Women and Birth 33 (2020) 479–489

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Women and Birth

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Indian migrant women’s experiences of motherhood and postnatal

support in Australia: A qualitative study
Vibhuti Samarth Raoa,* , Hannah G. Dahlenb , Husna Razeec
a
School of Public Health & Community Medicine, University of New South Wales, Gate 11, Botany Street, Randwick, NSW 2052, Australia
b
School of Nursing and Midwifery, University of Western Sydney, Building EB/LG Room 34, Parramatta South Campus, NSW, Australia
c
School of Public Health & Community Medicine, University of New South Wales, Gate 11, Botany Street, Randwick, NSW, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Background: The postpartum period can be challenging for many women. For migrant women, the arrival
Received 11 April 2019 of a new baby brings unique issues. This study aimed to explore the experiences of motherhood and
Received in revised form 16 August 2019 postpartum support of Indian migrant mothers.
Accepted 23 September 2019
Methods: A qualitative descriptive naturalist inquiry was adopted, with data collected through face-to-face,
semi-structured, in-depth interviews with a purposive sample of 11 English speaking Indian migrant
Keywords: women over 18 years old, (6 weeks to 6 months postpartum) in 2016. The data were thematically analysed.
Indian
Findings: Four themes were found in this study: the role of social support in postpartum care, support from
Australia
Immigrant
health services, a psycho-emotional journey with socio-cultural expectations and struggling to bridge two
Postpartum cultures. Many of the women felt alone and were distressed with undertaking household duties and caring
Mental health for older children, as this would not have happened in India. The women expressed needing practical
Midwifery support support until they settled back into their normal lives. Women never sought professional advice for their
ongoing mental health concerns. Conflicting advice from health professionals left some women confused
about their expectations of traditional and modern postnatal care.
Conclusion: This study gives a unique insight into the experiences of Indian migrant women following birth.
There is a need for culturally sensitive and appropriate postnatal services that encourage Indian men to
support their partners and help women to find alternative sources of culturally appropriate support. It is
vital that mental health support is a key component of any such program of care.
© 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

issues and the ability of women to mobilize support from

Statement of significance
Problem or issue
Indian women can experience poor maternal mental health
when migrating to a developed country. The struggle of fitting
into the western way of motherhood, lack of extended family
support and a lack of familiarity with the maternity system can
impact on these mothers in the postpartum period.
What is already known
Indian women tend to be reluctant to speak about mental
health problems outside of close family. There are various
programs to support culturally and linguistically diverse
people in Australia.
What this paper adds
This study highlights the significant gap in the literature in
this area, while highlighting the struggle of adaptation to a
new birthing culture. Beliefs about postnatal mental health
* Corresponding author at: 20 Folingsby Street, Weston, ACT-2611, Australia.
E-mail address: 19859167@student.westernsydney.edu.au (V.S. Rao).
their husbands in absence of other social support have a
significant impact. While women get support from midwives
this is for only a short time period.
1. Introduction
The postpartum period is a vulnerable time for many women.
The joy of motherhood can be mixed with feelings of isolation and
distress. This may have an impact on women’s mental health,
especially if previous mental health issues have existed before the
birth.1 For migrant mothers, the postnatal period brings unique
pressures and needs that are informed by language barriers,
communication issues, socio-cultural beliefs, expectations and
behaviors, and poor engagement with health services which may
influence these women’s help-seeking behavior.2,3 Literature
suggests that migrant mothers are more vulnerable to postpartum
mood disorders, particularly depression, compared to mothers

http://dx.doi.org/10.1016/j.wombi.2019.09.006
1871-5192/© 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

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480 V.S. Rao et al. / Women and Birth 33 (2020) 479–489
who were born in the country they live in.4 Socio-cultural
displacement and lack of support and resources are the main
factors.5 Many women may remain undiagnosed due to stigma and
language barriers.6
Mental health issues experienced by childbearing women are
known to impact on morbidity and mortality rates amongst
women in the year following birth.7 Failure to recognise and
receive professional help for ongoing postnatal depression has an
adverse impact on migrant women’s well-being.8 This in turn can
have an adverse influence on the emotional and socio-psychologi-
cal development of their children.9 This, promotion of positive
postpartum mental health of migrant women in developed
countries is of public health importance, and inattention to such
issues can have serious consequences.
Almost 29% of the Australian population is made up of migrants
who come from diverse cultural and ethnic groups.10 Migrant
mothers in Australia continue to experience poor postnatal mental
health compared to Australian born women despite efforts in
improving maternity services.11 Population based surveys in
Australia have provided inconsistent findings regarding satisfac-
tion level with maternity care among migrant populations.12–14
Cross-cultural studies among Australian migrant populations
highlight the unaddressed postpartum needs of these mothers
and moreover, they are expected to comply with the Western
model of maternity care.15–17 Migrant mothers experiencing poor
postpartum health are unlikely to be involved in making choices
about their health care.17 Therefore, it is essential to explore the
factors that influence postpartum experiences of migrant women
from different cultural backgrounds and understand their needs
and expectations in order to provide culturally competent care.
People born in India are the leading migrant group to come to
Australia.10 The number of Indian-born women giving birth in
Australia has significantly increased in the last decade from 5% in
2007 to 14.1% in 2017, surpassing those from New Zealand and the
United Kingdom (UK).18,19 Among Indian communities, a postnatal
period has cultural and social significance for new mothers, their
family and community.20,21 Traditionally, Indian societies consider
the postnatal depressive or ‘low moods' as usual and not a
significant psychological problem.22 Consequently, they are not
inclined to seek professional help for their poor postnatal mental
health. Mental health is a taboo among Asian-Indian communities,
primarily because of their superstitious beliefs surrounding
mental illness and the desire to keep such issues within the
family.23
Women born in India also have some of the highest intervention
rates in birth compared to Australian born women and other
migrant groups living in Australia24 and this can have a significant
impact on women’s wellbeing in the postnatal period. Australian
research has also indicated low reporting of psychosocial
vulnerabilities, such as mental health issues for Indian women,
and researchers question whether this is a true picture of risk.25
Although both the Australian-born and migrant women face
similar postpartum difficulties, such as extreme tiredness/exhaus-
tion, back pain, breast issues and relationship issues,15,26 migrant
women are more likely to experience loneliness and depressive
symptoms compared with Australian-born women, as they face
additional challenges of language barriers, cross-culture commu-
nication, understanding health care practices in Australia and
inability to discuss emotional and cultural support, and family
relationships.15,27
Further, several risk factors such as social isolation, the birth of a
female baby, poor relationship with a partner, are known to have
an adverse influence on the mental wellbeing of Indian women.28
Hence, it is likely that in most cases, Indian immigrant women’s
postpartum psychological health goes undiagnosed, unrecognised,
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and therefore untreated. This could severely affect their mental
health, and not least, the wellbeing of the whole family.
A literature review from 2014 highlighted the significant gap in
the literature exploring Indian women’s birthing experiences in
Australia.29 A systematic review suggested the importance of
exploring the postpartum experiences of different ethnic groups
and understanding the factors influencing the postpartum health
of migrant women in order to overcome cultural differences in
delivering quality of care.30 Despite being one of the fastest
growing migrant groups within Australia, the postpartum expe-
riences of Indian mothers living in Australia has not been explored
yet. Therefore, the aim of this study was to explore experiences of
motherhood and postpartum support of Indian migrant mothers.
This may further help health care providers to identify specific
postpartum health needs and socio-cultural barriers and explore
postnatal models of care that could contribute to promoting their
postnatal mental wellbeing.
2. Methodology
This study was undertaken in 2016. It is a qualitative study
aiming to understand individual experiences and views. Therefore,
considering the sociocultural paradigms of this study, we used a
qualitative descriptive naturalist inquiry approach. Naturalistic
inquiry aims to understand the meaning of women’s postpartum
experiences in a natural setting in the socio-cultural context. This
encourages the understanding of multiple truths behind a context
and the need to represent it as a whole with low degree of
manipulation.31
2.1. Study setting
The study was conducted among migrant Indian women in
Canberra, Australia. Canberra is home to many Australian migrants
especially Indian born.32 The majority are skilled professionals
who migrated for better job opportunities and quality of life,
leaving families behind in India.33
2.2. Study participants
Participants were Indian migrant women living in Canberra.
Participants diagnosed with any mental illness including postnatal
depression were excluded as we wanted to focus on women who
were well and not in need of additional specialist services after the
birth. This would enable us to focus on these culturally isolated
women who are dealing with everyday postnatal challenges that
most women experience but focus on the unique experiences of
being Indian. Inclusion criteria were as follows:
 aged 18 years or above
 born in India and migrated to Australia, either from India or other
countries in the last ten years
 currently living in Canberra
 spoke English fluently
 gave birth in Canberra and were 6 weeks to 6 months
postpartum
2.3. Sampling and recruitment
We used purposive sampling to recruit participants.34 Snowball
sampling was used to further reach out to mothers who are in the
similar situations due to the community links these women may
have. We asked the participants if they knew someone who could
meet the eligibility criteria and would be interested in
 V.S. Rao et al. / Women and Birth 33 (2020) 479–489 481

participating in the study.35 Participant recruitment ceased once
we reached data saturation as this was when no new themes
emerged.36
Two Canberra based Indian community organisations: Karna-
taka Association of Canberra and a local multicultural Radio
Channel associated with Hindi Samaj of Canberra helped to recruit
the participants for the study. These organisations circulated the
study advertisement and a letter to members through online
newsletters and social media. We also advertised the study,
including the contact details of the researcher in the weekly Indian
program on a local radio station. On receiving verbal consent from
the potential participants, we emailed them a Participant
Information and Consent Form (PICF) and arranged the interviews.
2.4. Ethics
The Human Research Ethics Committee, UNSW Australia
granted the ethics approval (approval number HC16030) on
9thMarch 2016. Before conducting interviews, the participants
were required to read and sign the PICF. Confidentiality was
maintained during the study.
2.5. Reflexivity
The first author is an Indian migrant woman living in Australia
and she collected the data. However, the participants did not
previously know the first author. Being an insider, the first author
found it easy to connect with some of the cultural issues being
raised by the Indian women. However, most of the participants had
migrated from different parts of India to the first author and held
different cultural values to the postpartum care. This supported the
first author to negotiate a balancing path of an insider and outsider
when reflecting on the meanings of the participant’s experiences.
Regular reflecting of thoughts and assumptions regarding the data
with the third study researcher (who is not Indian) helped to keep
perspective on the issues being raised and ensure what the women
said was being heard and interpreted correctly. The Second author
has undertaken research on Indian women’s psychosocial screen-
ing, interventions in birth and mental health but she is also not
Indian. This helped in true interpretation of the data.
2.6. Data collection
Semi-structured interviews in English were carried out with
eleven participants in their homes. Before starting the formal
interview, demographic data were collected. Interviews lasted
40–60 min and were recorded on a digital recorder with the
participant’s consent. Written field notes were taken throughout
the process. Participants signed the PICF and were informed that
they could withdraw their participation at any stage of the study.
The interview topics (Table 1) were developed in consultation with
the third author who is an experienced qualitative researcher. To
protect participant’s identity pseudonyms were used and other
identifying information was omitted from the reported data. At the
end of the interview, the researcher encouraged the participants to
contact their health professionals if they felt distressed.
2.7. Data analysis methods
Using Braun and Clarke's method, the data was thematically
analysed37 Renner, M. and E. Taylor-Powell, Analyzing qualitative
data. Programme Development & Evaluation, University of
Wisconsin-Extension Cooperative Extension, 2003. Each interview
was summarised after multiple readings. Initial concepts and
themes were summarised and topics for exploration in subsequent
interviews were also noted. During the analysis process, there was
regular discussion between the two researchers, which helped to
understand the participant's true meaning related to the event and
avoid the influence of the researcher's own internal beliefs and
ideations.
Once all the interviews and field notes were transcribed, initial
concepts were derived after several extensive readings of the
transcript. The transcript that was most typical and the one that
seemed most different were first selected and manually coded by
the first author, who looked for the uniqueness of each transcript to
understand the participant’s experiences within socio-cultural
dynamics, traditional values and their understanding of postnatal
mental health. In consultation with the third author, each
transcript was discussed, definitions were assigned, and coherent
categories were formed.38 The categories were reviewed to explore
data patterns and themes were generated through discussions
between the researchers. Themes were further revised and
checked as an entire data set to confirm the relationship between
the category and theme and subthemes.
3. Findings
3.1. Participants characteristics
Eleven Indian immigrant women aged between 28 to 38 years
participated in this study. All women had lived in India and
married Australian-resident Indian men before migrating to
Australia. Seven women had arrived in the past five years while
the other four migrated in the last five to ten years. All women had
a tertiary qualification. Nine out of eleven women were in paid
employment, and the other two were self-employed. Of eleven
women six had been diagnosed with gestational diabetes. Women
were in their postnatal period ranging from six weeks to six
months and had between one and three children. Table 2 reflects
the women’s demographic characteristics.
3.2. Thematic findings
Four themes emerged from the data and these included: role of
social support in postpartum care, support from health services, a
psycho-emotional journey within socio-cultural expectations, and
struggling to bridge two cultures. Each theme had several sub
themes which are explained in Table 3.

Table 1
List of significant interview topics.

Discussion about family and family members

Discussion about the recent pregnancy
Experiences with the health services in Canberra following the birth
Experiences during the postnatal period concerning emotional and psychological wellbeing
Support system immediately after the birth of a baby from various social networks
Influence of postnatal cultural practices (if any) on mental well-being
What worked or did not work during the postnatal period
Participants’ views of what helps Indian women to maintain their mental health during the postnatal period
Challenges that Indian women face during the postnatal periods that may contribute to poor mental health

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482 V.S. Rao et al. / Women and Birth 33 (2020) 479–489

Table 2
Characteristics of Indian immigrant women at the time of interview.

Demographics Sub-demographics title Number of participants

Migration Last 5 years 7
Last 5–10 years 4
Family support Nuclear family 9
Living with extended family 2
Education levels Bachelor degree 4
Master degree and above 7
Employment status Paid job 9
Self-employed 2
Unemployed 0
Occupation Public Servant 7
Community services 2
Other 2
Number of children (including recent birth) First-time mothers 2
Two children 8
Three or more children 1
Birthing mode Instrumental birth 2
Normal spontaneous 3
C-section 6
Antenatal health issues Gestational diabetes 6
None 5
Age of the newborn (at the time of interview) 6 weeks 1
6 to 12 weeks 2
13 to 20 weeks 5
21 to 24 weeks 3

3.2.1. Theme 1: role of social support in postpartum care
The theme social support in the year following birth captured
both practical and emotional support provided by family members
and friends. Women highlighted importance of family, friends and
health caregiver’s support for a smooth transition to motherhood.
Most women were second-time mothers living with their husband
and children, and their narratives were focused on feelings of
constant worry and guilt due to concerns they would have poor
bonding with their older child as they were busy looking after the
newborn baby. They were also concerned they would not be able to
meet household needs. As noted by the women there were many
opportunities for their extended family members, husbands and
close friends to support and encourage the postpartum recovery.
3.2.1.1. Extended family support is essential and culturally
expected. Extended family members, particularly the women’s
mothers, often travelled from India to provide much-needed
support such as “taking care of the elder and younger one and the
house”, especially when the “husband has been pretty busy”. Such
support enabled them to recover faster, “spend quality time with the
newborn” and provided an opportunity to socialise, which made a
"big difference in their physical and emotional wellbeing".
For women who faced pregnancy related complications such as
gestational diabetes or birthing through caesarean section, family
support was the pillar of strength and they were able to overcome
all the difficulties (to manage household duties, to get enough rest
and have a nutritious diet) during the birthing process and early
postpartum care. Having family support was a ‘feel good factor’
during the postpartum period and one woman stated about her
family support ‘I don’t know how we would have done without her’.
I am a very emotional, family-oriented person. So having people
around me is like more than anything for me. There were people
to talk to like mum and dad were around to do all the other stuff
at home. So I didn’t have to bother about cooking or doing other
things or washing. Even they did the washing. So my whole
focus was looking after the baby. And that’s what you need. You
need time to look after your newborn, which is like a fair bit of a
deal. You don’t get time to do anything other than that. I had to
squeeze in my stuff in between all that. I think if you have a good
support system around you, that’s what is, what’s more
important and that’s what you need more. I think basically
having family around and help from them was the main deal.
(Priya - first time mother).
When the support person (mother or mother in law or aunt)
departed and the husband started going back to work, women
expressed being in shock and felt an overwhelming sense of stress
in being left alone to manage on their own and transition from a
well-supported environment to an unsupportive one.
My aunt in law was going to leave. This was going to be a bit
challenging because my daughter was starting school and I had
this one (second child), and he had some medical issues as well. I
was a bit overwhelmed because of his sleep and look after the
house, look after my daughter; there is school, make sure she gets
enough attention. I have got a newborn to look after. I would be
like completely tired cooking and washing up and then changing
him and bathing him. He had medical appointments and then
(it is the) time for my daughter's school pickups. It was just getting
too much. (Indu-second time mother).
Indus’s statement portrays the constant struggle to meet the
cultural expectations immediately after having a baby in the
absence of extended family support. This reduces the opportunity
for these women to focus on their postpartum recovery which can
affect their own and their newborn’s wellbeing and is their cultural
expectation. Women clearly stated that having extended family
support until the mother settles back into her usual routine would
most likely lessen the difficulties.
3.2.1.2. Needing a hands on husband. Although happy with the
emotional support from their husbands (all women were married
and hence this term is used), women wanted their husbands "to be
hands-on things", "look after the older one" and support them in the
household chores, particularly in the absence of extended family
support. However, women whose husbands did not understand the
postpartum needs felt less supported and struggled to cope with
ongoing household demands. Even if partners were supportive of
the women, limited paternity leave prevented more extended
support. Nimmi, was satisfied with the support from her husband
who is a medical doctor by profession and understood her health
needs.

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 V.S. Rao et al. / Women and Birth 33 (2020) 479–489
Table 3
Grouping of codes and categories under theme.
Themes Sub themes
Role of social support in Extended family support is
postpartum care essential and culturally
expected
Needing a hands on husband
Friends have limitations but
may have an essential role
Support from health services Private versus public health
care
Support from Midwife
A psycho-emotional journey Socialization, independence
within socio-cultural and needing time off
expectations
Expectations of giving birth to a
male baby
Reluctance in acknowledging
mental health concerns
Struggling to bridge two Conflicted roles and
cultures expectations
Traditional Postpartum
practices
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483
Concepts
Overseas visit from the family
Mostly mother or mother-in-law travelling for the support
Shouldering the workload of the new mother
Providing essential postpartum care of baby and the mother
Help in practical household chores
Caring for older children
Women travelling to India to receive the necessary support
The prime support person in the new country
Increased expectations of husbands in postpartum period
Absence of other extended family support
Changed roles of Indian husbands in Australia
Dependency on husband following birth
Need of practical Support – cooking cleaning, paying bills, driving the woman around,
taking for health appointments, and caring for the older child (Indian husbands don’t
traditionally do this)
Early days struggles in the absence of familiar community support-talking with friends
helps
Practical support with other child/children helps- playgroup/night outs
They cannot be available all the time
Not much expected from them
Going out for coffee with other Indian mothers
Sharing feelings with other Indian neighbors who are in similar situations helps
Professional health services
Better than India
Focus on emotional wellbeing too
Public system can be difficult- several limitations
Less staffed, unavailability, inconsistent advices
Excellent private care model
Women want to have a normal birth
Normal birth is painful but recovery is faster
Good orientation to Australian models of care is required
Information needed about benefits and harms of normal birth or surgical birth
What to be expected during the birth for mothers is important
Even second time mothers need similar support as first time mothers
Every birth is different and unique
Preference for midwife led care program in Canberra
Midwives are professional and caring
Emotional support from midwives valued
Midwives can be a support person for women who do not get family support or emotional
support from husband
Having a good midwife is ‘luck’
Importance of seeing one midwife throughout pregnancy and birth of the baby
Relationship with midwife influences emotional wellbeing of the mothers
Keeping feelings inside to show you are a strong woman
Some time off helps women
Going out helps
Talking to people and sharing helps
Preference to have a male baby
Gender of the baby may not matter in the western country but for Indians it does
Male baby will carry the generations forward
Pressure to have more babies until the birth of the male baby
Low moods and unsatisfactory feelings when women do not have a male baby
Strange new feelings
No reason for these low feelings
Cannot share feelings with health professionals.
Hormonal effect
Normal feelings after birth
The low mods are temporary
Cry alone and complain of physical hardship
Role of Indian women in the western country
Expectations to be Indian even after migration
Housemaker and income earner
Expectations to manage things on own and multitask also as other Indian women do in India
Not mandatory to follow postpartum cultural practices in the western country
Depends upon how cultural practices are enforced by elders.
Scientific reasoning of postpartum traditional practices
A few are good and a few do not make sense
Generally good for a healthy baby and mother
Need support to follow such traditions
Requires lots of preparation
Did not follow as no support available
Conflict between modern and traditional practices and advices
484 V.S. Rao et al. / Women and Birth 33 (2020) 479–489
He does understand about post-natal depression. Even though, I
did not have (postnatal depression), because, I had too many
people in (the) house to interact (had mother in law’s support).
But he made sure that I listen to music or I lie down myself for a
few minutes, not thinking about anything else but myself,
or watch a movie and that would relax me. So I think he tried
to help me emotionally, physically and that was good.
(Nimmi-second time mother)
Other women who did not have extended family support
expected their husband to offer them support and help them cope
with their postpartum needs, which is uncommon in Indian
culture. Nevertheless, the women in the study expected a change in
traditional roles.
My husband is pretty good, hands-on when it comes to looking
after the kids. So he gets home and pretty much looks after the
older one-bathing her, putting her to sleep, makes sure she
finishes dinner. (Indu-second time mother)
3.2.1.3. Friends have limitations but may have an essential role. As
migrants, having support from their Indian friends was seen as “big
factor of the Indian community’’. Most women recognised that
friends could only provide limited support in duration and
frequency, however it was seen as necessary support. Moreover,
they did not "expect friends to do anything or didn’t expect much help
from them”. They shared their difficulties of motherhood only with
their close friends, and such sharing helped them feel better.
While they shared day to day struggles of taking care of the
newborn baby and other household chores, they were unable to
talk about their distress and deep feelings. Sheena, a government
employee, spoke of how "positive friends make much change”. She
was a first-time mother with no extended family but had a friendly
neighbor to talk to. Sheena's experience suggests the need of
having a formal postnatal Indian mother’s groups to enable sharing
experiences among mothers with similar cultural values.
I felt friends, especially me and my neighbor, both around the
same time we use to have similar talks, what happens to me,
what happen to you, what you are planning to do. What am I
planning to do and thing? It helps a lot. That helped me a lot. Go
around with friends, whom you think are positive. Positive
friends make a lot of change, makes a lot of difference, going
around with people you like, people who you think like minded
going out coffee with them. (Sheena- second time mother)
The women who were interviewed suggested where there are
no extended family members, having Indian friends or a
community of people who are in the similar situations was
important in supporting postpartum mental and emotional well-
being. However, there was no formal postnatal Indian mother’s
group available in Canberra for these mothers to socialise in.
Recent migrant mothers appeared to seek their social support from
their work colleagues or husband’s social network.
3.2.2. Theme 2: support from health services
Overall, women received satisfactory health services from the
hospitals. They talked about their experiences with public and
private health care. Women had limited interaction with the health
services after they left hospital. Therefore, their postpartum
experiences with health services were primarily driven by their
experiences during the birthing process. The women did report
inconsistent advice from health care providers regarding mode of
birth and postpartum diet.
3.2.2.1. Private versus public health care. Women believed that
private health care is the best for them, especially if they had
pregnancy complications such as gestational diabetes or if they
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opted for elective C-section. They believed that “they can get the
best care available and their decision will be respected there”. A few
women who received care from public health care raised issues
such as differing views between the doctors, lack of accountability,
‘impersonalized care” and “shortage of staff and theaters during public
holidays’. Moreover, continuity of care was considered a major
issue when “you do not have one doctor to see” “everyone gives you a
different opinion", which was particularly frustrating for Sammy.
I had the public system. It’s really hard because everyone
gives you different opinion in terms of doctors and because
you don’t have one doctor for your entire care. You see
whoever is on that day on duty (nurses or doctors). So that
nurse will tell you something, and then the next day someone
else will come and they will say, “Oh why don’t you opt for
cesarean?” Then another nurse will be like, “Never do a
cesarean. You should never ask for that.” So there is, there are
always different opinions. And if they don’t have enough staff
they will say, “We will do it (birthing) tomorrow morning.” So
they keep lagging it off which irritated me. And there was no
one talks to you. I kind of felt there was no accountability. If
you are a private patient, doctors’ say- this is my patient so I
am accountable for my patient. Anything goes wrong; it’s
that entire doctor’s responsibility. Private doctors want the
best for their patient and so they will do everything for them.
(Sammy -first time mother)
3.2.2.2. Support from midwife. Support from the midwife was vital
for these women who had no family support or limited social
connections, or were at home alone. The relationship between the
midwife and the woman provided emotional care during the
birthing process. Four women out of eleven of the women had one
midwife throughout their pregnancy and birth and they felt
emotionally supported. They appreciated the midwife’s
knowledge, attitude and sensitivities towards their cultural
practices of becoming a mother. However, lack of continuity of
care after the birth left women feeling unsupported.
Most women felt empowered with the professional and
emotional support from their midwife. They considered their
midwife “a great source of inspiration”. Moreover, the midwife's
guidance during breastfeeding difficulties was greatly appreciated.
However, some women such as Suma observed that the advice
received from midwives did not consider the cultural context of the
mothers. This was problematic as they conflicted with “whom to
listen to (mother of the women or midwife)”. Moreover, it is likely
that these women were expecting their health care providers to
suggest Indian dietary advice related to postpartum periods and
not the western dietary suggestions.
Oh then the nurses are telling you do this and my mother is
telling me to do this. Who do I listen to?” If they can just say
that, “look, I understand in your culture they may ask you to do
this or eat this, you know, yeah, this is the way you can do that.
You can do that as well.” And even the dietary suggestion they
give you, like at least for me for diabetes, they will be like,
“Yeah, yeah eat this, eat more protein, and eat more thing”.
(Suma -second time mother)
They felt that the midwife showed empathy, understood their
specific needs and provided great care if they got to know them
during their pregnancy. Although satisfied with the midwife’s
support during pregnancy and birth, women did not see them long
enough in their postnatal period. Moreover, many women did not
know what to expect from a midwife in their postnatal period.
Around the 6 weeks postpartum period, women accessed the
Maternal and child health (MACH) nurses for the scheduled
immunisations for the newborn baby. Women believed that this
 V.S. Rao et al. / Women and Birth 33 (2020) 479–489
service was only for the wellbeing of the baby and most women did
not talk about their ongoing difficulties and stress with the MACH
nurses. Limited interaction with their MACH nurses after the birth of
a baby influenced their emotional and psychological well-being, as
they felt home alone with the newborn, and had ‘no one to talk to’.
3.2.3. Theme 3: a psycho-emotional journey within socio-cultural
expectations
Most women had no extended family support, and more than
half of the women had a caesarean birth which affected their
mobility, independence and recovery. Further, their socio-cultural
beliefs and expectations regarding pregnancy and mental health
prevented them from seeking medical assistance although they
were constantly struggling in their postpartum period.
3.2.3.1. Socialization, independence and need time off. Some of our
women acknowledged that they needed time off from their
routine of looking after their babies and time away from their
caring role so they could focus on their self-care and socialisation,
which helped them to feel better. The barriers to taking time off
for them included lack of family support, not able to drive and
lack of a culture-specific mother’s group. According to Suma,
"supporting the woman and not leaving her alone and just building
like a sort of sisterhood around her to help her get through this time”
was important. Another woman named Reena acknowledged that
it was acceptable sometimes for women to not worry about their
role as a homemaker and focus on self-care rather than being
confined to their own company and thoughts. Nimmy found a
supportive husband helped who provided the much needed
quality time post-birth.
“He does make sure you know we go out for lunch or just have
you known some meal together so that I have my time off. So I
think that’s, that’s really nice and kind of him. And these small
things really matter”. (Nimmy- second time mother)
3.2.3.2. Expectations of giving birth to a male baby. The gender of
the baby seemed to have an effect on the mental well-being of
women in the study. A woman who had an older female baby and
gave birth to a male baby stated "I have a complete family now, so I
was very happy at that point. I did not have any more [mood]
fluctuations at that point". Women who were the mother of girl
babies wanted to have one more pregnancy with the hope of
conceiving a male child. Deepa, a nurse by profession who already
had two female children describes how the gender of her babies
contributed to her mental wellbeing.
I was not sad but like I have a girl. So I, what I expected, I like a
boy, and I thought like the first kid should be a boy, then you
have two to three girls, no issues. But [for me], the first one was
a girl, second is again a girl. Then, what I was thinking like, Now
again I have to plan for the third one because I want both [a boy
and girl]. (Deepa- third time mother)
For Deepa having only female children is likely to impact on her
status within her extended family. Thus she wants to be pregnant
again with a boy baby. This socio-culturally generated pressure to
have a male child is likely to influence the mental wellbeing of
Indian immigrants even though they are living in Australia where
different beliefs are held.
3.2.3.3. Reluctance in acknowledging mental health
concerns. Cultural stigma related to mental health was visible
during the conversation with the women. They believed postnatal
depression is normal and a hormonal thing. What is more
significant is that some women considered post-partum
depression as a sympathy-seeking behaviour. For most of the
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485
women, it was their physical health that was of concern, such as
the pain and struggle of managing the pain. Emotional
disturbances were seen as natural and postnatal depression was
more of a physical disorder. Women were not aware about what
postnatal depression actually was.
They (other Indian women) say I have postnatal depression. I
was like sometimes maybe if it is with your body and stuff,
then yes, that would be postnatal depression, but if you had
the same issues with your husband (arguments) before birth as
well and after the birth (then it is normal) and not because of
postnatal depression. I know a lot of friends who fight for pithy
things. But they come and said you know this is all because of
postnatal depression. It is just a way to cover-up things
(woman thinks). And I saw some people who were crying
when distressed because of the plan to deliver the baby in a
normal birth but ended up with a C section, and they feel bad
about it and cry for it. That would be postnatal depression?
(Sammy- second time mother)
Only a very few women spoke directly about their feelings or
mental state.
I admit that I felt a bit depressed. I don't have any reasons why I
felt that way but I was very, very quiet, I didn't want to talk to
anyone. I have heard that usually, females go through
depression but I didn't know what depression means because
I had never felt this way before. Also, this time I felt like it could
be depression, could be something else. I can't explain it. I didn't
want to talk to anyone, and I wasn't in a mood to socialise or go
anywhere, or I wasn't even talking to my husband much as well.
(Suma -second-time mother)
Suma's words suggest a reluctance to acknowledge that she
may be experiencing postnatal depression. Her words also indicate
even when women in our study may be experiencing post-partum
depression, their condition goes undiagnosed and therefore
untreated because of their reluctance to seek help. Such reluctance
is likely to be either because there is an unawareness of postnatal
depression or stigma associated with mental illness.
3.2.4. Theme 4: struggling to bridge two cultures
This fourth theme explores the women’s experiences of the
constant struggle with their culturally expected roles and
postpartum cultural practices in the western country.
3.2.4.1. Conflicted roles and expectations. Women in the study
stated that there were times when they felt emotionally vulnerable
especially when there was no family support, but they did not
know how to manage that. Women's emotional feelings and
experiences seemed to be related to the culturally expected roles of
women. Indu experienced such conflict stating, “Why I cannot make
a quick fix dinner when I have got two young kids to look after than a
long traditional Indian cooking". Reena, a recent migrant, believed in
equality and sharing between men and women and hence did not
believe in the culturally “Pre-decided roles where only women cook
and clean’’. Reena went on to say the following.
The role that Indian women play in their own life is not the
dominant one. I think they do not take things on, in their hands,
which you see out here, in Australia, I mean everything is what
they decide, like no one decides for you. Look I am from a very
forward and very open-minded Indian family, but still, I face a
few problems. The constant low self-esteem that Indian women
have, because of not being able to decide what they want to do
in their life. There have been times where I feel really shaken
even for little bit of you know, you know the cultural thing and
that you are a girl you know, you cannot be, do these things and
you can’t the other things (Reena- second time mother).
486 V.S. Rao et al. / Women and Birth 33 (2020) 479–489
Reena’s words clearly show the struggles that immigrant Indian
women faced trying to mediate their own first culture and the
opportunities that Australia provided for them as a woman. This
struggle is particularly evident among women in our study as they
are left on their own with very little or no social support, and yet
they have to cope with having a new baby and also do what is
culturally expected of them in their role as a mother and wife.
3.2.4.2. Traditional postpartum practices. Women had contrasting
views regarding traditional postpartum care. For some women it
was important to observe the postpartum practices while others
did not care about it. Women were able to follow the ‘good parts’ of
their cultural postpartum practices with the help of the support
person. The good parts of these practices include, able to rest, time
off from baby care and household work and opportunity for better
recovery. Women who had strong cultural beliefs wanted to follow
these traditions, despite having no support. For them, these
cultural practices were seen as their traditional values, time for
postpartum recovery, social affairs and occasions for celebration.
They also justified these ancient practices.
We have the 40 days thing, where the mother and the baby
don’t leave the house. That is you know, lot of people over here
say, “Oh my god, it’s like criminal. How can you not leave the
house?” But it actually ties up really well with the six week
immunization, because till then they (newborn) don’t get those
shots. Really the baby shouldn’t be out there. So I thought it
actually made a lot of sense that it all worked out really well
(Priya, a first time mother).
On the other hand some women also highlighted the presence
of unnecessary postpartum cultural restriction, such as staying
confined to the house for six weeks post-birth which influenced
their independence and socialising. As Reena, a professional
doctor who gave birth to her first baby in India and second in
Australia said:
When I was in India (gave birth there) where you are not
allowed to go out of the house for 42 days, maybe for reasons
during that ancient period, but I don't think there is any more.
We will really go mad if we don't go out. If you just don't come
out of your bed, you are going to have clots in your leg. There is
no good reason for not going out of the house. And you are (this
is) not even good for your mental wellbeing. And then there
are a lot of cultural things about giving your baby something to
eat very early. Like giving honey or giving all those things
which are we all know like medically is not good in the
beginning. I have not followed any of that, and I have parents
and my in-laws, they have never forced all that upon me.
(Reena- second time mother).
These women observed only selected practices which were
meaningful or therapeutic to them, probably to avoid the conflict
with the Western model of care. Women like Suma believed that
some cultural traditions "could be scientifically correct", but the
“significance has been lost”. This clearly suggests that in the absence
of social pressure and expectations, women utilised their decision-
making power in following such postpartum traditions.
4. Discussion
This qualitative study explored experiences of motherhood and
postpartum support of Indian migrant mothers 6 weeks following
birth. The findings of our study suggest that these women's beliefs
and expectations are embedded in their social and cultural context
and influence their postpartum experiences. Furthermore, wom-
en’s experiences indicate a struggle between what is expected of
them as an Indian woman, a mother and a homemaker within
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socio-cultural postpartum practices and their desire to adopt what
they believe are the positive aspects of the Australian model of
maternity care and practices. This struggle has implications for
their postnatal mental wellbeing. Further, these women had
additional socio-cultural factors that add to the stress that comes
with having a baby as a migrant.
Firstly, it is essential to have a support system which enhances
the positive experiences of motherhood. A traditional postpartum
model of care surrounds this support system among Indian
communities,20 which encourages social, emotional and practical
support. However, being an immigrant, living in a nuclear family
and having the responsibilities of a newborn influenced our
participant's social support and triggered a sense of fear and
feeling low. This led to some women struggling to cope with the
demands of the postpartum period.
To help cope with the feelings of loneliness, participants sought
to socialise with their friends and other new mothers. However,
factors such as being a new resident, limited social network, not
able to drive, lack of a local Indian mothers group, or being busy in
fulfilling their household responsibilities restricted social outings
and interactions. Previous studies have identified similar factors
among migrant women living in Australia and suggested the need
of a community-based mother's group to help create an environ-
ment to share their positive and negative experiences of
motherhood and overcome isolation and loneliness.16,17,39 Social
support is a crucial foundation of a smooth transition to
motherhood for Indian migrant mothers, which they often expect
from their partner, other family members, friends and the local
community. Cross cultural studies in Australia have also highlight-
ed the importance of social support among migrant population
groups.23,40,41 However, none of the studies have examined
support systems or models of care among Indian migrant women
in the postpartum period.
Secondly, cultural conflict and gender based-roles are known
barriers to positive postpartum care among Indian immigrants,21
and this continuously overshadows Indian migrant women's lives.
This is evident in our study as women’s belief in equality and
sharing between men and women in a Western country were in
conflict with traditional expectations from men, causing emotional
distress and “low self-esteem”, as they constantly found them-
selves trying to bridge between two cultures. Some women dealt
with expectations to observe social norms, such as being a good
wife and mother by fulfilling their socially expected roles of
cooking, cleaning, caring for older children and the newborn and
following postpartum cultural traditions.
Although changes in Indian men’s cultural roles in Australia is
noticeable according to a previous study,15 women in our study
highlighted that they would further benefit from a skilled and co-
operative husband who can provide necessary practical support.
For example, women could make a “quick fix dinner”, yet they were
expected to spend many hours cooking. Such unrealistic cultural
expectations in the absence of family support in Australia splinter
their experiences of motherhood leading to feelings of being a ‘bad
mother' which adversely influence their and newborn's wellbeing.
Finally, the relationship between the gender of the baby and
postpartum mental wellbeing of Indian women is interlinked and
reported in previous studies.42,43 Women in our study who gave
birth to male babies had more positive experiences of motherhood
than women who gave birth to female babies. Additionally, these
women wanted to have more pregnancies in a hope to give birth to
a male. This suggests the cultural norms and expectations follow
these women to their migrating country. These women face similar
challenges as Indian women would face in their homeland
regarding expectations to give birth to a male baby. This unmet
expectation may affect the relationship between the women and
 V.S. Rao et al. / Women and Birth 33 (2020) 479–489
the partner or the family, the bond between the mother and baby
and women’s overall postpartum mental wellbeing.
Birthing experiences of migrant women in Western countries
have been reported as a potential influence on postpartum mental
health.5 Contrary to the stereotypical beliefs, and consistent with
the findings of recent inter-cultural studies,15 women in our study
had positive experiences with the maternity care, were confident
to interact with the health professionals and in some instances
overcame postpartum difficulties. This positive experience was
drawn from two things. Firstly, women’s ability to access health
services was evident, chiefly because they were highly educated,
were able to speak English well and were working professionals.
This finding is consistent with the findings of a Victorian study15
where English speaking women from non-English speaking
country reported to have positive birthing experiences. Secondly,
having support from their ‘good-midwife’ who is caring, empathic,
and professional helped enormously. Particularly, this satisfaction
levels were due to having a primary midwife (caseload midwifery)
care. A randomised controlled trial (RCT) from Australia has
demonstrated similar findings, where women expressed a great
level of satisfaction from the caseload midwife.44
Half of the women interviewed had a caesarean section. A
previous study the second author led showed Indian women giving
birth in Australia had the highest rates of caesarean section.24 The
fact that caesarean section rates are now very high in India, and
way beyond World Health Organization (WHO) recommenda-
tions45 , may mean this felt normal for them and reflective of the
experience they would expect in India. However, women struggled
to transition to their early mothering, due to lack of continuity in
postpartum care.
Women in our study expressed concerns at having only one-
two postpartum visits with the midwife and then abruptly losing
this care. In a previous RCT, women’s postpartum satisfaction
levels were attributed to the higher home-based postpartum
visits.44 Therefore frequent visits soon after birth and then slowly
reducing the visits and handing over the care to the maternal and
child health (MACH) nurses could help these women overcome
postpartum difficulties. The MACH service is a free service that is
available during the postpartum period for all women and their
children in the ACT. The MACH nurses support new parents in early
days of parenting by providing information and advice, and
referring to appropriate health services and community support.
None of the women in our study appeared to access MACH nurses
other than for vaccinations. Therefore, more education is needed
about this service to support postpartum wellbeing and to promote
continuity of care. Further studies should be conducted to
understand utilization of this service among Indian migrant
women.
Migrant mothers receiving sub-standard postpartum care can
have worse mental health outcomes.6 In our study due to limited
understanding of Indian postpartum traditions among health
providers and culturally insensitive advice given, women found
themselves torn between two models of postnatal care and this
created distress for them. Previous studies have also found that the
incongruity of the Western model of care with complex postnatal
care among Indian migrant communities can deprive them of their
familiar and supportive cultural practices.22,46,47 This may influ-
ence their mental health and well-being. India is a culturally
diverse country with many languages and traditions. It is suggested
that the health providers should not assume all Indian women fall
under one tradition and therefore, formulate a personalised
postpartum care informed by the individual’s choices and beliefs.29
In the best of circumstances, the postpartum period is a
challenging time for migrant women, especially if they are
experiencing postnatal distress and anxiety. Most Indian women
are often not aware of their psychological wellbeing and underuse
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487
mental health services47 and express their psychological needs
through somatic symptoms.43 Women in our study did experience
low mood and irritation; however, none of them ever talked about
their postpartum mental health with their health professionals.
Moreover, notions of stress and worry, low mood and irritation
were considered normal or attention-seeking behaviour which
suggests stigma could be associated with mental illnesses. For
example, participants like Suma “did not want to talk to anyone”,
and "wasn't in the mood to socialise or go anywhere" or even to “talk
to her husband”. She did not recognise that she may have needed
professional help and did not seek relevant services. This suggests
some Indian women could remain undiagnosed or at the risk of
developing significant mental health issues if they are not
appropriately supported.
5. Strength and limitations
To best of our knowledge this is the first study which explored
the experiences of Indian women giving birth in Australia. This in-
depth exploration used a qualitative approach that created an
opportunity for these women to speak about their postpartum
experiences and perceptions that would not have been possible in
a quantitative study. Additionally, the presence of the first study
researcher assisted in initial rapport building and enhanced the
cultural sensitivity and acceptability of the research process. This
helped minimise language and cultural barriers and enabled
understanding in-depth the socio-cultural sensitivities.
However, there are several limitations, such as recruiting
women from two community organisations, which could have
limited the participation of other Indian women who are not
attached to such organisations, or living in isolation. Only Indian
women from who spoke English were included further limiting the
diversity of experiences. All the women came from one city in
Australia and those who come from other cities or states may have
different experiences. Most of the women were second or third
time mothers, so this study may not well reflect the experiences of
first time mothers. Furthermore, women were highly educated and
all married Australian-resident Indian men before migration to
Australia and so may not be representative of immigrant Indian
women. Further studies are needed to explore the extent of
postpartum mental issues among this population, including the
perspectives of family members and health care providers in order
to gain insight into the socio-cultural aspects of the postpartum
period.
6. Conclusion and implications for care
This study revealed that Indian immigrant mothers with young
children at home struggle with the responsibility of having a
newborn and their culturally expected roles. A supportive husband
who can shoulder some of the responsibilities and provide
practical, hands on support can make a significant difference in
Indian women’s lives after the birth of a baby. Additionally, these
women would benefit from extended postpartum follow up visits
and from being involved with a local Indian mother’s group. An
optimal way to address some of the postnatal issues identified
would be with continuity of midwifery care. It was clear midwifery
care was appreciated by the Indian women but they wanted more
midwifery care postnatally. Continuity of midwifery care may also
impact on the high intervention rates seen in this group and also
reported on in population based.24
In particular, lack of knowledge about what Child and Family
Nurse Services bring is a major gap that needs addressing. Future
research should aim to uncover and discuss the stigma related to
mental health within the socio-cultural framework. More work is
needed regarding the misconceptions and stigma with mental
488 V.S. Rao et al. / Women and Birth 33 (2020) 479–489
illness. This would help to proactively meet the emotional and
socio-psychological health requirements of these women and to
advance strategies to develop skills, build confidence and
encourage independence and participation of these women and
their partners in maternal mental health services.
Funding source
None declared.
Conflict of interest
None declared.
Ethical statement
The Human Research Ethics Committee, from University of New
South Wales (UNSW), Australia granted the ethics approval.
The approval number is HC16030.
Granted on - 9th March 2016.
CRediT authorship contribution statement
Vibhuti Samarth Rao: Conceptualization, Data curation,
Formal analysis, Investigation, Methodology, Project administration,
Resources, Writing - original draft, Writing - review & editing.
Hannah G. Dahlen: Formal analysis, Resources, Validation, Writing -
review & editing. Husna Razee: Conceptualization, Methodology,
Project administration, Supervision, Writing - original draft,
Writing - review & editing.
Acknowledgement
The authors acknowledge the women who gave their time and
shared their stories with us.
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