Qualitative findings
Three themes emerged: 1) Understanding of maternal depression; 2) Protective factors for mental health; and 3) Barriers to mental health services.
Understanding of maternal depression
Despite the high proportion of women with high EPDS scores, participants did not disclose any depressive symptoms during the FG, and used other terminologies instead, such as being bored or tired, to describe their feelings. Moreover, participants had many misconceptions around maternal depression; its meaning, its causes, and how common it is in Syrian women.
When asked if they knew what is maternal depression, most of the women had heard of it. They tended to describe extreme cases as “depression” whereas they used terms such as bored or tired, to label milder depressive symptoms.
Marwa: “Sometimes you feel bored. It’s not depression, it’s just that I might be bored and my mood will change and this is something normal. But depression means being sick and requiring a treatment. I’ve never had that, but I have heard of it. I’ve heard that many women will experience this either before birth or postpartum…. The woman will be sick to the point where she can’t see anyone or speak to anyone and will need a physician.”
The women ascribed maternal depression to a range of causes including having a girl baby whilst expecting a boy, giving birth away from family, baby’s death, or worries about the baby’s birth, especially in a first pregnancy.
Afnan: “If you ask any Syrian person why a woman is depressed, they would say “being away from her family, alienation”.”
Yusra: “I had a depression before I was pregnant in Syria and I was injured. ...After birth, I wasn’t able to walk because of the injury, so I became depressed. … I was very depressed but I had a hope because I wanted to feel better for my girl. After 3 months, she died, and I was very depressed.”
Most of the participants said that maternal depression happens less in the Syrian women, compared to other women. They believed that Syrians in general love to have children and hence everybody is very happy and pleased after birth. One woman described the strong support that was provided to women in Syria around birth as a possible factor that may explain why she thought depression is less in Syrian women.
Eman: “It’s less. Everybody is happy. I think that it is less. Whenever I hear about a woman gives birth, she will be happy and will be relieved. It is for sure less. ... the women will be with her family and will be happy. She will have a baby. Things were very good in Syria before, so maybe because of that.”
Protective factors for mental health
Despite all their difficulties, the women described strategies that protected their mental health. The women defined support as the social support they receive around the time of birth, either during labor or afterward, with emphasis on emotional support.
Joud: “You feel that you aren’t alone and you will feel that someone is standing beside you.…Like when you are going to give birth, you really need your mother, your aunt or somebody.”
However, they also appreciated other forms of support.
Kadiga: “There is also the support for the other children…. Also the help with housework and also for the new baby, who will need care. The mother will be depressed/concerned about whether to take care of the baby, her health, other children, or for the house.”
Reem: “I used to have my mother and my sisters around me during labor, but I will be alone here. This is a big thing for me. I am displaced and all my family is away and this is something so big for me.”
When they were asked about things that might help a woman with depression, all thought that reconnecting them with their family would be most beneficial.
Reem: “It should be like we can go and visit them or the family can come and visit us. This way we would not feel like a bird in a cage or imprisoned…. This is the most important and critical issue here. This is what can cause depression.”
Participants greatly appreciated the support from Canada and welcoming them by providing them with housing, medical care, and financial support.
Afnan: “Feeling of hope, feeling that there is a good future here…. Hope and feeling safe.”
Spiritual practices, such as prayer and reading the Holy Quran were mentioned as a source of support and strength for all the women.
Joud: “For us, when somebody has a low mood, they will open the Quran and read.”
Participants believed that support programs would be useful for their mental health, but suggested that to avoid stigma from their community programs should be named in a way that does not refer directly to depression but rather wellness.
Afnan: “Programs for Syrian women to speak about their situation and about everything related to them, like the challenges they face.... Make a program for them under another name, like for example “towards a better life”, so the topic of discussion will be depression, but in front of the general public, it’s not, so they can talk about depression and they will not be shy to participate, and they can talk freely.”
Participants felt that exercises like walking and swimming would be helpful for their mental health. However, they felt that all recreational programs in Canada are mixed “both gender”, which they thought hindered their engagement in such activities. As Muslim women who are covering their hair and body, are used to have special places for women where they can participate easily in various outdoor and indoor activities.
Reem: “We have to make sure that we have these kinds of things are not mixed-like men and women. There should be something special for the women.... So, men have a lot of things that are set for them, but there are no special programs for the women with hijab.… So here, I miss swimming and I miss special farms/gardens for us. This is something that I really miss here in Canada.”
Meditation activities such as yoga, that are very popular in western culture for depression [
48] were not well-known in the Syrian culture, and most of the participants have never engaged in such activities.
Participants were strongly against the use of medication for depression, with only a few saying that medication may be needed in severe cases, but then only as the last treatment choice. Some however, believed that medication may help a woman to get enough sleep.
Barriers to mental health services
Participants described two major obstacles that may prevent Syrian refugee women from seeking or accessing mental health services; stigma of mental health and privacy concerns.
Marwa: “I might have depression… If I went to a psychiatrist, they would say that she “went crazy”. So, society would think that she is a psychiatric patient and is getting treatment. …. She might only have a low mood and want someone to talk to, someone to make her aware, but no, they will think immediately that she is crazy.”
Even though there is that stigma associated with seeking mental health services, some felt strong enough to seek help, if they needed to.
Kadiga: “If I have depression, I will not have a problem going to a psychiatrist and seeking help. I’m sure that they will speak about me and say that I’m crazy but this doesn’t matter to me. What is important to me, is to treat myself so I can live comfortably with my family.”
Participants also spoke about the possibility that a husband may prevent the woman from seeking help or from disclosing her symptoms, even to her family, for fear of social stigma, although they denied that this had happened to them.
Eman: “For every woman, her husband’s way of thinking is different…. Some men, they don’t like that their wives to speak, even to her neighbors. It’s a form of privacy.”
Concerns about privacy, confidentiality, and whether other people, especially Syrians, would know that a woman is seeking help for her mental health were also cited by participants as possible barriers. Nonetheless, they felt that privacy concerns were less of a concern here in Canada than it was in Syria or in other Middle Eastern countries.
Yusra: “Maybe she will be shy that somebody will know, somebody will know her name, her story, her life, how she is living, etc. She would think that this is private life.… Her privacy might prevent her from this…. She might think that this is her private life.”
Language difficulties also impacted their privacy, especially when seeking healthcare services. Women said that they would be willing to share their symptoms with a healthcare provider, but not necessarily in the presence of an interpreter, especially where there is a small community of Arabic speaking people.
Yusra: “If you speak with a psychiatrist, you would speak normally, but if there is an interpreter as a mediator, and this person might speak about what you said, and now like you have told your story to this and may be this mediator will tell everybody in Canada.”