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General Hospital Psychiatry 32 (2010) 17 – 25

Falling through the net — Black and minority ethnic women and perinatal
mental healthcare: health professionals' views
Dawn Edge, Ph.D.⁎
School of Nursing, Midwifery and Social Work, University Place, The University of Manchester, Manchester M13 9PL, UK
Received 6 January 2009; accepted 16 July 2009

Abstract

Objectives: The objective of this study was to investigate health professionals' views about perinatal mental healthcare for Black and
minority ethnic women.
Methods: Qualitative data were collected from a range of healthcare professionals (n=42) via individual interviews and focus groups.
Participants were recruited from antenatal community clinics, a large teaching hospital, general practice and a specialist voluntary sector
agency in the north of England, UK.
Results: Participants reported inadequacies in training and lack of confidence both for identifying the specific needs of Black women and for
managing perinatal depression more generally, particularly in women with mild/moderate and ‘subthreshold’ depression. Inadequate perinatal
depression management was associated with failure to screen routinely, confusion about professional roles and boundaries, and poorly
defined care pathways, which increased women's likelihood of ‘falling through the net,’ thus failing to receive appropriate care and treatment.
Conclusions: Suboptimal detection and treatment of perinatal depression among ‘high-risk’ women highlight gaps between UK policy and
practice. This applies to women from all ethnic groups. However, evidence suggests that Black women might be particularly vulnerable to
deficiencies in provision. Effective management of perinatal depression requires a more robust implementation of existing guidelines, more
effective strategies to address the full spectrum of need, improved professional training and a more coordinated multiagency approach.
© 2010 Elsevier Inc. All rights reserved.

Keywords: Perinatal depression; Ethnicity; Healthcare; Minority women

1. Introduction Inequalities in access, care and treatment are antithetical

Detection and treatment of perinatal depression are
important public health issues because of the condition's
potentially serious consequences on women's life-long
mental health and the health and well being of their
children and families [1]. Perinatal depression is known to
adversely affect children's physical, cognitive and psycho-
logical health [2,3] (particularly among disadvantaged
populations [4–8]) and is associated with family break-
down and institutionalization of children [3,9,10]. This
suggests that suboptimal management of perinatal depres-
sion might have particularly serious ramifications for Black
Caribbean women in the UK, as a high percentage are lone
parents [11,12].
⁎ Tel.: +44 161 306 7650; fax: +44 161 306 7707.
E-mail address: dawn.edge@manchester.ac.uk.
0163-8343/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.genhosppsych.2009.07.007
to the core values of the UK's National Health Service
(NHS), which is founded on strong social principles of
providing high-quality, accessible and equitable healthcare
based on solely on clinical need (rather than ability to pay).
However, despite major reform [13,14], inequalities persist.
In response, a number of policies aimed at improving the
health of vulnerable and underserved communities have
emerged in the last decade or so. However, policies designed
to ‘tackle health inequalities’ [15], bring women's mental
health ‘into the mainstream’ [16,17] and ‘deliver race
equality’ in mental healthcare [18] appear to have made
little impact on improving the mental health of Black and
minority ethnic (BME) women [19,20]. For example,
although generally agreed psychosocial risks such as social
deprivation, lone parenthood and having a personal or family
history of mental illness [21–25] disproportionately affect
BME women, anecdotal and limited research evidence
18 D. Edge / General Hospital Psychiatry 32 (2010) 17–25
suggests that relatively few Black Caribbean women in the
UK access perinatal mental healthcare despite evidence of
significant levels of morbidity [26].
Detection and treatment of depression [27] and perinatal
depression in primary care [28,29] are known to be
universally poor. The reasons for this are not entirely
clear, but evidence suggests that personal and cultural
factors such as the attitudes and beliefs of practitioners and
laity may be as significant as structural barriers [26,30–36].
In relation to the mental health of minority groups in the
UK, research and service delivery tend to focus on serious
mental illnesses among BME men [37–40]. Accordingly,
relatively little attention has been paid to addressing the
specific mental health needs of minority women, particu-
larly in primary care [18,20].
This study aimed to begin to redress this gender
imbalance. To examine factors that might account for the
relative invisibility of Black women in primary mental
healthcare, NHS and voluntary sector practitioners were
consulted about their experiences of and views on
managing perinatal depression among women of Black
Caribbean origin.
2. Methods
A purposive sample of healthcare professionals (n=42)
and child-bearing Black Caribbean women (n=42) was
interviewed (either in focus groups or individually) about
their perceptions of the extent to which current services meet
the perinatal mental health needs of BME women. This
article reports only the views of healthcare professionals.
The views of women in the study will be reported in a
forthcoming article. In addition to examining barriers to
receiving care, the author encouraged participants to suggest
strategies that might better enable Black women to receive
appropriate perinatal mental healthcare.
As this was a qualitative study, participants did not
constitute a statistically representative sample [41]. Rather,
they were purposefully selected to represent a range of
viewpoints and experiences that are relevant to the
recognition and management of perinatal depression
among BME women. The sample of healthcare professionals
therefore included general practitioners (GPs), midwives,
hospital doctors and health visitors, as well as voluntary
sector providers who were purposefully selected to cover a
breadth of experience, expertise and provision (e.g., newly
qualified and senior staff and both statutory and voluntary
sector healthcare providers). Nine of the 42 participants were
of minority ethnic background, among whom five were
Black Caribbean. With only four male participants (two
hospital doctors, one GP and one voluntary sector worker),
there was a strong gender bias reflecting the demographic of
health workers.
Between September 2007 and June 2008, 42 participants
(Table 1) were recruited from a large inner-city teaching
Table 1
Study participants
Healthcare providers Participants (n=42) Total
Focus groups In-depth interviews
(n=73) (n=11)
Third sector 3 0 3
Specialist midwives 0 2 2
Hospital midwives 9 0 9
Community midwives 11 0 11
Midwifery managers 5 0 5
GP 0 5 5
Health visitors 5 0 5
Hospital doctor 0 2 2
Total 33 9 42
hospital, GP practices and community settings in areas
known to have high concentrations of Black Caribbean
residents [42]. Table 1 shows that the sample comprised 39
NHS professionals and 3 workers from a voluntary/third-
sector agency, which provides specialist mental healthcare
for Africans and Caribbeans in a large north of England
conurbation. Black Caribbean women were selected for the
study as they represent a relatively homogenous minority
group and because of well-documented negative associations
between people from this ethnic group and mental health
services [43,44].
Using a topic guide (available upon request) that was
developed from existing literature and from previous
research in which health professionals began to articulate
their views about perinatal mental healthcare for minority
women [26], participants were enabled to explore their views
about issues that might explain the low levels of consultation
and diagnosis of perinatal depression among Black Carib-
bean women despite high levels of psychosocial risk.
Digitally recorded interviews and focus groups were
conducted by the author at the participants' place of work
and subsequently transcribed verbatim.
Data were coded by the author. Data management and
analysis were supported by NVivo [45], a computer-assisted
qualitative data analysis program [46]. The principles of
framework analysis [47] were applied to data analysis.
Framework analysis is a matrix-based hierarchical method of
analyzing and synthesizing qualitative data [47]. Through
‘familiarization’ with and refinement of raw data, key
themes, concepts and emergent categories were organized
into a conceptual or thematic framework. Themes were
sorted and grouped into higher-order categories or main
themes, entered into a comprehensive matrix and used to
chart participants' views. Summarizing and synthesizing the
data in this manner facilitated interpretation and explana-
tions, as the views and opinions of individuals and
professional groups could be compared and contrasted.
Because of its methodological rigor and transparency, the
framework analysis approach has become increasingly
popular in health services research as a method that enables
 D. Edge / General Hospital Psychiatry 32 (2010) 17–25
researchers to develop recommendations for practice and
policy [48].
Data verification strategies to ensure the reliability or
‘trustworthiness’ of the data and consequent findings
included participant verification, peer review and use of
independent researchers to examine themes, findings and
conclusions [49]. As findings are illustrated by verbatim
quotes, participants' anonymity has been preserved by
assigning them numbers based on group designation (e.g.,
‘Senior Midwife 1’ or ‘GP 2’). For the protection of the
identity of the two specialist mental health midwives
(Table 1), their data have been combined with those of
midwifery managers, forming a ‘Senior Midwives’ category.
The study was approved by local research and university
ethics committees and relevant research governance bodies
of participating NHS Trusts.
3. Results
3.1. Antenatal contact and missed opportunities
Participants did not appear to regard antenatal depres-
sion either as a condition warranting intervention in its own
right or as a mechanism for identifying women who are at
risk for postnatal depression, even when women had
known histories of postnatal depression. According to
practitioners, this may be because antenatal care focuses
primarily on physical issues:
“Even though women may have had PND in the past, if
they've got other more pressing medical problems, for
example diabetes or some other problem… I think it tends
to overshadow their PND or postnatal issues. So though it
may be flagged up in the [medical] notes, perhaps antenatally,
it may not still get any attention, unless the woman herself
draws one's attention to it, which most women don't. One
tends to focus rather heavily on the medical issues rather than
the wider perspective.” (Hospital Doctor 1)
In terms of addressing perinatal mental health, NHS
participants reported feeling constrained by time, staff
shortages and other resource issues to focus almost
exclusively on serious mental illness. Pressure to prioritize
care in this way was a considerable source of guilt and anxiety
for some participants who perceived that this left the majority
of women experiencing psychological distress in the perinatal
period without the care and treatment they needed:
“…you're prioritizing, and the worry is… something might
happen to one of them… but I have to [prioritize] for my own
sanity. I have to think, ‘I can't do all that’… but still realizing
there are all these other women out there, which is terrible,
terrible.” (Senior Midwife 2)
“[We] can only deal with the women who are really, really
unwell, ‘moderate to severe’ if you like, and my concern is
that the vast majority of women [with psychological
difficulties] fit into ‘mild to moderate’ category.” [Original
Emphasis] (Senior Midwife 1)
19
However, such anxieties were not expressed by all
participants. For example, according to one GP, a significant
number of Black Caribbean women in her practice received
treatment for clinical depression prior to or during
pregnancy. Nevertheless, despite seeing “every woman
postnatally,” she rarely diagnosed Black women with
postnatal depression. Encouraged to reflect on the apparent
paradox of the virtual absence of postnatal depression among
women with high levels of depression at other times, coupled
with high levels of known psychosocial risks for perinatal
depression, she stated:
“Possibly we're missing them [nervous laughter], I don't
know, but they don't kill themselves. So, even if we're
missing them, we are managing them.” (GP 2)
The admission that practitioners might be “missing”
women with postnatal depression was interesting, as this GP
and her colleagues did not routinely screen for perinatal
depression. Their approach was not unique, but rather
reflected the practice of a number of professionals who
appeared highly resistant to using validated psychiatric
measures or screening tools such as the Edinburgh Postnatal
Depression Scale (EPDS) [50], as demonstrated below:
“I don't like the EPDS. I just think it's a waste of paper,
personally. I argued this with a doctor who was doing some
research into postnatal depression and she sort of agreed with
me, but said ‘there's nothing else in its place, so for now we'll
just have to use that.’ At university, when we did our degree,
they pooh-poohed it. The health visiting lecturer said, ‘it's not
worth the piece of paper it's written on’.” (Health Visitor 1)
“I am largely responsible for PHQ-9 being introduced… when
it comes to my own type of practice, I very rarely get the
PHQ-9 out and get people to tick boxes, but I will take the
questions from it and I will use those. So, umm, I would be
lying if I said I used a formal structured questionnaire to get a
clinical diagnosis, because I don't.” (GP 1)
3.2. Professional practice and perinatal mental healthcare
Ironically, while healthcare professionals apparently
privileged intuition over instrumentation, lack of confidence
and competence in identifying and managing perinatal
depression were recurring themes. Whereas some partici-
pants were concerned with acquiring cultural competence to
deal with women from a range of ethnic/cultural back-
grounds, the majority — including those who had specialist
perinatal mental health roles — stated that they lacked
relevant knowledge, skills and training to manage perinatal
depression and other mental illnesses in women, irrespective
of ethnic origin. Midwives and health visitors felt especially
disadvantaged in this regard. They reported that lack of
psychiatric knowledge and training added to the difficulties
that they encountered in referring patients to mental health
specialists:
“The problem is most midwives are not mental health trained
so when you pick someone up and refer them on, often the
20 D. Edge / General Hospital Psychiatry 32 (2010) 17–25
psychiatrists say, ‘they don't have a mental illness’ even
though it's sometimes so obvious that anybody could see it. I
had a woman… I tried to get her an urgent referral with
psychiatrists. When she was eventually seen, they said she
was a woman with social problems. That didn't seem right to
me. I was really worried about her.” [Original Emphasis]
(Senior Midwife 5)
“She was literally talking in tongues and ripping at her
clothes. I spent the whole day trying to get help for her. When
I finally got through, they wouldn't see the woman without
doctor's referral! He [psychiatrist] was actually very good
with me, very sympathetic. But I just couldn't get her the help
she needed.” [Original Emphasis] (Community Midwife 1)
Lack of timely access to appropriate care and the
absence of clearly defined care pathways were repeatedly
highlighted by participants as significant barriers to
delivering effective perinatal mental healthcare. As an
illustration, midwives providing antenatal care spoke of the
challenge of identifying psychological distress in busy
clinics. They suggested that detection was more likely in
postnatal wards, as staff have “far better insight into mental
health problems and women are picked up that bit quicker”
(Midwifery Manager 2). However, ward-based midwives
stated that it was virtually impossible to “pick up postnatal
depression” among women in hospitals because “they're in
and out so quickly” (Hospital Midwife 3) — a view
endorsed by this account, which also highlights the number
of professionals with apparent responsibility for delivering
perinatal mental healthcare:
“[I]f the mother appears to be ok, she'll be home within 24 h
if it's her second baby. Then [they're] on to the community
midwife who's in for, I don't know, half-an-hour… they don't
visit every day and then they're transferred to the health
visitor.” (Hospital Doctor 2)
Health visitors were regarded by other professional
groups as having primary responsibility for identifying and
delivering first-line treatment and care for postnatal
depression. However, practitioners reported that ongoing
NHS reform had resulted in health visitors being moved out
of general practice and into centralized services (often in
non-NHS settings), a development universally regarded as
deleterious to multiagency team work and delivery of
effective perinatal mental healthcare:
“We have terrible trouble with health visitors… because the
health visitors are now sectorized, we have to liaise with about
12 different health visitors. It is just a nightmare! Deeply
unsatisfactory! It's not the health visitors' fault — it's the
system.” (GP 1)
The same GP contrasted these new ways of working with
her previous experience of working in an effective
multiagency team. Working closely with a single health
visitor over a significant period of time had enabled the GP
to develop an unwritten protocol or “shorthand” for
proactively managing women with psychological distress.
Her account typifies those of other practitioners who
suggested that unfamiliarity between multiagency team
members had generated lack of confidence in colleagues'
professional competence:
“Now [I'll] get a letter from a health visitor I have never met. In
my previous practice, we had a health visitor and… she was
wonderful. I worked with her for 10 years. We had a shorthand.
If [name] told me she was worried, I knew she was seriously
worried. If she was worried, then I was really worried. I really
miss that system.” [Original Emphasis] (GP 1)
Health visitors also bemoaned changes to their working
practice. They shared other participants' perspective about
the importance of building trusting relationships not only
with other professionals but also with women in their care.
Knowing women antenatally was regarded as key to
recognizing changes in postnatal affect. However, increas-
ing workloads and pressure to prioritize child protection
and other health targets meant that health visitors no longer
had time to provide “routine antenatal care,” as this health
visitor explained when comparing previous and current
practice models:
“That was absolutely normal — to have time to do antenatal
visits — so you could actually find out if there had been a
previous episode [of perinatal depression], a history of
depression, or if there were social problems that you should
be aware of. But nowadays, we are tending to see women
‘first timers’ when their babies are between 4 and 6 weeks,
and that is the first time that you have met them, so you don't
really know how they were before.” (Health Visitor 2)
3.3. Black Caribbean women and perinatal mental healthcare
Establishing trusting relationships with Black women was
regarded as particularly important, as they were perceived to
be especially averse to health surveillance. Practitioners
suggested that there might also be sociocultural explanations
for the low levels of consultation for and diagnosis of
perinatal depression among Black Caribbean women. For
example, participants suggested that Black Caribbean
women's psychological responses were inextricably linked
to their cultural identity in ways that made it difficult for
them to ask for and receive help either from health
professionals or from social/family sources. Additionally,
as many were lone parents, they often lacked the kind of
emotional and social support that is said to protect women
from the onset of perinatal depression:
“I think maybe Black women still have a pride in not
expressing some of the deeper traumas that they may have
had, and also my experience is that more Black women come
from one-parent families so the mother is really the matriarch
— she's the one that actually controls the family…” (Senior
Midwife 1).
From a structural perspective, participants suggested that
services may lack the cultural competence to detect perinatal
depression in Black Caribbean mothers because “so few
 D. Edge / General Hospital Psychiatry 32 (2010) 17–25
medical or midwifery staff are themselves from the
Caribbean” (Hospital Doctor 2). Absence of ‘insider
knowledge’ of Caribbean culture might contribute to service
providers' lack of awareness of culturally specific issues that
are unique to women from this ethnic group. There was
evidence of this among some staff who also appeared to
adopt a ‘color-blind’ approach to dealing with ethnicity and
multicultural practice. In doing, so they tended to focus on
issues that had a more direct impact on practitioners' ability
to engage with women, such as overt language barriers. As
virtually all child-bearing Black Caribbean women in the UK
are English speakers and therefore do not require translation
services, this approach might mean that more subtle cultural
issues are overlooked, as this midwife explained:
“I would say that statement ‘We don't see Black women’ (the
name of the study), it's perfectly true. I would see women
sometimes and you could say to me afterwards, ‘What color
where they?’ I wouldn't have a clue! I could tell you if they
were Polish and didn't speak English or African therefore
definitely Black… to me, it's not color that you actually see,
it's other issues around it… language is probably the big one.”
(Hospital Midwife 4)
4. Discussion
This article explored practitioners' views about managing
perinatal depression in BME women. It focused on
examining perceptions of the factors that might explain the
low levels of consultation diagnosis and treatment for
perinatal depression among Black Caribbeans — an ethnic
group that is known to experience higher rates of other
mental illnesses, coupled with poorer access to and outcomes
from contact with mental health services in the UK [43].
However, the study has wider implications for other BME
groups and service users more generally. Key findings
indicate that the negative impact of service redesign on
multiagency team work, resistance to using psychological
screening tools, lack of confidence in depression manage-
ment and the absence of clearly defined care pathways
contributed to missed opportunities for detecting and treating
perinatal depression. Adopting a ‘color-blind’ approach
increased the likelihood of the condition being missed
among BME women, particularly in the absence of overt
language barriers and other cultural signifiers such as
religious dress.
In common with other developed countries, detection and
treatment of depression in the UK are suboptimal [35,51].
Currently, only around half of the people with depression
consult their GPs and, among those, only half receive a
diagnosis [27,52]. As the perinatal period is associated with
increased risk of depression [21,53] and high levels of
contact between women and health professionals, one might
theorize that this would significantly improve the likelihood
of detection and treatment. Findings from this study suggest
that this is not the case and that opportunities for managing
21
perinatal depression are not being maximized. Not only was
contact between women and professionals fleeting and
somewhat disjointed, professionals did not follow national
guidelines for good practice, which recommend routine
screening for women at high risk for depression [54]. Neither
women previously diagnosed with postnatal depression nor
those known to have been depressed antenatally or before
becoming pregnant were routinely screened. The National
Institute for Health and Clinical Excellence (NICE) recom-
mends asking three questions to assist in predicting and
identifying perinatal depression (Box 1). This approach does
not require psychiatric training. However, despite attempts to
make these questions accessible, they were either not being
used or were modified by practitioners in the field.
Despite validation and introduction of case-finding
instruments such as Patient Health Questionnaire-9 [55],
health professionals apparently remain reluctant to use them.
This is not unique to the UK or to perinatal depression
[56,57] and may reflect ongoing debates about the efficacy
of screening and other depression management strategies.
On one hand, it is argued that early detection and treatment
are a cost-effective means of reducing morbidity, especially
as such interventions are thought to reduce chronicity and
inequity of provision [58,59]. Alternatively, some clinicians
and theorists regard treating mild/moderate depression as
tantamount to ‘medicalizing distress’ [60–62]. Others
suggest that routine screening is ineffective [63] and that
patients whose depression remains undiagnosed might have
better outcomes [64,65]. This has caused some commenta-
tors to challenge the validity and utility of depression
guidelines and case-finding instruments [36,63,66].
Failure to screen for perinatal depression or to adopt
policy and practice guidance might result from failure to
regard perinatal depression as a serious illness. Participants'
Box 1
NICE recommendations for predicting and detecting
perinatal depression (NICE, 2007)
At a woman's first contact with primary care,
booking visit and postnatal visit (usually at 4–6
weeks and 3–4 months), healthcare professionals
(including midwives, obstetricians, health visitors and
GPs) should ask two questions to identify possible
depression:
During the past month, have you often been bothered
by feeling down, depressed or hopeless?
During the past month, have you often been bothered
by having little interest or pleasure in doing things?
A third question should be considered if the woman
answers ‘yes’ to either of the initial questions:
Is this something you feel you need or want help
with?
22 D. Edge / General Hospital Psychiatry 32 (2010) 17–25
accounts suggest otherwise. For example, the link between
maternal depression and risk of suicide did not prompt
proactive management among healthcare practitioners.
Instead, the mistaken belief that Black women “don't kill
themselves” (GP 2) was taken as evidence that perinatal
depression among them was somehow being managed
effectively. In light of findings from the Confidential
Enquiry into Maternal and Child Health [67], which
implicates practitioners' failure to act on guidelines and the
absence of effective multiagency liaison as key factors in
preventable suicide and infanticide in the perinatal period,
these are worrying findings that appear to endorse
participants' own concerns about their lack of competence
for dealing with perinatal depression.
The mismatch between clinicians' assessments and
treatment approaches and professional practice guidance
has been previously reported [51,56]. Practitioners' accounts
of lack of confidence in managing perinatal depression —
particularly in differentiating between mental illness and
mild/moderate or ‘subthreshold’ mental disorders — are in
line with concerns expressed elsewhere [68]. Criticism of
NICE guidelines [54] for assessing severity of depression
(Box 2) suggests the need to more clearly delineate clinical
syndromes from generalized distress [68]. In this context,
research suggests that clinicians' beliefs, attitudes, aware-
ness and knowledge about depression are important
determinants of why practitioners who advocate high
standards and consistency of care simultaneously fail to
use strategies and tools designed to assist them deliver the
quality of care they espouse [35,69].
Box 2
Assessing the severity of depression (adapted from Inter-
national Classification of Diseases, Tenth Revision, World
Health Organization, 1992)
Symptoms: for a diagnosis of depression, symptoms (including at least
2 ‘key symptoms’) must be present for at least 2 weeks
Key symptoms Other symptoms
Persistent sadness or low mood Disturbed sleep
Loss of interest or pleasure Poor concentration
Fatigue or low energy Low self-confidence
Poor or increased appetite
Suicidal thoughts, plans or actions
Agitation or slowing of movements
Guilt or self-blame
Severity
Not clinically depressed: b4 symptoms
Mild depression: 4 symptoms (including at least 2 ‘key symptoms’)
Additional indicators: some difficulty managing work, social
activities and other activities of daily life
Moderate depression: 5–6 symptoms
Additional indicators: considerable difficulty managing work, social
activities and other activities of daily life
Severe depression: ≥7 symptoms (including all 3 ‘key symptoms’)
Additional indicators: considerable distress and inability to manage
work, social activities and other activities of daily life, except to a very
limited extent.
Participants' reports of high levels of satisfaction with
pathways for managing serious mental illness in the
perinatal period (via the regional Mother and Baby Unit)
contrasted sharply with reports of lack of clearly defined
care pathways for mild/moderate depression. The evidence
from these accounts is that NICE guidelines [70] and
professional advocacy [71] for a clear national strategy to
provide more holistic, consistent care (delivered via
regional perinatal mental health networks) are some way
from being realized.
Perceptions of health visitors as being ideally placed to
deliver optimum perinatal mental healthcare are not
endorsed by NICE [70] and conflict sharply with
participants' accounts of the unavailability of health
visitors and/or their location outwith the multiagency
team. Despite these apparently negative consequences of
service redesign and delivery, no alternative strategies for
detecting and treating perinatal depression have been
advanced and, currently, no professional groups appear to
have overall responsibility for perinatal mental healthcare
[72]. While this has implications for all ethnic groups,
findings from this study suggest that the absence of a
coordinated multiagency approach and the lack of effective
oversight render women from marginalized communities
especially vulnerable to ‘falling through the net’ and failing
to receive suboptimal care.
4.1. Limitations and strengths
Black Caribbean women were chosen for this study as
they are a relatively homogenous group of settled English-
speaking migrants. Largely unaffected by issues that concern
more recent migrants such as overt language barriers [73],
they cannot therefore serve as a proxy for all BME women.
However, this ethnic group highlights the fact that even
settled migrants who were born in the UK and living in
circumstances that are known to increase their risk of
perinatal depression might have their needs overlooked. This
has serious implications for policies aimed at delivering
high-quality perinatal mental healthcare to all women and
reducing inequalities in access and provision [16,17].
Although a range of key healthcare professionals were
purposefully selected into the study [74,75], the sample
might have been enhanced by the inclusion of others, such as
midwifery assistants, who do not have professional mid-
wifery qualifications but are increasingly involved in
frontline delivery of care. Similarly, additional insights
about the extent to which ethnicity influences professional
practice and perceptions might have been gained by actively
recruiting Black healthcare professionals. However, as
articulated by participants, a paucity of Black Caribbeans
in perinatal (mental) healthcare rendered this unfeasible in
the context of this study.
Nevertheless, this article and the larger study from which
it derives, which also examines the views of Black Caribbean
women (forthcoming article), provide valuable insight into
 D. Edge / General Hospital Psychiatry 32 (2010) 17–25 23

Box 3 the impact of NHS reform, appear to be key factors that

The stepped-care model for the management of depression increase the likelihood of women from this and other ethnic
(NICE, 2004) groups ‘falling through the net’ and failing to receive the
care and treatment they need. As almost half of the Black
Step/focus of care Responsible for Interventions to Caribbean women giving birth in the UK are lone parents,
care consider this has important public health implications for the welfare
1. Recognition GP, practice nurse Assessment of women and their families, especially in the context of
2. Mild depression Primary care team, Watchful waiting what is known about the impact of maternal depression on
primary care mental Guided self-help
child welfare and development [4]. Findings from this
health worker Computerized
cognitive– study indicate that more ‘joined-up thinking,’ which
behavioral therapy transcends traditional boundaries between policy areas
Exercise and clinical specialisms such as between child and maternal
Brief psychological health and between physical and mental healthcare, is
interventions
urgently required [15,17,18,77–79]. It may be that, in order
3. Moderate/severe Primary care team, Medication
depression primary care mental Psychological to improve women's perinatal mental healthcare, govern-
health worker interventions ment targets of the kind that have been instrumental in
Social support dramatically reducing waiting times in emergency medicine
4. Treatment-resistant, Mental health Medication need to be implemented. Improved education and training
recurrent, atypical or specialists Complex psychological
of health professionals and more robust implementation of
psychotic depression (e.g., crisis teams) interventions
(those at ‘significant Combined treatments policy and practice guidance (e.g., by bringing them into
risk’) the NHS's governance and inspection frameworks) might
5. Risk to life Inpatient care, Medication truly bring women's mental health ‘into the mainstream’
(severe self-neglect) crisis teams Combined treatments [16,17], thereby helping to address inadequate management
Electroconvulsive
of perinatal depression not only for Black Caribbeans but
therapy
also for women from all ethnic groups.

stakeholder perspectives on the factors that influence the

perinatal mental healthcare received by Black women. It is
therefore an important step towards developing more
inclusive and responsive services, thus ensuring that all
women receive appropriate psychological care.
4.2. Implications for policy and practice
The absence of Black Caribbean women in perinatal
mental health research and practice has important implica-
tions for strategies that aim to reduce inequalities and to
improve access to mental healthcare. As the majority of these
women were born in the UK, they are not excluded from
services by obvious ethnocultural barriers such as language.
Few are excluded by religion or other cultural practices.
Nevertheless, measures taken to improve the management of
perinatal depression did not appear to have impacted their
mental health (Box 3) [11]. This may be partly because their
psychological distress fails to reach the threshold for formal
diagnosis [68]. It may also be that instrumentation and other
strategies for identifying perinatal depression are not
sufficiently culturally sensitive. Alternative conceptualiza-
tions of mental illness among this ethnic group might also
negate helpseeking for depressive symptoms [76]. The
findings do suggest, however, that policy makers, service
providers and academics need to actively facilitate the
realization of appropriate perinatal mental healthcare to
which women are entitled [77].
Health professionals' rejection of best practice guide-
lines in favor of more subjective approaches, coupled with
5. Conclusions
Despite remedial action at the policy and practice
levels, suboptimal detection and management of depression
remain persistent problems in primary care [52,80]. Some
ethnic groups may be more likely to have their symptoms
overlooked [44,81]. According to practitioners in this
study, the perinatal mental healthcare of Black Caribbean
women, who are at greater theoretical risk for the onset of
perinatal depression but largely absent from associated
clinical and research data [82], endorses this view. In light
of the potentially serious consequences of this condition on
women and their families, urgent action is needed to truly
bridge the apparent policy–practice gap in perinatal mental
healthcare.
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