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Empowering Somali Mums       research project              Final report            September 2012This project was supporte...
Contents1. Introduction ..............................................................................................32. ...
1. IntroductionIn January 2012 Tweddle Child and Family Health Service engaged Red Tree Consulting to conductresearch into...
2. MethodPlanning and background researchWe developed and submitted a draft work plan, and conducted background research o...
We organised a discussion forum with Somali workers and others active in their community (seebelow) and sent invitations f...
3. About the Melbourne Somali communityDemographicsWe were only able to obtain limited demographic data from the 2011 cens...
celebrated. These ‘good times’ were contrasted with women’s experiences of trauma, displacementand loss in the civil war (...
Refugee journeys and recent arrivalsSomali people in Melbourne have come here via many different journeys. Many spent year...
worker we spoke with also referred to the level of debt that many families incur by borrowing thefunds needed to bring fam...
Khat is likely to be of limited relevance to Tweddle, however service providers should be aware thatkhat abuse by men may,...
4. Practices, beliefs and pressing issuesSomali family structuresWe interviewed Somali women with a very diverse range of ...
The (sometimes) changing role of Somali fathersMany interviewees referred to the traditional division of labour as the mot...
Again, women’s experiences vary a great deal, especially according to whether they have family here;but key ways in which ...
As discussed, women’s and children’s experiences of family, household and community prior to thecivil war in Somalia were ...
•    moderate factors: high levels of childcare stress, marital relationship, neuroticism, low self-     estate, difficult...
De Haenea et al’s review includes studies on the mental health outcomes of refugee children andadolescents, which reveal ‘...
Interviewer: I am wondering about postnatal depression, not depression as in mental illness … [Is  there a Somali word for...
The MCH nurses we interviewed also frequently administer the EPDS, but reported that:  First MCH nurse: … [Somali mothers’...
The concept of counselling is also problematic. Talking to a stranger about your feelings doesn’t  come naturally to [Soma...
with the child, and about all these resources and toys that are available. In a lot of our houses – it’s  changing now – b...
children were removed from their families, reportedly because of their child had disclosed theirparents’ use of physical p...
One Somali worker we interviewed who had run a Somali mothers group for many years said thatparticipants benefited greatly...
Somali workers asked about the knowledge of safe co-sleeping in the community identified practicessuch as sleeping with th...
Some informants alluded to a range of traditional cultural beliefs that Somali women have in relationto breastfeeding, and...
Second mother: I had problems with my nipples, it was inverted and hard. I had to use sometraditional herbal medicines. I ...
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
Empowering Somali Mums Research Report
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Empowering Somali Mums Research Report


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The ‘Empowering Somali Mums’ research project explores and documents the challenges faced by Somali Mothers and their 0-4 year old children so that Early Parenting professionals can provide culturally respectful and appropriate care for Somali families. Somali mothers from North Melbourne and Flemington were recruited for research groups attended by 28 mums, 27 phone interviews with Somali health and welfare professionals were conducted and we held a Somali Health workers forum with ten senior community workers. We wanted to understand the challenges which prevent Somali mums from accessing parenting assistance and how we can understand parenting from a Somali mum’s perspective.

Tweddle staff are undergoing cross-cultural training and building knowledge and resources that will help strengthen relationships between the Somali community, and other migrant communities. Tweddle provide Halal food, have private prayer space and families can bring up to three children to Tweddle. Thanks to the Victorian Women’s Trust (Con Irwin Sub Fund) for providing the grant that enabled this learning.

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Empowering Somali Mums Research Report

  1. 1. Empowering Somali Mums research project Final report September 2012This project was supported by the Victorian Women’s Benevolent Trust — Con Irwin Sub Fund
  2. 2. Contents1. Introduction ..............................................................................................32. Method ....................................................................................................4 Planning and background research ..................................................................... 4 Somali cultural consultants ............................................................................. 4 Research with health/welfare professionals and Somali people active in their communities ............................................................................................... 4 Focus groups with Somali mothers ..................................................................... 53. About the Melbourne Somali community .............................................................6 Demographics ............................................................................................. 6 Immigration history and context ....................................................................... 64. Practices, beliefs and pressing issues ............................................................... 11 Somali family structures ............................................................................... 11 Parenting in a new, challenging environment ...................................................... 12 The loss of traditional supports, practices and sources of knowledge .......................... 13 Maternal wellbeing and emotional distress ......................................................... 14 Child development ..................................................................................... 19 Sleep and settling ...................................................................................... 22 Breastfeeding ........................................................................................... 235. Current help-seeking and barriers................................................................... 26 Where mothers turn for help ......................................................................... 26 Barriers to help-seeking from professionals ........................................................ 276. Implications for Tweddle ............................................................................. 31 Service promotion ...................................................................................... 31 First point of contact, waiting lists, intake and assessment ..................................... 33 Use of interpreter services ............................................................................ 33 Service types ............................................................................................ 34 Being culturally responsive ............................................................................ 35 A Somali worker or program .......................................................................... 37 Other issues ............................................................................................. 38Attachment 1: Bibliography ............................................................................. 40Attachment 2: Focus group questions .................................................................. 41Attachment 3: Forum questions ........................................................................ 42 Empowering Somali Mums Research Report 2
  3. 3. 1. IntroductionIn January 2012 Tweddle Child and Family Health Service engaged Red Tree Consulting to conductresearch into key issues and concerns of the Somali community in relation to early parenting support,with the aim of assisting Tweddle to provide culturally relevant and responsive services to thatcommunity. The original brief states that the research aimed to identify and explore:• Somali mothers’ parenting styles and preferences• pressing issues that Somali mothers face in relation to their parenting• who Somali mothers turn to for parenting support (both within and outside health and community services system)• barriers (including cultural barriers) to Somali mothers accessing Tweddle’s existing day stay, community-based and in-home services or other early parenting services• key elements of a culturally and linguistically relevant and accessible parenting support model.As agreed prior to work commencing, funding necessitated some caveats on these aims. Somalis inMelbourne are a culturally, socio-economically and geographically heterogeneous community withdiverse pre-migration, migration and settlement experiences. To answer the core questions in ageneralisable way (such that conclusions could be drawn in relation to the broad Somali community),the research would have needed to engage a spread of different groups across the community. Thiswould enable identification of common concerns/issues for Somali mothers, as well as importantdifferences within the community. However, this was not possible within available resources.The project was therefore refocussed as a ‘snapshot’ of the parenting issues and concerns of a smallnumber of Somali mothers (the final number of community participants was 28) in two communities,based around the Flemington and North Melbourne Public Housing estates. Other perspectives, and asense of the broader issues, were gained from interviews and a forum with Somali professionals andother professionals working with the Somali community, and a targeted scan of the literature. Seebelow for a fuller description of the research method.Our findings have led to a number of recommendations, outlined on page 31 onwards. However, oneof the strongest themes emerging even from this small-scale research project is that of diversitywithin community: of experience, social connectedness, resources, circumstances, values, attitudes,knowledge and practices. Thus, care should be taken not to generalise about the needs of Somalimothers and families. The recommendations address a range of differing needs; we furtherrecommend that any model that Tweddle develops in response to these recommendations be trialledand evaluated for their relevance and effectiveness for the whole Somali community in Melbourne. Empowering Somali Mums Research Report 3
  4. 4. 2. MethodPlanning and background researchWe developed and submitted a draft work plan, and conducted background research on Tweddle’scurrent parenting support model and approach through interviews with three key Tweddle staff:Kerrie Gottliebsen, Cammy Naidoo and Brigid Jenkinson.Literature scanA literature scan was conducted. As a way of reducing project costs, Tweddle and Red Tree agreedthat we would review the most relevant research for incorporation into this report, rather thanconducting a full literature review.The literature scan was conducted using a several popular health and social science academicdatabases. We began with the two search terms, Somali and Australia, and combined them with aseries of third search terms which included: children, infants, babies, parenting, Post NatalDepression, post partum, breastfeeding, service seeking, maternal and child health, early childhoodand sleep. The bibliographies of the most relevant references were checked for other relevantreferences.References were eliminated if they did not directly engage with or offer substantive content onparenting issues — the experiences, beliefs and practices of Somali mothers in particular, and Somalifamilies generally. However some references on the settlement experiences of Somali women inAustralia were included, as they offered important background information. The process ofeliminating references primarily involved reading abstracts and occasionally scanning an article’s text.We then broadened the search by repeating the above combinations but omitting the search termAustralia. These searches yielded many more references.Again, references were eliminated that did not directly engage with or offer substantive content onparenting issues, experiences, beliefs and practices of Somali mothers in particular and Somalifamilies generally. The most relevant literature came from European or North American countrieswhere Somalis have migrated in the past 20 years, particularly Sweden the USA and the UK.The review was conducted concurrently with the interviews of Somali and other professionalsworking with Somali families (see below); this interview process was invaluable for building up apicture of key issues and support needs of Somali mothers and families, and helped us to focus ourreading. See Attachment 1 for a select bibliography (published and unpublished documents).Somali cultural consultantsWe worked with two Somali cultural consultants for this project. Their primary role was to engageSomali mothers for the focus groups, and as such they each have strong connections in the targetgeographic communities of North Melbourne and Flemington. The cultural consultants also providedcontacts for the research with professionals, and gave information about the community and itsneeds that contributed to both the conduct of the research and its findings.Research with health/welfare professionals and Somali people active intheir communitiesOur next step was to seek out, contact and interview by phone a number of health and welfareprofessionals working with the Somali community (most of whom were themselves Somali womenand mothers), and Somali people active in their community, including in leadership roles. The latterwere harder to engage, although some of the Somali workers we interviewed clearly have seniorityand leadership roles within their community. Empowering Somali Mums Research Report 4
  5. 5. We organised a discussion forum with Somali workers and others active in their community (seebelow) and sent invitations for the forum to all of Melbourne’s Somali community organisations; wealso had phone contact with a number of people from those organisations. However, those peopleactive in their community who engaged most were those whom we contacted in their professionalsrole and/or their associates.We spoke with 27 professionals for the research: 12 Somali workers, four other Horn of Africanworkers, and 11 workers from a range of other backgrounds. We prioritised Somali workers, as well asthose whose services are most relevant to Tweddle’s, including Maternal and Child Health nurses inthe target communities, a GP with many years’ experience working with and conducting her ownresearch with Somali people, parenting support workers, housing support workers, NeighbourhoodRenewal workers and family services staff and management in municipalities with significant Somalipopulations. This provides the basis of a list of potential referrers to Tweddle’s various services.This stage of the research took some time due the work roles of many interviewees. Almost all arepart-time, most we spoke with have quite a heavy case-load, and almost all Somali workers weinterviewed combine work with parenting. It took several phone calls to make contact with mostworkers, and to arrange and conduct 20 to 40 minute phone interview. Yet we persisted, as thisprocess enabled us to gather some rich information about the beliefs, practices, challenges andsupport needs of Somali mothers and families in communities across Melbourne.We then held a professional forum at Tweddle that was widely promoted to Somali workers andpeople active in the Somali community, and attended by seven Somali people, and by Tweddle staffKerrie Gottleibsen and Janis Shoesmith.Focus groups with Somali mothersOur intention was to hold four small focus groups in two locations, with each group comprising sixmothers, to maximise the potential for indepth discussion. However, there were difficulties withengaging two female Somali interpreters simultaneously due to circumstances beyond our control.Indeed, one session was postponed for two weeks as there was no female interpreter available at all.As a result, the focus groups were larger than intended, and discussions necessarily less indepth. Eachgroup comprised 14 women, including the Somali cultural consultants (see below) who bothparticipated in the discussion in a personal capacity. Despite the groups’ size, a number of womenwere able to share their experiences and views, and the discussions proved a useful way to confirmand deepen our learning from other sources.The very different demographics of the two focus groups also provided a good illustration of thediversity of the community, and the differing experiences women often have of parenting, based onfactors including their age, migration history and social connectedness. Both community consultantsutilised their individual community networks to recruit participants to the groups, as a result of whichthere might also be differences between these participants and other sub-groups amongst the Somaliresidents of North Melbourne and Flemington. Empowering Somali Mums Research Report 5
  6. 6. 3. About the Melbourne Somali communityDemographicsWe were only able to obtain limited demographic data from the 2011 census, as basic data from thislatest census was released late in the project, and detailed data have not yet been released. However,the 2011 census does show the number of Victorian born in Somalia to be 3061, a 16.7% increase onthe 2006 census figure of 2623. The number of Victorians who spoke Somali at home (which includesmany born in Australia or elsewhere) was 5613 in the 2011 census, a 32.4% increase on the 2006figure of 4240.At the time of writing, 2011 census information was only available about the top 20 CALDcommunities in Victorian local government areas (LGAs), none of which included the Somalicommunity. The 2006 census showed that 46.8% of Somali-born Victorians lived in the westernmetropolitan region or Melbourne City LGA. Overall, Somalis were concentrated in the LGAs ofMoonee Valley (19.1%); Banyule (15.0%); Darebin (12.7%); Melbourne City (10.9%) and Maribyrnong(7.1%).The Somali community is relatively youthful compared to the total Victorian community, with 2006census data showing a median age of 29, compared to 37 for the total population; 24% were aged 18years and below; 17.5% were aged 19 to 25 years; and 42.1% were aged 26 to 44 years.The percentage of Somali Victorians living as a couple without children in 2006 was 3.4%, comparedwith 18.7% of the total Victorian population. The percentage living as a couple with children was51.8%, compared with 47.9% of the total Victorian population. The percentage living in sole parenthouseholds was 29.3%, compared with 10.5% of the total Victorian population. The percentage livingalone or in other circumstances was 11.4% of the Somali population, compared with 22.9% of thetotal Victorian population.In 2006, the majority (86.8%) spoke Somali at home, 3.3% spoke Arabic, 1.6% spoke Italian, and 3.9%spoke only English. A significant proportion (15.3%) assessed themselves as speaking English ‘not well’or ‘not at all’. Most Somali-born people identified as Muslim (96.2%). Over three-quarters (79.5%)were Australian citizens, compared to 67.5% for the total overseas-born population in Victoria.The 2011 census figures were obtained from the Australian Bureau of Statistics website. The 2006figures were obtained from the Victorian Multicultural Commission website, at:•• history and contextThe ‘good times’ prior to civil warSomali people in Melbourne come from a range of socio-economic backgrounds prior to the civil warin Somalia, which began in 1991. Prior to the civil war, some older women we spoke to had had verycomfortable lives in Somalia, especially some of those who had been city-dwellers. Others had lived inrural areas, including one woman who referred to herself as having been ‘a nomad’, and having had ‘ahard life’ in comparison with those from Mogadishu or other cities. This diversity is confirmed in CeliaMcMichael’s research with Somali women in Melbourne, which also revealed the range of women’ssupport and family networks in Melbourne, with some women having extensive family here and someliving alone and unsupported (McMichael and Manderson, 2004).A number of older women we interviewed spoke nostalgically about the ‘good times’ in Somalia priorto the civil war, when there were accessible public health facilities, people lived in extended familiesand communities with a strong ethic of mutual support, children could play outside in safe, familiarneighbourhoods all day, and cultural traditions like the 40 days confinement were observed and Empowering Somali Mums Research Report 6
  7. 7. celebrated. These ‘good times’ were contrasted with women’s experiences of trauma, displacementand loss in the civil war (although these experiences were not discussed) and with their struggles asrefugees and since resettlement.Civil war and traumaSomalia, in the Horn of Africa, is a coastal country bordered by Kenya, Ethiopia and Djibouti. It has apopulation of 9.5 million, although many Somalis live outside the national borders established bycolonial and other powers. Almost a third of Somalis live in Djibouti, in the Ogaden region of EasternEthiopia, in the Northern Frontier District of Kenya and in other eastern African countries; there havebeen conflicts between Somalia and its neighbours over these territories at various times in thecountry’s history. In the past 20 years, many thousands of Somali people have now settled in Westerncountries including Australia, the US, Canada, Britain, Sweden, the Netherlands and Denmark.Somalia has been without effective central government since the overthrow of President Siad Barre in1991 and outbreak of civil war. Within a year of that event, almost half of all Somalis had died orfaced starvation, and hundreds of thousands had fled their country (BBC country profile). Manyattempts have since been made to establish government and reconcile warring clans. In 2011, theworst drought in 60 years forced hundreds of thousands more people to leave Somalia.The civil war resulted in profound divisions along tribal or clan lines that had not been a strongfeature of pre-civil war Somalia. Many older Somalis speak of a strong sense from the pre-civil wartimes of being a united people, especially through religion; virtually all Somalis are Sunni Muslim.The literature indicates – and Somali workers we spoke with confirmed – that Somali people tend tobe very private about their traumatic experiences in the civil war (Johnsdotter et al, 2011), and willnot discuss them except with those they trust deeply. However, it is important for service providerssuch as Tweddle to have some awareness of the level of trauma that many experienced. Communitieswere splintered and many people experienced terrible violence, loss and displacement: homes andproperty lost, two thirds of women exposed to rape, adults and children witnessing family memberskilled, and many experiencing mock executions and other torture.Service providers need to understand the impacts that such experiences can have on people’semotional wellbeing, on their parenting, and on their children as they grow to adulthood andparenthood (De Haenea et al, 2010). This provides an important background to Tweddle’s work withSomali mothers, as discussed below under ‘The impacts of refugee experiences’, although clientsmight never disclose or discuss their experiences with staff.Some studies suggest that it is more productive for people who do need to talk about theirexperiences to do so within a community of people with similar experiences (Guerin et al, 2006, citedin Johnsdotter et al, 2011). Tweddle staff should also be prepared to offer clients referral to specialistagencies like the Foundation for Survivors of Torture and Trauma for support.Service providers also need to understand that people have a wide range of experiences of traumaduring and after conflict, and a wide range of responses to those experiences; there is diversity withinany community. A US paper on community nursing practice with Somali and Oromo women(Roberton et al 2006) identified a range of differences between people’s experiences, for examplestating that: Higher levels of reported trauma were associated with older age, illiteracy, limited English speaking skills, less than a high school education, absent spouse, caring for children and living alone at the time of the interview. (Roberton et al 2006)They also found that women with large families reported more experiences of trauma than others.Some of Tweddle’s potential clients might have been very young when they arrived in Australia, andmight have been affected by their own early experiences and/or by being raised by parents or otherrelatives or caregivers who have experienced trauma. Some — especially those with good extendedfamily support, community connections and resources – will be less affected by these issues.High-quality training is available for service providers in this area. Empowering Somali Mums Research Report 7
  8. 8. Refugee journeys and recent arrivalsSomali people in Melbourne have come here via many different journeys. Many spent years inrefugee camps in countries such as Sudan and Egypt. Almost all have come as refugees under thehumanitarian program, including those who came through family reunion and sponsorship. A numberof women came under the ‘Women at risk’ program, for women who have lost their male relativesand as such, are at high risk of persecution, whether in Somalia or in refugee camps elsewhere. Thepeak period for arrival from Somalia was 1994 to 1998, when about half of the current Somalia-borncommunity arrived in Australia, mainly as young adult refugees or through family reunion.Although the numbers of Somali people coming to Australia have slowed considerably, some continueto arrive through family reunion, and some minors under Orphan visas, to be cared for by Somaliguardians/adoptive parents. A number of women are also coming to marry Somali men living here.Somali workers explained that although sometimes these women might be distantly related to thefamily they are joining, others will have no relations here. They described how vulnerable thesenewer arrivals can become as a result of language barriers, economic pressures, social isolation andthe demands of raising a young family with little or no support. If a woman comes here as a wife … she can’t speak the language. Most likely she ends up staying at home because she is having a child every one, or one and a half years … women are frustrated, [and] the husband tries to keep everything silent because of the stigma in the community. Imagine: no language, almost no one you can trust, staying at home, your husband’s a taxi driver or working in a factory all night, and having four kids under the age of five. It’s really hard for these women to seek information, and the only communication they have outside of the house is the MCH nurse. If the nurse is not providing the right information, and especially if it is not translated into Somali language, these women are not getting it. (Somali worker)The challenges of resettlementPrograms such as sponsored immigration and family reunion are based on the assumption thatsupport for newly-arrived people will be provided by pre-established communities, ethnicorganisations and informal networks (McMichael & Manderson 2004). Many studies have shown suchnetworks to be critical to good mental health and resilience (Farwell 2001; Manderson et al 1998;Garmezy 1985; Howard 1996; Coleman 1988 cited in McMichael & Manderson 2004). However, atleast in the early years of Somali resettlement in Melbourne, the effectiveness of such networks waslimited, in part because the ‘community’ comprised relatively low numbers of people scattered acrossthe metropolitan region. In Somalia, people had strong neighbourhood communities; connecting withpeople in Dandenong, Flemington or Heidelberg was more challenging.Clan-based divisions arising from the civil war have also continued to affect Somalis in Melbourne to agreater or lesser degree. The significance of these has diminished over time, according to someSomali workers interviewed, although other interviewees reported that these clan structures remainsignificant, to some extent, in who will access particular support services.In 2004 McMichael and Manderson reported that divisions along clan and status lines weresignificant, but less of a cause of social isolation than the fact that Somali people here did not knoweach other as they had known their neighbours at home, and that everyone was ‘just struggling ontheir own’ with the challenges of resettlement (quote from Samia – not her real name – in McMichael& Manderson, 2004).As outlined by our interviewees, these challenges continue for many people: unemployment; financialstress; transport and language barriers; experiences of racial discrimination by services (AustralianHuman Rights Commission 2010) and in the broader community; poor quality, unsafe and inadequatepublic housing; and long hours in low-paid work such as taxi-driving and manufacturing for men, andchildcare or aged care for women.McMichael and Manderson reported that people’s capacity to help each other can also be limited bythe responsibility for remittances; for regularly sending money to family in Africa. One non-Somali Empowering Somali Mums Research Report 8
  9. 9. worker we spoke with also referred to the level of debt that many families incur by borrowing thefunds needed to bring family members to Australia.Khat: a health/family issue identified by Somali women activistsA recent Australian study by Douglas et al found that the legally available drug khat is widely used bySomali men and by a very small number of Somali women. Khat is ‘usually chewed in prolongedsessions, producing mild psychostimulant effects such as increased energy, enhanced mood, reducedappetite and reduced sleep.’ (Douglas et al 2011). The authors report found that excessive use of khatcan have the following effects:Central nervous Dizziness, impaired concentration, insomnia, headaches, mydriasis, conjunctivalsystem: congestion Impaired motor coordination, fine tremor Agitation, labile affect, fatigue and disrupted sleep often occur after cessation of use Transient psychosis is uncommon and generally associated with heavy daily use or other risk factorsDependence: Misuse potential appears to be low Discontinuation features (mild withdrawal, including agitation, labile affect, fatigue and disrupted sleep) are common after regular use Dependence has been reported, usually associated with daily khat useCardiovascular Tachycardia, arrhythmias, palpitations, hypertension, vasoconstrictionsystem: Ischaemia, infarction, pulmonary oedema, cerebral haemorrhage (all uncommon) Exacerbation of pre-existing cardiac conditionsRespiratory system: Tachypnoea, dyspnoeaGastrointestinal Dry mouth, polydipsia, periodontal disease and dental cariessystem: Chronic gastritis, gastric ulcer Constipation, paralytic ileus Reduced appetite, weight loss Increased risk of upper gastrointestinal malignancy Liver disease (acute toxic effects in high doses)Reproductive and Spermatorrhoea, impotence, altered libidoobstetric effects: Low birth weight, stillbirth, impaired lactationIn a 2009 literature review for the Centre for Culture and Ethnicity, John Fitzgerald reports ‘anemerging consensus among international health authorities that khat has a low abuse potential’, andthat harms are associated with ‘excessive use’ rather than use as such. He concludes the availableliterature suggests that although the importation of khat in Australia has increased, evidence of harmis minimal (Fitzgerald 2009).However, concerns have been expressed among a significant number of women in the Somalicommunity about khat. The East African Women’s Foundation, of which Somali women are anintegral part, lodged a parliamentary petition of 1087 signatories to the federal House ofRepresentatives in 2008 (referenced in Fitzgerald 2009) seeking to prohibit the sale, distribution, use,importation and production of khat in Australia. Fartun Farah, the Somali woman who heads theFoundation, told the Australian newspaper in 2008, ‘Each month, we see women walking into ourcentre saying khat is destroying their family’. She also described the effect of khat misuse on her ownfamily: ‘He chewed it all night, then was too tired to go to work and he lost his job and would spendwhat little money we had on khat. My family broke up because of khat.’ ( Khat has beenan issue of disagreement within the community (Fitzgerald 2009), with some community membersseeing it as unproblematic or even beneficial to the users health (Douglas et al 2011). Empowering Somali Mums Research Report 9
  10. 10. Khat is likely to be of limited relevance to Tweddle, however service providers should be aware thatkhat abuse by men may, on occasion, be one of the many pressures on Somali families accessingTweddle’s services. Very few Somali women also reportedly use khat; if a Somali woman accessingTweddle’s services is using khat excessively, then symptoms of this — such as impaired lactation orsleep disturbances — might make it a factor in her presenting issues. However, it is important to notethat khat abuse among women is very rare, and such symptoms are much more likely to have morecommon causes. Sleep disturbances are, of course, a likely effect of trauma and depression.Douglas et al found that people were reluctant to talk with health professionals about khat, and it isunlikely that families accessing Tweddle’s services would speak about it. Many khat users reportedvisiting their health professionals for treatment of adverse effects of khat use without disclosing thatuse. Douglas et al also found many users were unaware of the effects of excessive use. If a Tweddleworker suspects khat abuse could be an issue in a family, they should raise it sensitively, and only if itis directly relevant to their work with the family, and they have develped a rapport with that family.Protective factors and positive developmentsIn two decades of Somali resettlement in Melbourne, many religious, cultural, community andwelfare organisations and businesses have been established. These — along with programs such asplaygroups, women’s groups and homework clubs — have helped to create and strengthencommunity networks and assisted many people.McMichael (2002) also discusses Islam as a critical source of solace and support for many Somaliwomen in Melbourne. Both McMichael and O’Mahoney & Donelly cite range of studies point to therole of religious faith and practice as protective factors for women’s health, including post-partummothers. McMichael cites the argument that one study makes that: religious practices promote social networks and support and provide a coherent framework, religious doctrines encourage altruistic behaviour, and devotional activities allow people to relinquish psychological control responsibility for circumstances with minimal self-blame (Ellison 1991, 1995).O’Mahoney & Donelly also cite a global literature review (Bina 2008) which found that many studiesidentified cultural traditions such as ‘the 40 days’ as alleviating factors for postnatal depression, andanother study’s findings that greater religiosity was associated with a decreased risk of postnataldepression (Dankner et al 2000). The altruism and ethos of mutual care within Islam continues tobenefit women in Melbourne, even if they do not have extended family here: People who have family here will get support from their family, because that’s our tradition. Even if you don’t have family, like myself, the community used to come and help me, and did a lot for me. We support each other. It’s not only the culture, it’s about the faith that we have, supporting each other. (Somali worker and mother)Less positively, as in many communities with a strongly faith-based set of values, norms and practices,those members of the Somali community who are seen as contravening these might be ostracised,although such a response will not be universal (see discussion below about unwed mothers).Mainstream service providers also need to understand that spiritual beliefs and practices amongstMuslim people are far from monolithic; for example, McMichael discusses variations amongst theSomali women she interviewed in practices such as veiling, prayer and responses to ill-health, forexample whether women are more likely to seek assistance from medical services and/or engage intraditional healing practices such as Qu’ran reading.A recent positive development for Melbourne Somali women is the entry (supported by targetedtraining programs) of large numbers into paid work, especially in childcare, including as day care staff,family day care providers, and running family day care-based businesses which provide coordination,intake and training for other women entering this workforce. Somali workers described how, over thepast few years, this development has given many Somali women greater financial independence, andadditional money to spend on their children’s education and other needs. This development also hasimplications for the way service providers such as Tweddle might reach out and offer support andinformation to Somali mothers, as discussed in Chapter 6. Empowering Somali Mums Research Report 10
  11. 11. 4. Practices, beliefs and pressing issuesSomali family structuresWe interviewed Somali women with a very diverse range of family structures, ages and number ofchildren. A few younger women had no children yet. A few had one or two, and many had three ormore. The largest number of children amongst the 24 women interviewed was seven (in the case oftwo older participants who had had their children in Somalia); the largest number among those whohad had their children in Australia was five. A number of interviewees referred to the high value givento having children in Somali culture, and that Somali mothers tended to have large families.Information from Somali workers and MCH nurses indicates that Somali couples tend to use mainlybreastfeeding, withdrawal or abstention to minimise the chance of conception. However, a GP whohas worked with Somali people for years commented that while that was generally the case, recentlyshe had begun to encounter more Somali women interested in birth control, especially Implanon.Many of our interviewees referred to the traditional role of extended family, especially older femalerelatives, in supporting mothers and participating in the raising of children. For those women who hadrelatives in Australia, this kind of support continued to be important, although it was perhaps limitedby the ‘struggle’ that everyone experienced with the challenges of living here.A number of Somali mothers we spoke with were ‘on their own’ in Australia, having had their child orchildren without any support from grandparents or other relatives. One mother said that althoughshe had come to Australia with some relatives, there were none amongst them who could teach thenew mothers about childrearing. We were a group of friends [who] could help each other in other ways, but most of us were young people who were not experienced at raising children and babies.One worker explained that although many younger mothers might have a lot of friends – perhapsfrom school — after having a child they can become very isolated: Once they get married and have a child, they lose the group of their own school friends [and] they didn’t socialise with women with children before. Also some mothers might be really quiet people who just work or study, but when they become a mother, that’s when they really need the support.Most women we interviewed lived with their husband, although a number of workers alluded to thefact that some Melbourne Somali women do not live with their husband full-time. Sometimes this isbecause their husband is often overseas, although some interviewees referred to women whosehusbands had more than one partner or wife, whether in Australia or overseas.One Somali worker who works with young women discussed the situation of a number of youngmothers who had had a child ‘out of wedlock’ and had experienced stigma within their communityand homelessness as a result. In contrast, other Somali workers said it was very rare for Somaliwomen to have children out of wedlock, and it was more likely that most were married, but did notlive with their husbands most of the time, and were perhaps officially ‘sole parents’.One worker referred to a young women she knew of who had conceived a child out of wedlock,hidden her pregnancy, moved to another state and after three years given her child up for adoption;the worker indicated that this woman’s experience was exceptional. This worker and others explainedthat a Somali woman who had a child out of wedlock would bring shame on herself and her family,which is why that young woman would have hidden her pregnancy and given up her child.In contrast, another Somali worker said that in her experience, families might have a range ofreactions to a daughter having a child out of wedlock: Everyone is different. Some families think, ‘This girl has made a mistake, it happens’. Some think she is bad, bringing shame. Some younger girls, they might run off because they are afraid of the reaction they will get. Even within the same family there will be a range of reactions and attitudes. Empowering Somali Mums Research Report 11
  12. 12. The (sometimes) changing role of Somali fathersMany interviewees referred to the traditional division of labour as the mother as active parent andfather as breadwinner; this division was not problematised in the Somali context, because mothersare so well supported by extended family and community. Yet in Melbourne, this broad support issimply not available to most women, or is only available to a very limited degree; intervieweesdiscussed that some Melbourne Somali fathers were recognising this, and responding by taking moreof an active role in parenting their children. However, in families where this was not happening, therewere potentially serious consequences for some women: First Somali worker: Maybe 10 years ago Somali men had their own culture and they were dominant. But now, because they live in Western culture and they see that [couples] helping each other is the way they can build their relationship well, they are doing well now. Second worker: Traditionally the fathers were not very involved when the children were very young – under five years old. The children were predominantly under the mother’s care. But notwithstanding that, culturally the father was the breadwinner, but the mother has a lot of support with extended family. All the structures were there. So the need for a father to be involved was very little. But now that they are here, and those supports are not there, the fathers see that the mothers are not coping, so they have to chip in. Third worker: But then again, there are fathers [for whom] that just doesn’t sink in. [With] that mentality, the women are suffering. I have about four clients who end up in mental hospital. Every couple of months they go back home. But [in one example] because she was trying to cover everything, to put up with him as well as the kids, at the end it went out of her hands. What we are looking at is recognising that these women have depression.One non-Somali worker we interviewed with many years’ experience working with the Somalicommunity described a recent trend in which fathers were increasingly at home during the day withtheir young children, because they were unemployed, underemployed or worked nights, while theirwives worked during the day. Many Somali women are becoming family day care providers because itallows them to care for their own children and others, but others are gaining employment in othercaring roles, for example in daycare centres or aged care services.This worker’s service (Banyule Community Health) had a partnership to run a group for Somali menthat was beginning to discuss this changing role for some men; it is possible that there might be somerole for services like Tweddle in supporting fathers of young children affected by this change. IfTweddle was interested, this could be explored in discussion with Banyule Community Health.Parenting in a new, challenging environment Parents are really anxious in terms of the safety and wellbeing of their children. All the mothers I come across are really interested in information about child health and child development. The community has their own culture, but when they come here they are confused about how to adapt. Back home there were Elders involved, neighbours involved. Here it’s everyone on their own. What has been lost was the communication. (Somali worker)Somali parenting beliefs and practices, like those of any culture or group, developed over time in aspecific physical, cultural, social and economic environment. This environment will have varied, ofcourse, according to factors such as class and whether a family were city-dwellers or rural. However,a strong unifying characteristic is that responsibility for raising children – including supervision,discipline, the teaching of values, and providing stimulation to support children’s emotional, socialand intellectual development – was shared in a very real, daily sense across close-knit extendedfamilies and neighbourhood communities.A key learning from this research is the impact on Somali children’s development of being raised in avery different environment, here in Australia, from the environments in which Somali parentingbeliefs and practices developed. Empowering Somali Mums Research Report 12
  13. 13. Again, women’s experiences vary a great deal, especially according to whether they have family here;but key ways in which families’ environment in Melbourne varies from that which they might haveexperienced in Somalia include:• the lack of significant extended family and community support for mothers and input into raising children, putting the responsibility for children’s care and development primarily on mothers, and to some extent fathers (see discussion under ‘Child Development’, below)• the lack of many traditional sources of knowledge about caring for newborn babies and young children• the lack of safe, appropriate physical environments where children can play outside their homes, and of strong neighbourhood communities that allow children to play with their neighbours without constant direct parental supervision• inappropriate and low-quality housing, often without private outdoor spaces for children to play in, or for women to gather in without having to cover themselves• the scattering of other Somali people in housing across metropolitan Melbourne, and the difficulties and cost of public transport for women with large families• economic pressures including the costs of living, unemployment, underemployment, remittances and family debt, and the nature of paid work available, including long hours and low pay• other challenges of resettlement, including language barriers, experiences of racism and exclusion, and the multiple stresses adapting to a very different cultural environment• a range of ongoing impacts of diverse refugee experiences (discussed below).The loss of traditional supports, practices and sources of knowledge I had only one child. When I had my child, I was not an experienced mum. I did not sleep very well, the baby did not sleep very well. I still remember the hard times, she is 12 years old but I still remember as if it was recent. I did not have relatives who could help me or give me advice, I did not have anybody who could help me. I had sleeping problems for the first two years. I feel myself that I wasn’t coping well for the first two years of my daughter’s life. That’s what I can remember. I didn’t have any help. (Somali mother)A number of interviewees referred to the key role of older female relatives in Somali culture teachingmothers the range of skills and knowledge required to care for their young children. This was seen bymany as a loss for many new Somali mothers living in Melbourne, in that those without older relativeshere often struggled with knowing some basic information about how to care for their babies,especially their first child. This would include, for example, how to breastfeed, wash, soothe andsettle their baby, how to deal with common maternal and infant health issues, and the needs ofinfants and young children as they grow through different ages and stages. Back home, we used to learn things passed on from parent to child – breastfeeding and things like that. [They were] passed on from the elderly to the young generation. It’s different here. (Somali worker) When young women become mums, the hardest thing they face is how should I feed this baby, put them to sleep. How can I build them up to be better than I am? How can I do that now, rather than worry about them when they are teenagers? They don’t want playgroups, they want education [about] what the system is, what food [to give their children]. Some kids are obese, and mothers are confused. (Somali worker)Some women, like the worker/mother quoted on page 10, experienced support from her communityon becoming a mother, despite her lack of family members in Australia. Yet the challenges ofresettlement are such that most people in the community don’t have the capacity to offer significantday-to-day support to others: First Somali worker: Most of the people here are students, or are trying to work, to earn money for living or supporting families back home. Second worker: Sometimes nobody can support you, even from your own [extended] family! Empowering Somali Mums Research Report 13
  14. 14. As discussed, women’s and children’s experiences of family, household and community prior to thecivil war in Somalia were typified by support from extended family. A range of important cultural andreligious practices underpinned a strong ethos of mutual support, assisting people in need, andcelebrating and supporting mothers. The older women in one focus group discussed how thetraditional 40 days confinement helped with healing from birth and establishing breastfeeding byensuring that women had no responsibilities other than resting and feeding their baby. An olderparticipant who had her children in Somalia described how confinement would finish with ‘thedecoration, a new dress, taking us to our homes. It’s like a wedding! [But] now we are refugees, itdoesn’t happen here’.Many interviewees, including the following three Somali workers (who are mothers themselves)contrasted the richness, supportiveness and celebration of these traditions with many Somaliwomen’s experience of motherhood in Australia: First worker: [In Somali culture] When the woman is pregnant, it is joy, happiness. Everyone is happy for her that she is bringing a new life, and congratulating her and supporting her all the way until the baby is born … even if she has ten kids or eleven kids, we believe this new life is joy. Second worker: Baby shower! Third worker: But here we don’t have that baby shower, and even for us we get used to not having that. When I had the first baby and I didn’t have that baby shower, I thought, ‘Maybe it was not important’, but I went and left that culture. We can feel how important it used to be and now it’s not that important. First worker: The main thing is that we lost our way of celebrating. We had a culture, the first generation who came here — we are the first generation. We want to hold our culture, and also at the same time we want to integrate new culture. So we are in the middle of confusion. Imagine for our kids what that would be. If the mother is confused, we are now aware of the impacts on the child in early childhood. As a mother, we lost all the connection and the support, and the joy and happiness of sharing. We end up with lonely and isolated women, who can’t speak English. We are lucky we can speak and understand English – but 90 per cent of the community can’t.Maternal wellbeing and emotional distress I am raising seven kids. Four are my own. When I had my first baby, things were very hard for me. When I stand up I felt dizzy, had a headache. The baby would sleep, however I think physically I was unwell. When I was breastfeeding I was unwell, when the baby was breastfeeding I felt like she was sucking out of my brain, my head. I would ask people to hold me. The first baby, when you have newborn, everything is a struggle — [such as] how to hold [them]. When she had a bath, I was worried she might slip out of my hands and drown. Everything was new, and I was not sure if I was doing it the right way or not. I was struggling and everything seemed to be so bad, and it was so bad: you breastfeed and change the nappy, then the baby throws up. I thought maybe it was the wrong choice to be a mother. But then after a few months, when she starting smiling and making noises, and then I felt much more relaxed. (Somali mother)Many factors can lead to mothers of young children experiencing significant emotional difficulties. Asdiscussed, social isolation and lack of support are highly significant factors for Melbourne Somalimothers. Indeed, one Somali worker who provides parenting support for women in their homes citesthese as the critical differences between mothers who are doing well and those who are not: A lot of [Somali] families with these issues are quite isolated. The ones who have relatives here are doing fine. It’s the isolated mums without any other support who are the ones who are struggling.Canadian researchers O’Mahony & Donelly (2010) reviewed a large number of studies into variousaspects of postnatal (postpartum) depression and immigrant women’s health. Based on two meta-analyses incorporating over 70 studies, they summarise the predictors for postnatal depression as:• strong to moderate factors: depression or anxiety during pregnancy, past history of depression, recent life stress, lack of social support Empowering Somali Mums Research Report 14
  15. 15. • moderate factors: high levels of childcare stress, marital relationship, neuroticism, low self- estate, difficult infant temperament• small factors: obstetric and pregnancy complications, socio-economic status.Our research project was not able to gather evidence of individual women’s experiences in relation tothese risk factors, but our informants raised a range of common pressing issues for Somali mothersthat point to a likelihood of their having an elevated risk of emotional difficulties in early parenthood,especially their lack of social support and recent life stress in the form of trauma, and lossof/separation from family members in the civil war. Somali women also experience a number of otherrisk factors identified in studies cited by O’Mahony & Donelly in relation to immigrant women’smental health, discussed below under ‘The impact of refugee experiences’.This quote from one Somali worker summarises the difficulty for many in her community, of: … taking [on] many things at the same time. It’s finding your own identity and how can you fit into this society, because this is where you belong to. You don’t have a way to go back, there is still the issues there [in Somalia]. So we are juggling a lot of things – not only postnatal depression, but we are carrying a lot of trauma, worry about our family members back home, and some of the women are not lucky – their partners are not helpful like the others. (Somali worker)O’Mahony & Donelly cite two other studies that found that the difficulties experienced by womenfrom cultures that support and value mothers can be further ‘exacerbated’ by the loss of thosepractices and supports. Thus, ‘many find themselves without a support net where normally theywould have found recognition, nurturing and assistance within their culture’ (2010).The impact of refugee experiencesIn addition to the generalised risk factors for PPD listed above, O’Mahony & Donelly cite risk factors toimmigrant women’s mental health identified in a range of studies. These include ‘marginalization andminority status, pre-migration experience, intolerable memories, socioeconomic disadvantage, poorphysical health and difficulty adapting to host cultures’ (Dhooper & Tran 1998, Ziguras et al. 1999, Li &Browne 2000, Thompson 2000, Bhui et al. 2003, O’Mahony 2005, in O’Mahony & Donelly, 2010).A number of Somali and other workers referred in a range of ways to the trauma experienced bymany Melbourne Somalis, and how critical it is that service providers understand and acknowledgethis, although it might never be appropriate to discuss these experiences directly with Somali clients: You need to approach people in a sensitive way, not judging, and acknowledge their perspective, their background. They really have high anxiety, you need to keep that in mind … I always talk with my colleagues about these issues, about acknowledging that people are traumatised before they come here. (Somali worker)The nature of this research did not allow us to delve into the impact of this trauma on women’sexperiences as mothers. Instead, we highlight findings from O’Mahony & Donelly and anotherinternational literature survey by De Haenea et al (2010) on the impact of refugee experiences onparents and children. The latter survey cites a growing body of research identifying the refugeeexperience as ‘a chronic process of traumatisation’: The complex cluster of pre-flight and post-flight stressors of war, violent loss, persecution, ethnic conflict, family separation, cultural uprooting, acculturation stressors and legal insecurity forms a pervasive cumulation of life-threatening events and multiple losses and, thus, identifies the refugee experience as a long-term adverse context (Lustig et al., 2004, cited in De Haenea et al, 2010).De Haenea et al also cites a number of studies that document how post-migration stresses such as‘social isolation, unemployment, insecurity due to extended asylum procedures, extended familyseparation, or the loss of valued social roles’ can aggravate pre-migration trauma, (Birman & Tran,2008; Ellis, McDonald, Lincoln, & Cabral, 2008; Montgomery, 2008) so that for some, ‘traumaticresponses, prolonged grief, and chronic exile-related distress interfere with stabilization and recoveryin the host society’ (Bala, 2005). Empowering Somali Mums Research Report 15
  16. 16. De Haenea et al’s review includes studies on the mental health outcomes of refugee children andadolescents, which reveal ‘patterns of anxious, post-traumatic and depressive symptomatology’ (Fazel& Stein, 2002; Heptinstall, Sethna, & Taylor, 2004; Montgomery & Foldspang, 2005); it is likely thatamongst young mothers who might benefit from Tweddle’s services are many who came to Australiaaged from middle childhood to early adolescence, with a parent or parents or other caregivers. Otherstudies reveal the ‘potential long-term persistence’ of psychosocial difficulty amongst refugee adults,some of whom might be potential clients for Tweddle, or the parents of potential clients.Is ‘postnatal depression’ a relevant concept?O’Mahony and Donelly’s broader research question was whether postnatal/postpartum depression(PPD) is universally recognised across cultures, and what parents and professionals perceived to beappropriate health responses. They concluded that ‘participants described a morbid unhappinesscomparable to PPD; however, concerns were raised about the cross-cultural equivalence of PPD, andwhether it was an illness remediable by health interventions.’The relevance or otherwise of the concept of postnatal depression was discussed at some length witha number of informants. The answers were complex and varied, but broadly in line with the first partsof O’Mahony and Donelly’s conclusion; that is, that there is an equivalent concept, at least inrecognition of symptoms of emotional distress in mothers of young children, but terms such aspostnatal or postpartum depression were less likely to be culturally relevant, and should be used withcare or avoided by service providers due the stigma associated with traditional Somali conceptions ofdepression and other mental illness. There is a stigma about depression in our community. We see depression as mental illness, [and believe that] stress leads to mental illness. The community think the person [with depression] would need medication, and that means you can’t look after the children. (Somali worker) People think depression is a mental illness, and the community is afraid to talk about this. Now, women are beginning to understand that depression is normal, and are more likely to talk about it, about life being hard. [But still] People tend to look at it very negatively. [They might say] ‘You are in Australia so how can you say life is hard for you?’ We ask parents if they want us get anybody to come and sit with them. It’s a sensitive issue. Most [members of the community] have gone through [depression] and still deny it. They don’t want to talk about it. They feel criticised by that, like they are not a good parent. (Somali worker)Several interviewees suggested that this stigma is changing slowly, and that some Somali communitymembers were becoming more interested in talking about mental health: We are moving on from the model of depression being a word you couldn’t use. We have been on the radio, doing information sessions about depression. We didn’t have a word for it in Somali … When we ran Tuning in to Kids, women wanted to talk about mental health, so now we are organising some sessions for them. It’s about constantly being consultative, checking in about and meeting their needs. (Somali worker)One Somali worker said that the community was becoming more open to learning about mentalhealth issues, especially following the recent suicides of two or more community members.Another Somali worker identified postnatal depression as something that Somali workers were‘coming to recognise’ that some women are experiencing. She also gave some insight into how somein her community might link symptoms of postnatal depression and traditional conceptions of mentalillness associated with the influence of spiritual entities called djinn: First Somali worker: Somali people believe in djinn, and they say that if a woman has a baby, she has to stay inside for 40 days. (laughter) When I came here, the nurse who visited me, she said, ‘Okay, next time you’re coming to my centre’. And she gave the address. I looked at her and thought, ‘Is she crazy? I’m not taking my baby out before the 40 days’. [According to this belief] in the evening you don’t go out, and you don’t wash the baby’s clothes and put them outside. Otherwise the djinn will see you or hear you. Empowering Somali Mums Research Report 16
  17. 17. Interviewer: I am wondering about postnatal depression, not depression as in mental illness … [Is there a Somali word for] when a woman comes home, and she’s crying and can’t sleep, right after she’s had a baby? Second Somali worker: We don’t have a word for that. Interviewer: Does it happen? First Somali worker: Maybe some women face that at the end of the 40 days. The community might say [of such a woman] that she stepped outside, maybe the djinn saw her within the 40 days. At the beginning [of the 40 days] you don’t have that problem [because] you have everyone around you.Thus, there is some indication of a cultural link between symptoms of what might be called postnataldepression in a Western framework and Somali conceptions of mental illness. Many workerssuggested that it might be more appropriate to talk with Somali mothers about their emotionaldistress during early motherhood using terms other than depression, as we discuss below. It iscertainly clear that service providers need to take great care and be sensitive in the language thatthey use when exploring individual Somali women’s risks for and experiences of emotional difficultiesin the context of parenting young children.O’Mahony & Donelly also cite many studies that have found ‘culturally determined barriers’ to help-seeking around depressive symptoms in many cultures, including barriers related to a culturally linked‘fear of stigma’, ‘lack of validation’ of symptoms, and: a perception that it is inappropriate to seek out external help for depressive symptoms. Post- partum depression may not be viewed as a medical problem and therefore medical assistance is not considered appropriate (Holopainen 2002, Rodrigues et al. 2003, Ugarriza 2004, Teng et al. 2007).This finding of O’Mahony & Donelly around help-seeking from professional healthcare providers wasinconsistently supported by our research. On the one hand, we interviewed a GP who had worked formany years with Somali people, and who had also conducted research with Somali people aboutunderstandings of and help-seeking for mental illness, who said that most Somali informants in herresearch identified postnatal depression as: … more a social problem [with the perceived solution being that] this woman needs more help, help with children, someone to talk to.On the other hand, many of the community informants were very interested in Tweddle’s services,and in how they might support mothers who were struggling with parenting young children,especially those who had little social support. This might be because they perceived Tweddle’sservices to be more akin to social support and assistance with the children, rather than being a‘health’ intervention to support mothers who were experiencing issues with their mental health.‘The label is sometimes the problem’ People do not want emotional support, they want practical support. You could talk about it as, ‘Is the baby not sleeping, do you need a break?’ (Somali worker)Overall, our research pointed to a willingness of Somali mothers to seek professional help if theyknow it is available, accessible and appropriate. An appropriate approach to service provision includesprofessionals using culturally sensitive language when working with/and or referring Somali mothersand families, whether into a service such as Tweddle, or to other services from Tweddle. We spokewith a number of interviewees about how they speak with women about their emotional difficultiesin early parenting, including during screening for postnatal depression.We interviewed one Somali worker who routinely administered the Edinburgh protocol (EPDS) as partof her work with families. O’Mahony & Donelly cite an Australian study (Small et al, 2003), whichfound the EPDS to be a consistent, valid and ‘effective tool’ across English-speaking and non-Englishspeaking samples, although these authors specify that ‘careful translation processes and piloting oftranslations are always necessary’ (Small et al, 2003). Empowering Somali Mums Research Report 17
  18. 18. The MCH nurses we interviewed also frequently administer the EPDS, but reported that: First MCH nurse: … [Somali mothers’] Edinburgh scores are zero. They don’t acknowledge it, it isn’t in their vocabulary. There isn’t an African word for it. And if they’re religious, they’ll say, ‘Allah will look after me’, or ‘I wouldn’t become depressed because I’ve been given these babies’. They wouldn’t allow themselves because of their religious feelings.The difference between the MCH nurses’ experiences of administering the EPDS with Somali mothersand that of the Somali family support worker was notable. Given that the EPDS is administeredthrough an interview, it might be that the Somali worker was already ‘translating’ the EPDS intoculturally relevant language and concepts as she administered it in their shared language. The MCHnurses administer the EPDS through an interpreter or in English; but it is important to note that aliteral translation of a document does not guarantee its cultural relevance, especially if there is noequivalent word or concept in the other language. There is also a common problem with serviceproviders overestimating the English proficiency of their CALD clients, as discussed on page 33.The MCH nurses went on to explain the language they have come up with in their own practice to tryto bridge the cultural gap and ask women about their emotional state in the weeks following birth: First MCH nurse: [Somali mothers score zero in the EPDS] … but they understand crying. It’s not that everyone with PND cries, but you know how you get all those emotions. I’ve been struck a few times, especially if the dad’s around, and [what happens when I] talk about emotions. They don’t relate to that concept. But if I ask, ‘Have you been crying every day?’, the dad will be standing there, and I’ll see the light go on in his head, and he’s nodding away. Second MCH nurse: I talk about, ‘How are you feeling in your heart?’ First MCH nurse: I do too. Second MCH nurse: (puts her hand to her heart) I say, ‘How are you feeling in your heart, in here?’ In our program, at four weeks we are [also] meant to ask about family violence, so we start to say, ‘How are things at home?’ and we ask about the physical and emotional wellbeing of the woman. But if you said, ‘How is your emotional wellbeing?’ they’d say, ‘Fine’. So I say, ‘It’s four weeks since you’ve had your baby. Lovely. And I wonder how you’re feeling? I wonder how you’re going? Your body is getting back to normal. And I wonder how you’re feeling in your heart? How you’re feeling about this baby, and how things are going at home.’ Interviewer: And will they open up? Second MCH nurse: Maybe.These MCH nurses – who all worked with a large number of Somali mothers — emphasised thecentrality of their personal, long-term relationships with individual women in establishing trust, andthe possibility that women would speak openly and come to them for assistance. You might not know about the domestic violence, or whatever might be going on, with the first baby. But you’ll find out about it with the second baby. You can’t just go in for a year and think you can make a difference. If you’re at the centre for a few years, and get a reputation, if you’ve helped them in one other way, they might come to you for something else. (MCH nurse)A few Somali workers suggested that it would not be appropriate to use terms such as ‘depression’with Somali clients, but instead to enquire about whether mothers are ‘having difficulties’, ‘crying’, orexperiencing tiredness or insomnia. It would be okay to talk about … [experiences that women might have] after childbirth, like when you cry, and are having difficulties, you are tired, you can’t sleep. It would be okay to talk like that. (Somali worker)Similarly, the GP we interviewed steers away from words like ‘depression’, preferring to talk withpatients about their symptoms of emotional or psychological distress, such as ‘sadness’, ‘thinking toomuch’, ‘crying’ or ‘finding it difficult to cope’, ‘worrying a lot’ and ‘having trouble sleeping’.When referring people to specialist counselling, for example by Foundation House, she also pointedout that: Empowering Somali Mums Research Report 18
  19. 19. The concept of counselling is also problematic. Talking to a stranger about your feelings doesn’t come naturally to [Somali] people. So when we refer people, we don’t necessarily say, ‘I’m sending you to have counselling’. We describe that services are being ‘people who can help with the difficulty of settling into a new country’, or with ‘problems from having to leave your country’ or ‘going through hard times’. I find it useful to not necessarily give things labels, but just talk about the cause of the problem, and what might help solve it. The label is sometimes the problem.Child developmentAttachment and responsivenessAccording to Tweddle staff interviewed for this research, the key frames of reference for Tweddle’swork with parents are infant mental health and maternal attachment, including responsiveness toinfant cues in feeding, settling and care and play.Interviewees describe a range Somali parenting practices that can be seen as attachment-oriented,including co-sleeping, frequent carrying of infants and young children, responsiveness to children’scrying and long-term breastfeeding. One Somali worker emphasised the importance of mainstreamproviders working within this cultural framework, and understanding that these practices are key toSomali mothers’ care for their children: [Service providers] have to be culturally sensitive, otherwise it is not going to work. [Somali mothers] find it really crazy to leave kids in another room, even when they are a little baby. They have to be around their baby, always carrying their baby at the back. And they don’t want the baby to cry. They tend to carry them everywhere to do their work.Several interviewees described the Somali mothers they worked with as ‘dedicated’, and motivatedby a strong desire to do the best for their children.Yet research shows that the multiple pressures experienced by Melbourne Somali women (like otherrefugees) are likely to compromise many women’s own emotional wellbeing, as well as their capacityto provide the level of responsiveness they might wish to their children.The core enquiry of De Haenea et al’s survey of international research (2010) is about the impact ofthe experience of refugees on parental attachment and capacity to respond, in particular to theirchildren’s emotional needs. The studies they survey emphasise the importance of parental presenceand a supportive family environment for building children’s resilience and ‘adaptive developmentaltrajectories’. However as the authors point out, this capacity for parental emotional responsiveness is‘precisely what becomes subjected to extreme pressure’ through the range of people’s refugee andpost-settlement experiences. De Haenea et al cite various research showing that grief, social isolationand a range of stresses can lead to parental withdrawal and decreased responsiveness and/orincreased family conflict, and sometimes violence (De Haenea et al, 2010).The loss of traditional stimulation for child developmentSeveral Somali workers explained how traditionally, child development in Somalia was stimulated andsupported by raising children in a close, safe neighborhood community, in which children playedtogether outside, cooperatively and inventively, for the majority of the time: First Somali worker: Somali women tend to have large families, so by the time the oldest is four or five, the mother might have two or three younger. She will be more attentive to the younger ones, so the four-year-old will be pretty much on their own. In Somalia, that four-year-old will be playing with all the neighbourhood kids. So that’s where the child development and the language development was all coming from. It was not necessarily from the mother sitting with the child and singing to them. It was from the neighbours and the outside structures that we were getting the child development, all the play with the neighbours and so on. It was never ‘my mum plays with me’. It never happened that way. Second worker: Here, we don’t have those structures — there are no neighbours children can go and play with. The children are at home. And parents don’t know much about sitting and playing Empowering Somali Mums Research Report 19
  20. 20. with the child, and about all these resources and toys that are available. In a lot of our houses – it’s changing now – but traditionally you didn’t have a lot of toys. Traditionally the kids would play outside. That’s how all the child development was happening, through siblings and peers.The MCH nurses we interviewed also identified issues with some Somali mothers ‘not knowing how toplay with the children’.A few Somali workers highlighted the number of Somali children exhibiting speech and learningdelays, arising, they thought, from the loss of this rich traditional environment for play, learning anddevelopment, and the challenges of parenting in often overcrowded housing and unsafeneighbourhoods. Second worker: I did research about speech pathology in the Somali community. We have lost community connections. Back home we used to feel safe and free that kids can explore many things, and think [about] how they can make their own toys, and gather together and most of the time play outside. When we came here, we discovered that we lived, some of us, in two bedrooms for nine people. Imagine — some of the kids are teenagers, some of them are babies. They live in two bedrooms in a high rise. If they even try to come outside the play, there are needles, a lot of police attention, drugs and all these issues, which they are never used to. So the mother, to do her job, she has to lock them into these two bedrooms and let them run wild. And now we are having a lot of late development of young kids. Even though they have six or seven siblings, there is a lot of high speech delays. All because of that lost connection.Financial pressures also mean that many mothers cannot afford toys or to take their childrenorganised sport or other activities, although this is changing for women who have entered family daycare and other paid employment. Nonetheless, Somali workers cited a range of problems arising fromthe ubiquitous use of television as a babysitter: Back home it was nice and quiet, but here the TV is on. That doesn’t help with that speech delay. A lot of problems come from that.Boundaries, ‘discipline’ and children’s behaviourA number of workers referred to problems with children’s behaviour, arising from the loss of inputfrom relatives and neighbours to raising children: There is a big issue with disciplining the children, that’s what I am seeing a lot of problems with in the community. Traditionally, disciplining the children was not only the role of the mother, it was the older relatives, the neighbours – whoever. Elderly people, they would do something if they see a child misbehaving. But now that all falls on the children’s mother, because most of the time the father is at work or whatever. (Somali worker)Without support, parenting several children of different ages in a small flat can present a problemwith managing children’s sleep. Many families make frequent use of television, which can potentiallyexacerbate children’s sleep problems and consequently their behaviour: You see the children staying up to midnight, and they don’t sleep in the bed all the time. The mother is maybe busy, so the children stay up watching TV that’s not suitable for them. That can produce nightmares for children, and problems with behaviour. (Somali worker)A number of Somali workers also referred to ‘confusion’ amongst parents about how to parent theirchildren in an Australian context. Several also referred to anxiety within the community aboutwhether and how they could put ‘boundaries’ on their children’s behaviour: This time around, our generation of women find it really challenging to put any kind of boundary on a child. It’s really very challenging for them. I really try to unravel that, when I am working with a family. (Somali worker)Several interviewees described how for many parents, such anxiety arose from shared stories aboutone or two cases early in the history of Melbourne’s Somali settlement, in which one or more older Empowering Somali Mums Research Report 20
  21. 21. children were removed from their families, reportedly because of their child had disclosed theirparents’ use of physical punishment to a teacher, who had then made a Child Protection report. People believe that if they smack a child, someone will call Child Protection. Or if a child didn’t go to school for a couple of days, that the school will call Child Protection. This fear came from early cases where Child Protection were involved. One mum said to me that one day her daughter broke her lunch box. She was scared to tell her mum what happened, and she told her teacher that she was scared. The school called Child Protection. Now, people will go to extremes, and … not discipline their children at all [because of this fear of Child Protection]. And so the children end up really wild. (Somali worker)Two different workers described how their organisations had used the same strategy to addresspeople’s fears about Child Protection: We organised people from Child Protection to talk to the community, to speak to groups about what the law is. That this is not going to happen if you tell off your child, or send them to their room for five minutes. And we have run parenting sessions about how they can deal with their kids if something happens. (Somali worker)The power of shared stories to impact on the choices and practices of parents across the communityis supported by a Swedish study (Johnsdotter et al 2011), which explores how the spread of verbalinformation through community networks in the Swedish Somali community influenced people’shealth choices. One example cited in that study was how women shared information about whichmaternity hospitals were less likely to perform caesarian births. Another was the low vaccinationrates in the Swedish Somali community, due in part to the widespread credence given to thediscredited link between the MMR vaccine and autism in that community. The authors cite anotherfactor in low immunisation rates for Swedish Somalis, which is that children born in Somalia or inrefugee camps had not had access to immunisation (2011). It is unclear whether vaccination is anissue for Melbourne Somali children; the MCH nurses interviewed reported good rates of vaccinationamongst their Somali clients.Parenting discussions and debatesOne Somali worker we interviewed explained that conflict would sometimes arise between parentsand children because of the disconnect between traditional ways of parenting — which, she said,might not involve much discussion with children, or involving children in decision-making — and theexpectations of children based on their experiences of school, whether Western or Islamic. Somali parents are using discipline, the way they were taught, but it’s different to [that experienced by] other children in school. Somali people need to keep their own ways of parenting, but [Melbourne] is a different environment. We have to give children responsibility, to communicate to them about what they need to do. Some people don’t understand why they would talk to the child like a big person, or involve them in decision-making in the family. Children have friends, go to school and receive encouragement, and when they come home it’s totally different. They misbehave when they see different ways of communication.She described how there were often discussions and debates within the community aboutapproaches to parenting: We have a lot of discussion, we come together to socialise, and talk about parenting courses. We say that Islam support the Western ways: communicate with children nicely, talk to children nicely, teach good manners. But we have the Somali culture, which is very different. A lot of Islamic schools encourage children, exactly the way that Western schools do. We have these debates sometimes in the community.A 2007 Melbourne study of the attitudes and approaches of parents and professional caregivers fromSomali, Vietnamese and Anglo backgrounds identified that Somali parents tended to be more positivethan parents from the other groups about reasoning with children as an approach to responding tochildren’s challenging behaviour, and less positive about the use of parental power in the samesituation (Wise and da Silva, 2007). Empowering Somali Mums Research Report 21
  22. 22. One Somali worker we interviewed who had run a Somali mothers group for many years said thatparticipants benefited greatly from sharing experiences and ideas about parenting: They use very different discipline to their own parents. But most don’t know meaning of ‘time out’, or ‘quiet time’. They are not used to that, but they love to hear about it. Women in the group like to have new strategies — to find that not punishing a child, but telling them to have time out really works. The mums love to hear about these issues, and talk about whose kids are more naughty! Older mums especially are finding it really hard.A number of other workers said that in their experience, parenting courses were often of greatinterest to Somali mothers, and that women would often welcome new ideas about approaches andstrategies for caring for their children, especially those parenting multiple children. Some mothers have a child every year. How can she handle that without support from extended family, and community support? They really need more strategies, plans to follow. [For example to know about] which behaviours to step in on, and which to ignore. Some mums have up to five kids younger than five, including babies. This mum might be doing great, but she will often have questions about whether she’s doing the right thing, about child development.’ (Somali worker)The Tuning in to Kids parenting course — which focuses on emotional intelligence and ‘emotioncoaching’ strategies — has been run by two different organisations we heard about for Somali/Africanparents, and was reportedly very popular. Another organisation whose staff we spoke with wasplanning to incorporate Tuning in to Kids into the upcoming program for their mothers group, as partof meeting a range of information needs expressed by group members. Sometimes we ask the mothers what they want to talk about, and run some sessions. We found out a lot of information they didn’t know, especially about the children’s behaviour, and how to work with the kids. We ran Tuning in to kids – lots of people ask about it all the time, about emotional coaching. They were really interested in how [it helps them] to talk to the children, to understand their feelings and how their behaviour comes about. (Somali worker)Sleep and settlingWe asked all of our informants about the practices of Somali mothers and families around children’ssleep. Responses pointed to a diversity of practices and beliefs in the community, the impact ofhousing on shaping the way mothers manage their children’s sleep, and again, the power of keystories (in this case, an infant death linked to co-sleeping) to influence practice community-wide. Interviewer: Do Somali mothers sleep with their babies? First Somali worker: It depends on the rooms that you have. Usually what happens is the mother will have her own room with her child, because they’re waking frequently. But it depends on how big is your house. Sometimes women sleep with the child, but some children have their own cot. It depends on the individual. Second worker: I see some women, as soon as they are close to having their baby, they move into a small room where they can feed the baby. Then there are the ones like me who say, ‘Why am I going to move away?’ There is the father as well, but if I wake up, he wakes up. I don’t care! Interviewer: So sometimes the baby might sleep in the bed with the mother and the father? First worker: Sometimes, but there was an issue where a baby died when the mother slept with the baby. Since that time the community aren’t really doing it. I slept with my baby, [and still] there might be issues where the women [continue to] sleep with the baby. It depends on the women’s individual background. We have that belief from what happened before [the war]. We have seen how our family did things before. But then there’s also what’s happening here.The MCH nurses we interviewed reported that: A lot of Somali mothers will co-sleep, and breastfeed children to sleep well into the second year … we talk about [how to co-sleep safely] in every home visit. It’s all about flat surface and no pillow. Somali people don’t tend to drink. Empowering Somali Mums Research Report 22
  23. 23. Somali workers asked about the knowledge of safe co-sleeping in the community identified practicessuch as sleeping with the baby against the wall, and placing pillows in ways intended to protect thebaby, presumably from the parent rolling onto them. The MCH nurses we interviewed identified SIDSFoundation resources on sleeping with a baby as important sources of information for advice tofamilies on this issue.When we asked Somali mothers in the focus groups if they co-slept with their babies, the answersranged from ‘yes, always’ to ‘no, never’. Many indicated that they used a combination of settling thebaby in a cot or bassinet, and bringing them to bed when they woke repeatedly and would notresettle. Interviewer: Do you sleep with your babies? First mother: No, never. Second mother: Yes, with my last baby. My youngest child, when she was a baby, she used to wake a lot. I used to bring her to the big bed, and put her on the side. It did not help her, but it was convenient for me. Every time she cries, otherwise, I have to get out of bed and go to her bassinet. Third mother: Normally the baby has his own bed. If the mum shares her bed with the baby, he would develop the behaviour that the baby will always want to share the mother’s bed. Fourth mother: I have five children – my three daughters first, then my son. My son was the hardest. He would not stop crying. I called those religious people to read Qu’ran with me, also they gave him camomile water. This calmed him down.Interviews with mothers also revealed a range of attitudes to ‘letting babies cry’: First mother: I never let my children cry, I don’t like it. Second mother: When my son cried, because I wasn’t with my mum [to advise me], I thought he was dying! (laughter) Third mother: If we sing the babies songs, lullabies, and carry them, they will fall asleep. Fourth mother: I read in a book to leave the children to cry, but that is old-fashioned.Many workers, Somali and otherwise, identified a range of problems that Somali mothers wereexperiencing with helping their children to sleep, and getting them into a regular routine around napsand bedtimes. Some identified this as a key problem for families, especially for dealing with thechildren’s behaviour problems and exhaustion that many mothers experience: The parents need to learn sleep techniques for children. If the child doesn’t have a routine sleep, then they don’t sleep properly. You see a child staying up to midnight, and they don’t sleep in the bed all the time. (Somali worker) What [mothers] see their parents doing is really different. Cosleeping and constant feeding of the baby means I don’t have to wake up [through the night]. They don’t understand that if they get baby into routine it will help. They are always wanting to change their routine. (Somali worker)BreastfeedingTraditionally, breastfeeding is very well supported in Somali culture and by Islam, which instructsmothers to breastfeed for at least two years. Across the culture, we believe in the mother breastfeeding. Some of the young mothers prefer to just breastfeed very short. Most are keen to be breastfeeding for a long time. For them, the cultural influence took over, and they are really keen to do breastfeeding. We run breastfeeding support in my organisation, mainly through Elders teaching them. (Somali worker)Somali workers described breastfeeding as ‘the default’ for Somali women, and detailed the strongtraditional support for Somali mothers to breastfeed, including through working conditions in pre-civilwar Somalia that would be the envy of many Australia women workers: four months’ paid maternityleave, and ongoing reduced hours for lactating women. Somali workers also described howbreastfeeding was often used to assist with child spacing by reducing ovulation. Empowering Somali Mums Research Report 23
  24. 24. Some informants alluded to a range of traditional cultural beliefs that Somali women have in relationto breastfeeding, and gave the following examples: Somali women stop breastfeeding when we are pregnant, because they think it is not good for the new baby. Also, many Somali believe that if a [breastfeeding] child gets sick when women have their period, it might be because of that. This is part of the culture.A US study of the breastfeeding practices and beliefs of Somali mothers in the US (Steinman et al,2010) that amongst the US Somali women surveyed, many would not feed their babies withbreastmilk that they believed had been ‘in the breast’ for several hours (if the baby had not fed forthat long), believing that milk would ‘spoil’ in the breast and make the baby ill (2010). However, therewas no reference to any similar belief by any of our interviewees.Steinman et al cite a 2007 review of breastfeeding practices in Somalia which found thatbreastfeeding is acceptable to women and their social support networks, and that most womenbreastfeed on demand, although the study also found frequent supplementation of breastfeedingwith water, animal milk or solid food (as the baby gets older), reflecting a widespread belief amongstSomali people living in Somalia that exclusive breastfeeding is inadequate for a baby’s needs (2010).The MCH nurses we interviewed reported that breastfeeding levels were relatively high amongstSomali mothers in Melbourne, with many breastfeeding and nursing to sleep ‘well into the secondyear’. Yet many Somali workers reported a significant decrease in the length of time that Somalimothers in Melbourne were tending to breastfeed, compared with traditional practices, or even withthe practices of older mothers living in Australia. First Somali worker: We came from a culture of very strong nursing. But now different things are happening here. I see a lot of younger women, if you ask them, ‘Why are you not nursing your child,’ they will say, ‘Oh, he doesn’t want it’ (general agreement). I think most of them might do six months maximum, or even some of them six weeks. Interviewer: Why is that? Do they think bottles are better? Second worker: Yeah. They want big fat babies. Third worker: When you are feeding the baby, that child is depending on you. You cannot go anywhere. First worker: But it is a matter of learning. I was working all the time or studying when I had my babies. It was a matter of learning to express and store milk. That’s what I tell the young women.A number of Somali workers attributed this decrease in mothers’ willingness to breastfeed to‘convenience’, with women wanting to go out, to work or study, and therefore wanting others to beable to feed their baby. One cited a lack of time for mothers with older children, quoting a friend whowas raising several children with little help from her husband, who worked very long hours: [She said] ‘I don’t have that time to sit there for 20 minutes and 20 minutes. I’ll offer, but if the baby doesn’t want it, I will just shut it up’.The MCH nurses we interviewed and one of the Somali workers cited the importance of teachingmothers to express milk, both to enable others to assist with feeding, and to maintain milk supplies.Lack of supply, especially amongst mothers who were combining breast and formula, was cited byseveral Somali workers as a reason that mothers would give for ceasing to breastfeed. Steinman et aland one of the Somali workers interviewed linked the combined use of bottle and breast (reportedlyquite common practice in the Somali community) with some maternity hospitals’ practice ofintroducing formula before mothers’ milk had ‘come in’.Asked who would help mothers with breastfeeding problems in Somalia, women who were citydwellers prior to the civil war referred to a combination of health services and older relatives,including grandmothers, who would show new mothers how to breastfeed and apply traditionalremedies for breastfeeding problems: First mother: In the good times before the civil war, there were nurses and doctors, and public hospitals that were free. They would help you. But sometimes when you are a new mum, the other ladies who are more experienced when tell you about how to hold your baby, how to breastfeed. Empowering Somali Mums Research Report 24
  25. 25. Second mother: I had problems with my nipples, it was inverted and hard. I had to use sometraditional herbal medicines. I was taken to an obstetrician, he gave me some medicines, and theypump out my breast. Then my mum applied some medicines, and the duct opened. Then I feltrelief. Empowering Somali Mums Research Report 25