women’s health update
Giving birth between two worlds – Goan women in NZ
caption Safety and success at home: A young Goan woman receives an achievement award. Photo credit: Fred 36
Ruth De Souza recently completed a masters degree on migration, mental health and motherhood. Ruth, born in East Africa of Goan Indian origin, works in NZ as a mental health nurse and nursing educator. Camille Guy asked her about the research and the birthing experiences of recently immigrated Goan women
It is hard for those of us born in this country to comprehend how disorienting it must be to be both a new immigrant and to be giving birth, perhaps for the first time, in a new country. Such women bring to the experience of pregnancy and delivery memories of the way it happened in their homeland. But at this period of extreme vulnerability they must reconcile comforting homeland rituals with new and unfamiliar practices. Which voices of authority to trust? While working in maternal mental health and in post-natal wards in Auckland, Ruth De Souza became curious
vol 7 no 1 • April 2003
I n s i d e ●
The health of a new generation - Youth 2000
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Latest news on HRT quality of life findings, NZ usage and labelling
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New breastfeeding advocate appointed
about why mental health services are under-utilised by migrant women. White, articulate and affluent women certainly used them. So how were migrant women, deprived of their traditional safety nets, coping? De Souza conducted in depth interviews with seven Goan women about their migration history, their adjustment to living in New Zealand and experiences of childbirth and motherhood here.
No place like home ? Ruth found that after migrating, traditional sources of support and knowledge were lost. One woman recalled of home: Everyone else does things for you and you know in that way you are just pampered. You get all these supposedly nourishing treats and foods and things you know. Like continued on page 2
Women’s Health Update features women’s health news, policy and scientific findings, to enable health care professionals and community-based workers to be at the forefront in women’s health. Women’s Health Update is published by the Women’s Health Action Trust
2 • Women’s Health Update • vol 7 no 1 • April 2003 Goan Women
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all these pulses and the sweets that you normally have. I’m not very sweet tooth, but I think they do help. (Greta) In Goan culture women giving birth are expected to stay home for 40 days after delivery and are cosseted. De Souza finds it ironic that the expectation of nurturing and endless care that the study participants had prior to their arrival in New Zealand positioned them as ‘backward’ in their new country. “This is one ‘tradition’ that many Western women are now crying out for,” says De Souza. So although these new immigrants were pleased with access to high standard maternity care, they did not receive the kind of support that they associated with childbirth in their own culture. In fact New Zealand hospital staff here, quite unfamiliar with Indian customs, were impatient of what they saw as “passive and demanding” Indian patients.
For better or worse ? On the other hand De Souza discovered, some aspects of this replacement culture were empowering for the Goan women. They were able to reclaim their power in motherhood rather than be inhibited by taboo. On home ground and with familiar faces and familiar happenings going on. … it would have been positively different. but … this child bearing experience is some-
thing different and there’s a big taboo …. What I experienced here was that child bearing is natural, that natural factor was a great thing. You know that it’s painful … at home they don’t put any pleasantness I think in the experience. (Lorna). The Goan women had to adjust to new rules, such as being entitled to complain about the health care that they received. Their history of subjugation, under colonialism and traditional medical practice, worked against such awareness. Assertiveness did not come easily and so these migrant women were seen as passive, says De Souza. On the other hand, the model of western women as educated, liberated and with control over their bodies was something that some Goan women tried to copy. Goan or women or whoever is coming from another culture … should know that they have the option. We should know that we … have a right to question, which you don’t know. You are not really aware of it, and the local New Zealander takes it for granted that you know…. Lorna. De Souza found that some of the women in the study re-appropriated their cultural rituals as western ways were inadequate in meeting their needs. They held parallel beliefs, maintaining some traditional practices whilst also valuing western care. This was not helped by the attitudes of some health professionals who considered these women had ‘over-invested’ in their home country as opposed to assimilating.
Caught in the crossfire The Goan women perceived that little support was available for them to maintain traditional practices, such as infant massage. Some of the women worked hard to ‘fit in’ while also attempting to acknowledge past values and traditions that had shaped them. It’s such a different situation out here. Mum says oh, it’s so cold in this country, don’t give a bath here. The midwife says give a bath every day, when hardly a week, the baby is born the midwife says why don’t you take her for a walk, it’s a sunny day, you know why don’t you go out? In India you wouldn’t go out for 40 days…. So many conflicting kind of things, which was very difficult (Muriel). The women De Souza studied were caught between offending old or new authority figures. The outcome for many women was loneliness and silencing. Yet there was resistance to having their experiences pathologised with one woman choosing to call her state ‘isolation’ not ‘depression’. These experiences highlight how a universal system that provides for everyone fails to cater for the individual needs of minority cultures and how this results in further disadvantage.
The Youth 2000 Study – health & wellbeing profile Findings from New Zealand’s first national youth health survey provide both good and bad news about the health of New Zealand’s young women. The mental health data provide the most striking gender discrepancies. Females reported being generally less happy than males, under more stress and more likely to feel worn out. Female students were much more likely to have times when they felt down (40.7% for males and 60% for females). Of most serious concern are the findings on depressive
symptoms, suicidal thoughts and suicide attempts (see box below) which are disturbingly high for both genders, but higher for young women. Terryann Clark says factors that help protect young women (and men) from mental health problems include good relationships with families and at school, and feeling safe in the community. The study provides much-needed information for policy-makers, educators, health providers and communities working with youth. It points to the need for
Male
Depressive symptoms 8.9% Thought about suicide 29.2%
Female
18.3% 16.9%
giving greater priority to youth health in policy and service provision, and alerts us to the need for urgent action in the area of young women’s mental health. Terryann Clark will present a seminar based
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Women’s Health Update
• vol 7 no 1 • April 2003 •3
Latest news on HRT Overseas study: HRT does not make women ‘feel better’ In March the Journal of the American Medical Association took the highly unusual step of releasing three months before publication the results of the Women’s Health Initiative study for quality of life. Overall, the study found no clinically meaningful effect of combined HRT on health-related quality of life or other psychosocial outcomes, such things as vitality, social functioning, mental health, depression or sexual satisfaction. Some earlier studies found improvements in wellbeing in women with troublesome menopausal symptoms, but not those without them. The WHI found no gain for either group. The WHI study found that after one year there was a statistically significant difference favouring HRT in only three of nine quality of life measures (sleep disturbance, physical functioning and bodily pain), but these differences were not clinically important, as they were only 1-4% over baseline scores. After
three years there was no significant benefits in any quality of life outcomes. These included measures of general health, mental health, depression, social functioning, insomnia, sexual satisfaction and cognition. The same results were found amongst women in the 50s, close to menopause, and among women with hot flushes, night sweats, sleep disturbances, and emotional or mental problems at baseline. In a commentary accompanying this paper, Dr Deborah Grady, one of the WHI investigators, said that if the rates of adverse events among 50-year-old women were half that of older women in the WHI trial, the net effect of HRT use would be one serious adverse event per 1000 younger women treated for one year . She pointed out that there are other treatments for hot flushes, but some women might find HRT worth the risk. There is no role for HRT in women without vasomotor symptoms, she said.
Changes in prevalence of HRT use There was a significant drop in prescribing of HRT in New Zealand when the WHI study was released, according to Pharmac figures. The number of units of HRT prescribed annually dropped from two-and-a-half million units in July 2002 to one-and-a-half million units in November 2002, a dramatic shift in a five month period (see graph).
Labelling of HRT In February Medsafe wrote to all companies supplying HRT products advising of extensive changes to be made to data sheets to reflect the results of the WHI and a recent study that showed an increase in ovarian cancer amongst users of oestrogen alone. These changes are to be submitted to Medsafe for approval by 30 June 2003.
Moving Annual Total of Units and Expenditure for HRT
$800,000
3,000,000
$600,000
2,500,000
$500,000
2,000,000
$400,000
1,500,000
$300,000
Graph supplied by Pharmac
1 Nov 02
Actual Date
1 Jan 02
500,000
1 Jan 01
$100,000
1 Jan 00
1,000,000
1 Jan 99
$200,000
Units (patches or tablets)
3,500,000
$700,000
Expenditure
Dr Grady advised women who use HRT for relief of unpleasant menopausal symptoms to use the lowest possible dose and to try to come off HRT at the end of six months. If symptoms are still making life difficult, a woman might decide to stay on for a further period, then try to come off again. The Ministry of Health advises women not to use HRT for more than three or four years at the most. This is because the risks increase the longer HRT is used.
Sum of Drug Cost SQ
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Sum of Units SQ
4 • Women’s Health Update • vol 7 no 1 • April 2003 The survey - Youth2000 - instigated by the University of Auckland’s Adolescent Health Research Group and headed by Dr Peter Watson, focuses on both protective and risk factors. Overall the research group says the survey finds secondary students are healthy, but does reveal some areas of serious concern. Co-investigator Terryann Clark says many areas showed surprisingly little
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Youth 2000 • A total of 9699 randomly selected
students from 114 schools all over NZ participated in the survey. • The anonymous survey consisted of 523 questions in a computer-based self-interview. • The questionnaire covered a broad range of areas – from home and school to sensitive topics like drug use and sexuality. • The survey produced 9570 ‘files’ for analysis.
Terryann Clark, Adolescent Health Research Group, University of Auckland.
difference in terms of gender, such as drinking alcohol, but there were some big discrepancies. “Some of the discrepancies were predictable such as differences about smoking and body image,” she says. Females were half as likely as males to eat breakfast and twice as likely to report trying to lose weight. Female students of all ages were more likely to smoke cigarettes. on a gender analysis of the data – the health status of young women attending secondary schools throughout New Zealand – at a Women’s Health Action seminar on May 28. To register, see below in Noticeboard.
References: Adolescent Health Research Group. NZ Youth: A profile of their health and wellbeing. Auckland: University of Auckland; 2003. (www.youth2000.ac.nz) A health profile of New Zealand youth who attend secondary school. Adolescent Health Research Group. NZ Med J 2003;116(1171). URL: http://www.nzma.org.nz/journal/1161171/380/
Noticeboard ●
NEW BREASTFEEDING ADVOCATE APPOINTED
WHA welcomes Louise James as the new breastfeeding advocate to replace Sian Burgess. Louise can be contacted at Women's Health Action. Phone 09 520 5295. Email: Louise@womens-health. org.nz
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CARTWRIGHT ANNIVERSARY LUNCH
ZEALAND CONFERENCE 2003
THE ROLE OF CONSUMERS ON ETHICS COMMITTEES Tuesday 5 August 2003 A reminder for your diaries
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WOMEN’S SUFFRAGE BREAKFAST
MANAGING MENOPAUSE
SPEAKER: HON. MARGARET WILSON
Tuesday 6 & 13 May 2003 Women’s Health Action, Newmarket, Auckland An interactive seminar held over two evenings, focusing on managing menopause without the use of drugs. For more information contact Women’s Health Action, phone (09)520-5295, email info@womenshealth.org.nz
Friday 19 September Ellerslie Convention Centre, Auckland In 1973 the United Women’s Convention was held in Hamilton with Margaret as one of the speakers. Margaret has come a long way since then but what about NZ women? We have asked Margaret to give her views 30 years on and outline the challenges that remain.
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● PUBLIC HEALTH ASSOCIATION OF NEW TINO RANGATIRATANGA IN PUBLIC HEALTH – WORKING WITH MAORI AND INDIGENOUS VALUES AND PRINCIPLES 2-4 July 2003 Turangawaewae Marae, Ngaruawahia Call for Papers The organising committee of the PHA conference 2003 is calling for papers to be presented at the conference. This is the first PHA conference to be orgainsed by the Maori Caucus and will offer challenges and experience never before had at a PHA conference. For more information contact Gayl Humphrey phone 09 366-6136 ext. 41352 or mobile 021-1100901, email g.p.humphrey@massey.ac.nz
● THE HEALTH OF YOUNG WOMEN IN NZ
Wednesday 28 May 2003 – 4pm-6pm Women’s Health Action, Newmarket Terryann Clark speaks on the findings published in “Youth 2000 – Adolescent Health Survey” carried out by the Adolescent Research Group, Terryann is a researcher and Adolescent Nurse Specialist at the Centre for Youth Health. For more information contact Women’s Health Action, phone (09)520-5295, email info@womenshealth.org.nz
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RNZCGP ANNUAL CONFERENCE
17-19 July 2003, Dunedin ‘Towards unity, Me mahi tahi tatou’. The conference will be about working together with other health professsionals. For more information visit www.rnzcgp.org.nz
CERTIFICATE OF ACHIEVEMENT IN INTRODUCING HEALTH PROMOTION
13 May 2003, Gisborne This course is jointly run by the Health Promotion Forum and Manukau Institute of Technology. For more information contact Raelene Buchanan, Manukau Institute of Technology, Dept. of Social Sciences, phone 0800-101030 or (09)968-8000 ext 7761 or email raelene.buchanan@manukau.ac.nz
Women’s Health Update is produced by Women’s Health Action Trust • Edited by Jo Fitzpatrick To receive copies of Women’s Health Update, make suggestions about future contents or send items for publication please contact: Women’s Health Action Trust • PO Box 9947, Newmarket, Auckland, New Zealand • 2nd Floor, 27 Gillies Avenue • Ph (09) 520 5295 • Fax (09) 520 5731 • email: info@womens-health.org.nz Internet address: http://www.womens-health.org.nz • Women’s Health Update is published with the assistance of the Ministry of Health