Psychological interventions for maternal depression among women of African and Caribbean origin: a systematic review

Background Maternal depression is a leading cause of disease burden for women worldwide; however, there are ethnic inequalities in access to psychological interventions in high-income countries (HICs). Culturally appropriate interventions might prove beneficial for African and Caribbean women living in HICs as ethnic minorities. Methods The review strategy was formulated using the PICo (Population, phenomenon of Interest, and Context) framework with Boolean operators (AND/OR/NOT) to ensure rigour in the use of search terms (“postpartum depression”, “maternal depression”, “postnatal depression”, “perinatal depression” “mental health”, “psychotherapy” “intervention”, “treatment”, “black Caribbean”, “black African”, “mothers” and “women”). Five databases, including Scopus, PsycINFO, Applied Social Science Index and Abstracts (ASSIA), ProQuest Central and Web of Science, were searched for published articles between 2000 and July 2020. 13 studies met the inclusion criteria, and the relevant data extracted were synthesised and thematically analysed. Results Data syntheses and analyses of included studies produced four themes, including (1) enhance parenting confidence and self-care; (2) effective mother–child interpersonal relationship; (3) culturally appropriate maternal care; and (4) internet-mediated care for maternal depression. Conclusion In the quest to address maternal mental health disparities among mothers of African and Caribbean origin in HICs, the authors recommend culturally adapted psychological interventions to be tested in randomised control trials. Supplementary Information The online version contains supplementary material available at 10.1186/s12905-021-01202-x.


Background
Women of African and Caribbean origins in High-Income Countries (HICs) are particularly vulnerable to the high risk of maternal mortality than women of other ethnic backgrounds. In the United Kingdom (UK), maternal deaths due to mental and physical health complications among African and Caribbean women are 41.1 and 62.2 per 100,000 pregnancies compared with 11.1 per 100,000 pregnancies of their white women counterparts [1,2]. Similarly, the prevalence of maternal mental health varies significantly by ethnic groups. For example, 29.3% of African and Caribbean women are more likely to suffer from mental health problems compared to 20.9% of White British women [3]. Evidence suggests that women from White family background have better access to culturally appropriate mental healthcare for maternal depression compared to the women of African and Caribbean origins [4,5], who are most likely to be ignored, not followed up about their current or past maternal health distress, and not offered any form of treatment for postnatal depression compared with their white counterparts [6].
According to the World Health Organisation in 2019, depression during or after childbirth affects approximately 13% of women during the postnatal period and 10% of women during pregnancy [7]. Mothers with maternal depression feel multiple symptoms such as the sense of hopelessness, withdrawn behaviours, severe mood swings, lack of concentration, and unexplainable pains and fatigue [8,9]. Maternal depression has potential risks and fatal implications for the mother, child and the entire family [5,8,9]. The attachment between a mother and child is critical for the child's physical and cognitive development at both present and later life [10,11]. This suggests that maternal depression can have multigenerational adverse effects.
However, little is known about the maternal mental health of African and Caribbean women. A systematic review has shown that women from ethnic minority groups are at a higher risk of developing maternal depression [12]. This may be due to racial discrimination, social deprivation and lack of culturally sensitive interventions [13,14]. Risk factors for maternal depression in ethnic minority women could be explained by the critical race theory which explores the unequal distribution of resources, diagnosis and treatment of mental health conditions, and societal and political manifestations as the result of racial stratification [15]. The current mental healthcare systems do not serve the needs of depressed African and Caribbean women effectively [12]. In the UK, mental health professionals predominantly from the white British background have reported a lack of confidence and inadequate cultural competence training and their inability to detect perinatal depression in women of African origin [16]. Thus, there are so few practitioners of African origin, and therefore, lack 'insider knowledge' relating to Black, African and Caribbean cultures [16].
The National Institute for Health and Care Excellence (NICE) guideline for postnatal depression recommends cognitive behaviour therapy and interpersonal therapy as first-line treatment [2]. Despite the evidential benefits of interventions in preventing or managing maternal mental health, culturally sensitive interventions are sparse in targeting women of African and Caribbean origin. A recent systematic review has suggested that culturally adapted interventions have better outcomes compared to routine treatment [17]. One study delivered a culturally adapted group psychological intervention for postnatal depression for the British South Asian mothers [18]. The intervention participants reported an overall positive change in their attitudes, behaviour and self-confidence [18]. The study also suggests the acceptability and feasibility of interventions of this kind.
Africans and Caribbean people's experiences are unique or different from mainstream culture and other minority ethnic people in HICs. For example, the adversities and legacies of slavery, colonialism, and racism potentially impact not only mental health issues but also social realities and general worldviews [19].
Therefore, there is a clear need to identify interventions that specifically address African and Caribbean mothers' psychological needs. The purpose of this study is to review the existing interventions for maternal depression aimed at women of African and Caribbean ethnicity living in HICs.

Protocol/search strategy
The review protocol was developed and registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42019149392). The review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to ensure methodological rigour and global best practice for systematic review [20]. Utilising Boland, Cherry and Dickson's [21] model, a protocol outlining the inclusion criteria and specific methods of analyses postulated in advance of undertaking this review [21]. All records were collected on RefWorks, a bibliographic tool used in research to develop personalised databases.

Inclusion and exclusion criteria
The review inclusion criteria were: (1) study population of women and mothers, self-identified as Black or having African or Caribbean origin; (2) providing intervention in the form of psychological therapy, educational programs or health visitor interventions; (3) studies which demonstrate maternal depression and well-being outcomes and/ or child development/ behaviour/well-being outcomes; and (4) studies using either qualitative or quantitative methods with pre-and post-intervention measures or randomised controlled trials.
Papers were excluded if: (1) the study population had a majority of Caucasian participants or contained ethnic minority groups that were not inclusive of participants with Black, African or Caribbean origin; (2) studies where interventions did not focus on maternal well-being and depression; (3) studies that only measured the outcomes of child development/behaviour/well-being; or (4) studies with correlational design, with an emphasis on the prevalence of depression only without any intervention tested or provided.

Information sourcing
The strategy adopted to formulate the review was the PICo model (Population [Black, African and Caribbean mother/child], the phenomenon of Interest [depression], Context [maternal mental health and child well-being]) [22]. The Boolean operators (AND/OR/NOT) were also used for strategic search [23]. The search terms include "postpartum depression", "maternal depression", "postnatal depression", "intervention", "treatment", "program*", "black Caribbean", "black African", "black", "Afro-Caribbean", "African" and "Caribbean" "mothers" and "women" to search five databases (Scopus, PsycINFO, ProQuest Central, Applied Social Science Index and Abstracts (ASSIA) and Web of Science) for published studies between 2000 and July 2020.

Screening and selection
The search yielded a total of 553 records, of which duplicates removed were n = 259. Two reviewers screened the available titles and abstracts by applying the inclusionexclusion criteria. After full texts were screened, 13 studies were selected for the systematic literature review. Any discrepancies between the two reviewers were resolved through discussion with a third reviewer.

Risk of bias assessment
The present review used the Standard Quality Assessment Criteria (QualSyst Tool) for the risk of bias evaluation [24] (see the Additional file 1 table showing the risk assessment of each study). All studies included in the review showed a low risk of bias. Majority of the studies used control groups (collaborative care or treatment as usual). Due to mothers' vulnerable nature with maternal depression, none of the studies withheld treatment as usual from participants. Most studies included in the review used randomisation to allocate participants to the different arms of the trial. The majority of the studies provided limited information on the process of blinding or whether this occurred.
However, one study reported proximal outcomes and related this to the small sample size [25], and another study only supported the conclusions made due to lack of significance in the results [26]. The majority of research were of small sample size pilot studies testing the feasibility of maternal interventions. Attrition is a challenge in these types of studies where the sample populations are under-treated. For example, one study had only 3% attendance in the control group compared to 83% attendance in the intervention group [27]. The majority of studies recruited non-treatment seeking participants which may reflect the challenges with engagement and one internet-based intervention study examined mothers' intention to seek treatment for maternal depression.

Strategy for data synthesis
The findings from the various studies were thematically synthesised into a qualitative narrative addressing the research question. Therefore, the conceptual framework of synthesis was adopted [28]. Each source was critically analysed and evaluated by major themes in terms of strengths, weaknesses and critical gaps using the synthesis matrix. The synthesis was conducted in four stages: (1) implementation of a relevant literature search; (2) identified key ideas and elements; (3) organised the key ideas and elements; (4) synthesised data and built a case for new research intervention. An 'index card' like method was employed to identify and organise the key ideas and elements from stages 2 and 3. Each pile or category of organised ideas were re-arranged into (a) a logical flow of information; (b) compare and contrast; (c) critique; and the (d) postulation of an alternative model for future interventions research aimed at African and Caribbean mothers/women.

Results
The extracted data were synthesised into the following four themes: (1) enhance parenting confidence and selfcare; (2) effective mother-child interpersonal relationship; (3) culturally appropriate maternal care; and (4) internet-mediated care for maternal depression.
The flow diagram in Fig. 1 showed a trajectory of the literature that was synthesised. Subsequently, the Studies excluded (n = 67): Studies with mostly Caucasians; interventions not focused on parental wellbeing/depression; without mother and/or child outcomes.
Studies included: Tested and measured intervention; recorded maternal and/or child outcomes; and involved pre and postnatal periods of African and Caribbean population.   None of the intervention effects appeared to have lasting impact on the participants, and treatment did not appear to impact perceived stress or baseline salivary cortisol levels characteristics of studies that met the inclusion criteria (see Table 1) illustrate data extraction from selected studies. Examples of studies excluded which were either mostly Caucasians, interventions not focused on parental wellbeing/depression; without a mother and/or child outcomes includes (1) Morrell et al. [29] who examined the clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women, (2) Horowitz et al. [30] employed nurse home visits to improve maternal/infant interaction and decrease the severity of postpartum depression.

Enhance parenting confidence and self-care
Findings from the reviewed studies showed that maternal depression and other mental health conditions could be best treated with interventions designed to enhance parenting confidence and self-care [25,26,[31][32][33][34][35][36]. This notion of the intervention was found to be effective across eight studies. For example, Crockett et al. [26] examined the feasibility, effectiveness and acceptability of an intervention program called Reach Out, Stand Strong: Essentials for New Moms (ROSE) for rural, low-income African American pregnant women who were at risk of postpartum depression. The program entailed interpersonal therapy that enhanced familial communication, social support, managing the transition, and focusing on factors associated with major depressive symptoms and perinatal depression. Women in the ROSE condition showed significant improvement in their depressive symptoms and parenting adjustment at 3 months postpartum than women in the treatment as usual condition.
In a randomised controlled trial (RCT) of skill-based intervention that empowers women at risk of postpartum mental health distress, Mendelson et al. [25] measured how Mother-Baby (MB) course could be adopted as a preventive measure for depression and the impact of perinatal depression on coping, social support and mood regulation among African American women. An MB course is a manualised skill-development training material blended with core elements of cognitive behavioural therapy to prevent the risk of perinatal depression among ethnically diverse and low-income mothers [37]. This was delivered by trained facilitators who taught mothers how to harness and utilise enjoyable and supportive contacts, modulate their negative automatic thoughts and increase pleasant activities. Findings showed 16% greater prevention of depression over time and more effective mood regulation from baseline to 6 months follow up in the intervention group compared to the control group. These findings have been supported in previous research on the effectiveness of the MB course and its ability to prevent depressive symptoms and other risks of mental health problems in mothers [37,38]. Crockett et al. [26] and Mendelson et al. [25] illustrated maternal programmes that encapsulate skills-oriented intervention, enhancing parenting confidence and self-care in postpartum periods and beyond.

Effective mother-child interpersonal relationship
Mother-child relationship has significant implications for maternal mental health, and therefore, the current review showed recurrent emergence of interventions targeting effective mother-child relation [25,31,32]. For instance, Holditch-Davis et al. [32] examined the mother-infant relationship and its effects on maternal mental distress using a maternally administered intervention designed explicitly for preterm infants in the neonatal intensive care unit (NICU). Two interventions were compared; (1) Kangaroo Care and (2) Auditory, Tactile, Visual, and Vestibular (ATVV) interventions. The effectiveness of these two interventions on the mother-infant relationship and maternal mental distress were evaluated and compared with an attention control group. Findings showed a rapid decline in maternal depressive symptoms and lower parenting stress across all intervention groups with higher scores on the Home Observation for Measurement of the Environment (HOME) inventory. HOME is a scale that measures the quality and quantity of support available in the child's home environment [39]. ATVV is an intervention that involves a series of activities with an infant such as moderate stroking, talking, rocking and keeping eyecontact [40]. Whereas, Kangaroo intervention entailed a process of holding an infant to ensure skin-to-skin contact around the mother's breasts [32].
Mendelson et al. [25] also focused on the mother-child interpersonal relationship in their study, in which the Mother and baby (MB) Course was adopted as the basis for preventing maternal depression. In this intervention, "the mother-baby relationship is emphasised throughout the course, including ways to enhance parenting practices using course skills" [25 p. 212]. The MB course involves core elements of cognitive behavioural intervention that translates into quality mother-child relationship and has consistently shown to reduce maternal depression, especially among low-income women [37,38].

Culturally appropriate maternal care
Previous studies have shown low engagement and high dropout rates of psychological treatment among ethnic minority populations in HICs compared to the native population which suggests that current treatment options lack cultural relevance or appropriateness [14,16]. Therefore, cultural beliefs, values and traditions are essential in intervention planning and execution for addressing maternal depression [25,26,33,35,[41][42][43][44]. In the Grote et al. 's [41] study using an RCT design, culturally relevant and enhanced brief Interpersonal Psychotherapy (IPT-B) had a greater effect on treating depression in low-income pregnant women compared to those receiving enhanced usual care. Enhanced IPT-B consists of engagement sessions and later followed by eight IPT-B sessions covering up to 6 months postpartum period.
Most importantly, the culturally relevant materials were embedded to augment the intervention. For example, the engagement session was based on ethnographic and motivational interviewing designed to build rapport and trust to address the practical aspects of lived experiences of cultural and psychological barriers to mother and childcare among lowincome depressed women. Therefore, the practitioners approached the mothers with the core elements of culturally sensitive principles of ethnographic interviewing in which the interviewer employs the role of a learner to understand the women from their cultural perspectives without any bias, focusing on; unconditional appreciation of participants' cultural values, beliefs and traditions in terms of their views about depression, health beliefs, coping practices or healthseeking behaviours. Women were asked what they would like to achieve during the intervention phase. Issues such as the importance of race, ethnicity and spirituality were put forward in the engagement sessions [41].
Considering the low-income and economically disadvantaged predicaments of the depressed women in this minority group, a pragmatic approach was integrated with the Enhanced IPT-B intervention to cater for basic needs (e.g. access to food and free bus passes and bay supplies) and to facilitate access to sustainable social services (e.g. effective childcare, job training and access to housing) which were included as core aspects of the intervention delivery. Findings from the Enhanced IPT-B intervention highlights its effectiveness in reducing antenatal depression, and further improving social functioning and preventing relapse in the postpartum period of up to 6 months.
Furthermore, two studies implemented reinforcement strategies, weekly from their home visitor [25], and the other weekly calls and/or texts about the upcoming session [27]. A combination approach is essential to be considered given the numerous obstacles that may hinder African and Caribbean women from engaging in treatment, especially when they are from low-income backgrounds. Translated materials and topics such as spiritual-related resources were added to the culturally adapted intervention [43].

Internet-mediated care for maternal distress
Modern technological innovation now plays a significant role in the mental health healthcare provision. One of the overarching themes in the present review is internet-mediated care for maternal depression [27,31]. For example, Logsdon et al. [31] examined the effectiveness of the internet-based approach to treating depression among African American adolescent mothers. The intervention included vignettes, resources, questions and answers developed based on the theory of planned behaviours (TPB). Immediately after the intervention and 2 weeks post-intervention, participants (n = 151) responded to questions on depressive symptoms based on TPB variables. They completed the intervention from any computer device of their choice. This was compared with the control group (n = 138) which entailed visits to homes and community organisations.
The intervention led to significant improvements in perceived control on maternally related self-care, positive attitude change, increased intention to seek help, and active behaviours for seeking actual treatments. Other advantages accrued to the internet-based intervention were about the cost of delivering it, which was least expensive with reduced costs of logistics and time, which may be especially beneficial for mothers with limited resources. A similar study, Boyd et al. [27] conducted a pilot RCT using social media for postpartum intervention for depressed low-income mothers. Groups were compared using social media (Facebook) and inperson interventions for African American mothers who screened positive with postpartum depression from paediatric clinics. Both interventions employed the parents interacting with infants (PIWI) which involved eight weekly sessions including behaviour activation and depression psychoeducation, parent-child interaction such as play, laughter and safety. Findings showed that women in the social media intervention group had lower depressive symptoms than women in the in-person.
Both Logsdon et al. [31] and Boyd et al. [27] studies showed the potential effectiveness of using online facilities for reducing maternal depression. Their findings have been supported in the previous literature. For example, online intervention to improve positive parenting behaviours and ameliorate child-related behavioural problems [45], treatment of depression, improve attitudes about treatment, relapse prevention among young mothers [46,47], and improved parenting skills and infant feeding [48].
This study was conducted shortly before the Covid-19 pandemic era; however, the unequal distribution of infection and death rates of the Covid-19 pandemic among African and Caribbean populations in HICs has exposed longstanding systemic issues of racial inequalities [19].
For example, in the UK, those who experienced higher societal disadvantages faced more significant health risks [49]. Reports have shown that there have been between a 10% and 50% higher risk of death among African and Caribbean populations compared to the White British population [49]. Considering the current pandemic, which may further alienate already marginalised people, there is an urgency to understand the effectiveness and engagement of culturally adapted online help or 'teleintervention' delivered remotely for these ethnic groups.

Limitations and suggestions for future research
The review explored psychological intervention for depressed African and Caribbean mothers in HICs. However, the review outputs were limited to a few studies (N = 13) that met the inclusion criteria and captured various North America interventions only. This implies that women of African and Caribbean origins are disproportionately affected by maternal depression and distress [1,[3][4][5]. Yet, there are limited evidence-based interventions for maternal distress that are specifically designed and made culturally appropriate for African and Caribbean mothers. Culturally relevant psychological interventions are essential for maternal depression [8,41]. Therefore, the present review recommends culturally adapted interventions for mothers of African and Caribbean origin living in HICs. In-person contact and online intervention studies are required to establish a nexus of evidencebased resources for usability in maternal health-related policies and clinical practice for these mothers.
Following on from the review of psychological interventions for maternal depression, the direction of the future psychological intervention-a Learning Through Play plus Culturally adapted Cognitive Behaviour Therapy (LTP + CaCBT) [50] may be useful for African and Caribbean depressed mothers living in HICs. LTP + CaCBT intervention package is manualised and piloted in Kilifi, Kenya and can be delivered by community health trained workers not requiring mental health experts [51]. The programme enables mothers to improve their children psychosocial development by engaging in mother-child play. The theoretical underpinnings of LTP are found in Piaget's theory of cognitive development [52] and Bowlby's attachment theory [53,54]. The SickKids Centre for community mental health (CCMH) Learning Institute illustrated LTP as a low-cost intervention with culturally appropriate homemade toys, books, and materials commonly found in the homes and used to promote cultural relevance and keep costs to the minimum [55]. The CaCBT instructions for each session are organised into modules that focus on feelings, thoughts, and behaviours with specific interventions focusing on psychoeducation, problem-solving, managing negative thoughts, behaviour activation, and relaxation [34,56].
The essential aspects of LTP + CaCBT were identified in the reviewed interventions. For example, Mendelson et al. [25] MB course focused on mood regulation, perceived social support, and coping. Similarly, the Auditory, Tactile, Visual, and Vestibular (ATVV) interventions which involve series of activities with an infant such as moderate stroking, talking, rocking and keeping eyecontact [40], appeared to capture some elements of LTP. Both LTP and ATVV seem to stimulate mother-child attachment and positive outcomes.
Our recommendation for culturally adapted psychological interventions might pave the way for preliminary efforts towards decolonising mental health provision in HICs. Other essential aspects of psychological intervention that could be integrated for these mothers may include their religion, philosophy, spiritualism, ritualism that are more 'organic' to the African and Caribbean people and culture.
The study's originality and significance are delineated in the paucity of research concerning depressed African and Caribbean mothers in HICs who are often neglected. Thus, the proposed LTP+CaCBT can offer a paradigm shift in culturally appropriate mental healthcare for African and Caribbean mothers. Finally, the researchers explored the possibilities of conducting a meta-analysis on the trials included in the present review; however, the trials included were mostly (a) pilot studies that tested treatment feasibility (b) various outcome measures with no fixed-effect, and therefore, appeared incompatible for a meta-analysis. Future reviews could be designed to perform an in-depth meta-analysis that could yield a more precise estimate of true effect outcomes [57].

Conclusion
The legacies of slavery, colonialism, and racism still impact African and Caribbean people's mental health experiences in unique ways, unlike any other ethnic people in HICs. Maternal experiences are emotionally demanding considering the delicate nature of care required during the prenatal, perinatal or postnatal periods. Due to insufficient culturally sensitive care, maternal depression is more challenging among African and Caribbean mothers living in HICs. The present review has synthesised intervention studies for maternal depression among women of African and Caribbean origin. The review also highlights that there is limited literature on maternal depression and culturally appropriate interventions. However, our proposal for culturally adapted psychological interventions (e.g. LTP + CaCBT) could serve as part of the preliminary efforts to decolonise mental