell and Creswell, 2018). Four South Asian women acted as patient and public involvement and engagement advisors to guide the study's development through feedback on the proposed design, recruitment approach and materials.
Participants
Eligible participants for this study were Sri Lankan women aged 16 years or older living in the UK who were pregnant, had given birth or had a miscarriage or stillbirth in the last 24 months and were literate in English or Sinhalese.
Flyers about the study were placed in local Buddhist temples and Sri Lankan community groups in the UK, and the same information was available on social media (Facebook, Twitter). The flyer contained brief information about the study and a link to the online survey.
The sample size for the study was not pre-determined as this was a small exploratory descriptive study. However, the authors aimed to obtain 50 responses through non-probability sampling. All women who fulfilled the inclusion criteria were eligible to take part and the survey remained open for 6 weeks.
Data collection
An anonymous survey was used for data collection, created using Online Surveys; the survey captured participants' responses to 12 closed and 12 open-ended questions. Creation of the questionnaire was informed by the literature and through consultation with the patient and public involvement and engagement advisors and supervisors. The questionnaire was not validated, although the Flesch (1951) Reading Ease process was used to assess its readability. The lead author is Sri Lankan born Sinhalese and was responsible for translating the questionnaire and materials into Sinhalese. These were then checked by one of the patient and public involvement and engagement advisors, who was fluent both in English and Sinhalese. The responses in Sinhalese were translated into English for analysis by the lead author.
The questionnaire was grouped into four sections: demographic data (Table 1), opinions about perinatal mental health (Table 2), views and opinions of accessing information about perinatal mental health (Table 3) and opinions of accessing support services (Table 4). The survey was advised to be an appropriate data collection method, and was pre-tested by the advisors. The wording of questions and responses was altered accordingly; some wording and imagery on the flyers used for participant recruitment were also amended.
Table 1. Survey questions on demographic data
| Question | Possible responses |
|---|---|
| What is your ethnic background? | SinhaleseTamilMuslimBurgherI prefer not to sayOther |
| What is your age (in years)? | 16–2021–3031–4041–5051 or above |
| What is the highest level of education that you have completed? | PrimarySecondaryVocational trainingDegree level or higher Other (please specify) |
| What is your employment status? | Never workedWorking now, full timeWorking now, part timeOn maternity leaveTemporarily away from workOther |
Table 2. Survey questions on opinons of mental health
| Question | Possible responses |
|---|---|
| Compared to before you were pregnant, how was your mental health during pregnancy? | Much betterBetterAbout the same |
| And how was it after you gave birth/had a miscarriage? | WorseMuch worseNot applicable |
Do you feel the topic of mental health in Sri Lankan women who are pregnant or have just had a baby in the UK should be discussed by the following people:
|
YesNoNot sure |
| Which of the following healthcare professionals asked about your mental health during pregnancy? | General practitionerHealth visitorMidwife |
| Which professionals asked about it after you gave birth/had a miscarriage? | Other (please specify)None |
Table 3. Survey questions on accessing information about mental health during pregnancy or after birth
| Question | Possible responses |
|---|---|
| Which of the following healthcare professionals provided you with information about mental health during pregnancy? | General practitionerHealth visitorMidwifeOther (please specify) |
| Which professionals asked about it after you gave birth/had a miscarriage? | None |
| What information were you provided with? | Free text response |
| If you were provided with information about mental health, how useful was this information to you? | UsefulNot usefulNot sure |
| If it was/was not useful, please say why. | I was not provided with any information |
| Were there any other places that you accessed information about mental health during pregnancy or up to 2 years after birth? | Free text response |
| In your opinion, what would help to improve access to information about mental health for Sri Lankan women? | Free text response |
Table 4. Survey questions on opinions of accessing support services
| Question | Possible responses |
|---|---|
| In your opinion, what would help you to maintain good mental health during pregnancy? | Free text response |
| In your opinion, what would help you to maintain good mental health after giving birth? | Free text response |
| If you needed mental health support during pregnancy, were you able to access it? | I did not need to access support. |
| And after giving birth/having a miscarriage? | I was able to access support.I needed to access support but was not able to. |
| If you were not able to access support, please explain why. | Free text response |
| If you did access support, please explain what kind of support you accessed. | Free text response |
| Were you satisfied with the support for mental health you accessed during pregnancy? | And after birth/having a miscarriage?Yes it was helpfulNo it was unhelpfulNot sure |
| If you found it helpful or unhelpful, please explain why | Free text response |
| What could have made this support better? | Free text response |
| What could have made this support better? | Free text response |
| In your opinion, what issues may Sri Lankan women in the UK who are pregnancy or have given birth face when accessing mental health support? | Free text response |
The literature (Dörnyei, 2007; Dewaele, 2018) suggests that an anonymous online survey can elicit honest and less inhibited information from participants around what could be perceived as a sensitive topic. Data were collected between the 3 August and 17 September 2021.
Data analysis
Quantitative responses from the online survey were transferred to an Excel database and analysed using frequencies and percentages. Sub-group analysis was not conducted because of the small sample size and variability within respondent characteristics.
The open text qualitative data were analysed using content analysis with a directed approach (Hsieh and Shannon, 2005). The initial inductive coding of data was conducted by one of the researchers, and the coding and allocated codes were examined independently by two other researchers. Any discrepancies or queries in interpretation were discussed at length and consensus reached. The coded data were then organised according to the broad areas of interest of the questionnaire.
Qualitative and quantitative data, collected concurrently, were merged and interpreted using a convergent mixed method framework (Creswell and Creswell, 2018). In this way, key characteristics and themes emerged.
Ethical considerations
The research project was approved by the Health Research Ethics Committee of Edge Hill University (reference number: ETH2021-0191). Key information about the study was given at the beginning of the survey and consent was assumed by submission (Ennis and Wykes, 2016). Participants were given the option to skip questions if they found them upsetting. Support links were provided at the end of the survey to signpost women who believed they had perinatal mental health concerns to appropriate support. The participants' responses were anonymised.
Results
In total, 34 responses were received, 30 submitted in English and four in Sinhalese. Of these, 15 women (44.1%) identified that they had given birth, eight (23.5%) were pregnant, three (8.8%) had experienced a miscarriage and one (2.9%) had experienced a stillbirth during the last 24 months. As shown in Table 5, the majority of respondents were Sinhalese women (73.5%), who were 31–40 years old (55.9%) and educated to degree level or higher (61.8%).
Table 5. Participants' characteristics
| Characteristic | Frequency, n=34 (%) | |
|---|---|---|
| Ethnicity | Sinhalese | 25 (73.5) |
| Tamil | 3 (8.8) | |
| Muslim | 2 (5.9) | |
| Burgher | 2 (5.9) | |
| Age (years) | 21–30 | 8 (23.5) |
| 31–40 | 19 (55.9) | |
| 41–50 | 3 (8.8) | |
| ≥50 | 2 (5.9) | |
| Education | Primary | 1 (2.9) |
| Secondary | 9 (26.5) | |
| Degree or higher | 21 (61.8) | |
| Vocational training | 1 (2.9) | |
| Employment | Never worked | 4 (11.8) |
| Working full time | 6 (17.6) | |
| Working part time | 7 (20.6) | |
| On maternity leave | 5 (14.7) | |
| Temporarily away from work | 10 (29.4) |
The findings are presented according to the main themes, which were developed through synthesis of quantitative and qualitative data. These themes are perception of the importance of perinatal mental health, accessing information about perinatal mental health, access to professional and non-professional support and sharing emotions about perinatal mental health.
Perception of the importance of perinatal mental health
Participants who responded to the question about their own perinatal mental health (n=31) identified that their mental health had stayed the same (35.3%) or improved (29.4%) over the perinatal period. Nine participants reported that their mental health was worse or much worse during the perinatal stage.
When asked about who mental health should be discussed with, the participants responses included their partner (76.5%), families (58.8%) or friends (47.1%).
Accessing information about perinatal mental health
The participants were asked to report if they had received information about perinatal mental health; 64.7% reported receiving information from a healthcare professional, while 35.3% had not received any information through health services during the perinatal stage. The participants reported that, of the healthcare professionals they had seen, midwives had the most involvement in providing information (41.2% during pregnancy and 26.5% after birth), followed by health visitors (23.5% during pregnancy and 35.3% after birth).
Of those who received perinatal mental health information, 32.4% found the information they received useful. Nine participants of the 11 who provided additional information in the open text space reported that information was useful to help increase awareness of perinatal mental health and that receiving information encouraged them to speak more about the topic.
‘Though I have not used the services they have recommended, I was pleased to know that my mental condition was recognised and that encourages me to access services if I ever needed’.
R-11
When participants were asked how access to formal information could be improved, nine emphasised that there was a need to make Sri Lankan women aware of perinatal mental health support services by making information available in a range of formats, in addition to the provision of booklets. The role of midwives in the provision of information was emphasised by four of the participants.
‘Women should be given information at antenatal clinics, and this information should be well explained by the midwife’.
R-14
Access to professional and non-professional support
The participants were asked what factors they thought contributed to good perinatal mental health. Emphasis on family support was highlighted by many of the respondents (52.9%).
‘Based on my experience of going through postnatal depression, my opinion is that it is good to have parents around and get emotional support through them’.
R-13
Many participants (64.7%) reported that they did not need to access professional support for perinatal mental health, with only a small proportion (23.5%) reporting that they had accessed support. Four participants identified that they had not been able to access support when they had needed it. When asked what could improve professional perinatal mental health support, five participants reported that professionals needed to tailor support for individual needs.
‘Frequent contacts from the midwives, and provide extra support for women who did not receive any help’.
R-6
Sharing emotions about perinatal mental health
The participants explained that sharing emotions with family and friends was important to them. Some provided an additional explanation as open text that sharing feelings with their primary social group could help to overcome emotional stress.
‘Sharing emotions helps me to release tensions in my mind, and it also helps me to improve better communication with my family. Also, my distress could be easily understood by my family and friends’.
R-10
Over a third of the participants (35.3%) reported barriers to sharing emotions and accessing support, and these included difficulties in accepting perinatal mental health issues in Sri Lankan cultures because of social stigma, and that this can prevent women from accessing support for perinatal mental health issues.
‘Mental health is such a pivotal part in a woman, whether they have had a pregnancy or not. It is less well discussed in our own country because of age-old taboos. However, in a nation where mental health plays a key role in societal wellbeing, we should take the opportunity to discuss our own mental health and promote this back home in Sri Lanka as well’.
R-16
Discussion
This study examined the views and opinions of Sri Lankan women living in the UK about perinatal mental health. To the authors' knowledge, this was the first study to focus on perinatal mental health issues and Sri Lankan women in the UK. The survey findings mirrored similar reports of worsening mental health during the perinatal stage, as shown in larger studies (Insan et al, 2020; Palfreyman, 2021) and indicated that perinatal mental health issues may differ across Sri Lankan ethnic minorities (Tamil, Muslim, Sinhalese and Burgher). These cultural differences have been highlighted in previous work by Beiser et al (2015) and Kanagaratnem et al (2020), who showed a higher incidence of depression, anxiety disorders and post-traumatic stress disorders in Sri Lankan Tamil refugees residing in Canada. However, these studies did not predominantly focus on perinatal women. While there is developing evidence to show that tensions exist in the provision of perinatal mental health services to women from other cultures in the UK (Smith et al, 2019; Watson et al, 2019; Jankovic et al, 2020), the specific needs and concerns of Sri Lankan women are less well known.
The respondents in this study who received information from midwives and healthcare professionals reported this was useful in increasing awareness about perinatal mental health, and such information encouraged them to speak about perinatal mental health. According to Hapangama (2021), perinatal mental health services remain largely neglected in Sri Lankan healthcare systems and have been given wider recognition in the British healthcare system, creating potentially different expectations around perinatal mental health information and support. While written leaflets can be a useful tool to share information, the present study's participants stated that the information would have been more useful in different formats, including verbal and by signposting to other services. Similar concerns have been previously identified by Noonan et al (2017) and Pinar et al (2022), who highlighted that despite readable information being routinely provided, it was less common for midwives to offer practical support and signpost women to appropriate support.
In the present study, there was a strong emphasis on relying on non-professional support from family and friends for mental health issues during the perinatal stage. This reliance on family seems to reflect Sri Lankan tradition, where a new mother's family is expected to provide guidance, care and support throughout the perinatal period (Lansakara et al, 2010; Nilaweera et al, 2016; Kandasamy et al, 2020). Women divulging feelings and psychological concerns with someone outside their primary social groups (eg family and friends) is often considered unacceptable in South Asian societies (Prajapati and Liebling, 2022). A systematic review by McCarthy et al (2021) on experiences and perception of anxiety and stress during the perinatal period among women in general further recognised the importance of sharing emotions between close social networks and identified that the understanding behaviour of a partner, family and friends significantly reduced women's stress and anxiety during the perinatal period.
A dominant barrier in sharing emotional stress and perinatal mental health issues was attributed to the social stigma surrounding mental health among Sri Lankan society. This may help to explain why 718 women accessed this survey but only 34 took part. Similar barriers were identified by a cross-sectional survey study on stigma and perception of postpartum depression in a rural suburb in Sri Lanka (Amarasinghe et al, 2019). The majority of women (61%) strongly believed that they were not susceptible to perinatal mental health issues and normalised symptoms of postpartum depression (56%) and suicidal ideation (50%). Similarly, the study identified that some women (18%) did not wish to be friends with an affected women because of stigma in Sri Lankan society (Amarasinghe et al, 2019).
Strengths and limitations
The strengths of the study include that the surveys were translated into Sinhalese and therefore this research was able to approach ‘less heard’ Sri Lankan women in the UK. By conducting an anonymous online survey, the identity of the participants was protected, which aimed to facilitate reporting honest feelings and opinions. A further strength was the patient and public involvement and engagement consultation with Sri Lankan advisors to inform the development of the study.
However, the study sample was small and therefore findings cannot be generalised. Women who participated were asked to encourage others in their networks to take part, and the snowball sample may have created a self-selecting bias. Furthermore, the survey was only available to women who could read English and Sinhalese, and was not translated into Tamil or Malay, and could only be accessed through the internet, requiring participants to be computer literate and have internet access, which may have limited survey respondents.
Conclusions
This study identified that some Sri Lankan women did not receive any information about perinatal mental health issues, despite identifying that their perinatal mental health had worsened. Participants identified the need for information to be shared verbally as well as in written format and include signposting. Midwives need to ensure that perinatal mental health is discussed sensitively with all Sri Lankan women, recognising that the subject can be taboo in Sri Lankan culture. Any healthcare interactions or information provision needs to recognise the important role of family members and partners in the support of women's perinatal mental health in Sri Lankan societies.
Future quantitative research related to Sri Lankan women in the UK needs to examine if tools to detect perinatal mental health issues are culturally sensitive and qualitative research needs to include partners, families and offspring to explore how best to care for this population during the perinatal stage.
Key points
- One in four Sri Lankan women reported that they had mental health issues during the perinatal period.
- One in three Sri Lankan women reported not receiving any formal or informal information about perinatal mental health issues.
- Midwives and other healthcare professionals need to ask all Sri Lankan women about perinatal mental health issues and make efforts to increase verbal explanations and signposts.
- Sri Lankan women in the UK are more reliant on non-professional support received from primary social groups.
- Sharing emotions during the perinatal stage was important to women, but social stigma was identified as a dominant barrier to sharing.
CPD reflective questions
- How would you open up sensitive conversations with Sri Lankan women in the perinatal stage about mental health issues?
- What information is available to share with Sri Lankan women about perinatal mental health issues?
- How would you signpost a woman to other healthcare professionals if they disclosed or shared perinatal mental health issues?