Artigo Maternidade e Imigração

Straiton et al.
BMC Psychiatry (2022) 22:211

https://doi.org/10.1186/s12888-022-03848-9
RESEARCH Open Access
The relationship between motherhood

and use of mental health care services
among married migrant and non‑migrant
women: a national register study
Melanie Straiton1*, Anna‑Clara Hollander2, Kamila Angelika Hynek1, Aart C. Liefbroer3,4,5 and Lars Johan Hauge1
Abstract
Background: Giving birth to one’s first child is a life changing event. Beyond the post-partum period, little is known
about the association between becoming a mother and mental disorder among migrant women. This study investi‑
gates outpatient mental health (OPMH) service use, a proxy for mental disorder, among married migrant and non-
migrant women who become mothers and those who do not.
Methods: Using Norwegian register data, we followed 90,195 married women, aged 18-40 years, with no children at
baseline between 2008-2013 to see if becoming a mother was associated with OPMH service use. Data were analysed
using discrete time analyses.
Results: We found an interaction between motherhood and migrant category. Married non-migrant mothers, both
in the perinatal period and beyond, had lower odds of OPMH use than married non-mothers. There was no asso‑
ciation between motherhood and OPMH service use for migrants. However, there was no significant interaction
between motherhood and migrant category when we excluded women who had been in Norway less than five
years. Among women aged 25-40 years, a stable labour market attachment was associated with lower odds of OPMH
use for non-migrants but not migrants, regardless of motherhood status.
Conclusions: The perinatal period is not associated with increased odds of OPMH use and appears to be associ‑
ated with lower odds for married non-migrant women. Selection effects and barriers to care may explain the lack of
difference in OPMH service use that we found across motherhood status and labour market attachment for married
migrant women. Married migrant women in general have a lower level of OPMH use than married non-migrants.
Married migrant women with less than five years in Norway and those with no/weak labour market attachment may
experience the greatest barriers to care. Further research to bridge the gap between need for, and use of, mental
health care among migrant women is required.
Keywords: motherhood, mental disorder, post-partum disorder, migrants, health service use
Background
The transition to motherhood is a major life-event. For
many, the perinatal period can be a time of joy [1]. How-
*Correspondence: [email protected] ever, it is also considered a sensitive time period for the
1
Department of Mental Health and Suicide, Norwegian Institute of Public onset of mental disorders [2]. Post-partum depression
Health, PO Box 222, Skøyen, 0213 Oslo, Norway is a common mental disorder thought to affect around
Full list of author information is available at the end of the article
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Straiton et al. BMC Psychiatry (2022) 22:211 Page 2 of 16
17% of new mothers globally, though estimates vary from happiness than non-mothers, whereas in countries with
3-38% [3, 4]. In addition to physiological and hormonal poorer provision, mothers report less happiness [18].
changes associated with pregnancy and childbirth, poor This suggests that the social and political context plays
psychosocial adjustment to motherhood can, over time, an important role in whether mothers experience better
have an impact on the mental health of mothers [5, 6]. mental health than women who voluntarily or involun-
It is unclear however, if mothers, both in and beyond tarily have no children.
the perinatal period are at higher or lower risk of men- One notably absent aspect from the limited literature
tal disorder than women who voluntarily or involuntarily on mental disorder among mothers and women with-
have no children [7]. Further, research from high income out children is attention to migrant women. Although
countries indicates that migrant women, particularly some research indicates that migrants are at greater
those from countries outside of the European Economic risk of post-partum depression than their non-migrant
Area (EEA), the UK, USA, Canada, Australia and New counterparts [19, 20], we know little about the relation-
Zealand, may be at higher risk of post-partum depressive ship between motherhood and mental disorder beyond
symptoms than non-migrant women [8, 9]. It is, however, the perinatal period for migrants. Additionally, it is pos-
not known if these differences are pre-existing or due to sible that the relationship differs for different groups
the transition to motherhood. of migrant women. We know that general differences
between mothers and women who voluntarily or invol-
Motherhood and mental health untarily do not have children may be time and context
While cross-sectional studies usually indicate that moth- specific [21]. For instance, in many parts of Europe, it is
ers report better mental health, well-being and life-satis- no longer considered a tragedy or failure not to become
faction than women who voluntarily or involuntarily have a mother [22]. Lower stigma overtime may lead to bet-
no children [10–12], a longitudinal study indicated that ter mental health for women who voluntarily or involun-
mother’s well-being may decrease over time to a greater tarily have no children. However, this may not apply to
extent than non-mothers [13]. However, direct com- all groups of women within a society. Childlessness for
parison of findings is difficult given the different study instance, may be stigmatised among Pakistani women
designs, definitions of mothers, the inclusion or exclusion in the UK [23] and it threatens the social status of Zim-
of non-mothers or mothers with older children as con- babwean women in Australia [24]. In the Netherlands,
trols and different ways of measuring mental health [7]. Turkish migrant women report more social pressure to
There are also few studies comparing the risk of mental have children, and more emotional distress if they are
disorder among mothers compared with non-mothers unable to, than their Dutch counterparts [25]. Thus, if
beyond the post-partum period. Self-reported studies in childbearing is more important for migrants from coun-
Germany and Australia found no difference in the rates tries with other predominating norms (for example, in
of current or life-time depression or other mental disor- Asia, Africa, Latin America, Oceania (except for Aus-
ders between mothers and non-mothers [7, 12]. These tralia & New Zealand) and European countries not in the
studies were, however, cross-sectional and were unable to EEA or the UK), the mental health difference between
account for mental health selection into motherhood. migrant mothers and migrant women without children
The association between motherhood and mental dis- could be larger than for non-migrant women.
order may also depend on sociodemographic factors. For On the other hand, migrant mothers in general, with-
instance, younger mothers appear to be at greater risk out family in their country of residence may be less likely
of mental disorder [14]. In a longitudinal Danish regis- to receive help and support from family with childcare
ter study, mothers aged 26 or less, had a higher risk of [26, 27]. Some may feel conflicted by different cultural
mental disorder, measured by hospital admission and child-rearing practices [26, 27], experience discrimina-
outpatient contact with mental health services, com- tion or social exclusion from non-migrant mothers [28].
pared with women without children [15]. In contrast, Some migrant women may also struggle as a mother in
mothers aged 30 or over, had a lower risk than women the public sphere due to language difficulties or unfa-
without children. Civil status and employment can also miliarity with the country’s system such as the organisa-
play a role. Single mothers are more likely to report major tion of childcare or school systems [29]. If motherhood
depression than married mothers [6, 16] and employed is a greater source of stress for migrant women, the asso-
mothers may experience less parenting strain and better ciation between motherhood and mental disorder could
mental health than non-employed mothers [6, 17]. Fur- be different for migrant women relative to non-migrant
ther, a study across 28 European countries found that in women.
countries with more extensive childcare provision, such Yet another aspect of motherhood that may differ for
as in the Nordic countries, mothers tend to report more migrant women, particularly those from countries where
men are predominantly the breadwinner, is that of com- between workforce participation and mental disorder dif-
bining motherhood with employment. Workforce par- fer for married migrants from Asia, Africa, Latin Amer-
ticipation is usually associated with better mental health, ica, Oceania (except for Australia & New Zealand) and
partly due to an increase in socioeconomic resources for European countries not in, the EEA or the UK compared
the family [17]. However, in the general population, an with married non-migrants and is this dependent on
unequal division of labour and more work-family con- motherhood status?
flict is related to higher levels of stress and more sick-
leave [30–32]. Partners’ involvement in childcare and Method
household tasks may be important for women’s wellbe- Setting of the study ‑ migrant women and healthcare
ing, especially in the early years of childhood. Father’s in Norway
involvement in housework and childcare has increased Migrants (those born abroad with two foreign born par-
substantially in recent decades in many European, espe- ents) in Norway now make up 15% of the population [40].
cially Nordic, countries [33]. However, migrant women Just less than half of migrants are from other European
from countries with a more traditional gender division countries, around one third from Asia and 14% from
of labour, may still have more responsibility for childcare Africa. Women represent around 48% of migrants. Half
and housework relative to their non-migrant counter- of migrant women come to Norway for family reunifica-
parts, regardless of their employment status [34–37]. The tion, one in five for work, 16% for protection and 13% to
‘double shift’ may thus be longer for many mothers from study. They are very diverse in terms of education and
for instance, Asia, Africa, Latin America, Oceania (except employment. Women from EEA countries and the UK
for Australia & New Zealand) and European countries tend to have a higher level of employment and are more
not in the EEA or the UK, resulting in higher levels of likely to have higher education than women from other
stress. Further, migrant women from these countries may countries [41, 42].
be more likely to work in physically demanding jobs and Health care in Norway is a publicly funded universal
have less control over their working schedule than non- system and is available to all long-term (over six months)
migrant women [38]. Greater control is associated with residents and registered asylum-seekers. It is divided into
better well-being among parents [39]. It is therefore pos- two main sectors: primary (including general practition-
sible that working outside the home could be less pro- ers (GPs), emergency care and long-term services) and
tective for mothers from Africa, Asia, Latin America, secondary (hospital and specialised services). Residents
Oceania (except for Australia & New Zealand) and Euro- are assigned a GP who is the gatekeeper to specialised
pean countries not in the EEA or the UK than for non- services, including OPMH services. OPMH services are
migrant mothers or mothers from for instance, countries local specialised services where those with acute mental
in the EEA, the UK, USA, Canada, Australia or New health problems or who need long-term follow-up can
Zealand. receive help. A referral from a doctor or psychologist is
In summary, there are potentially several reasons for required.
why motherhood could relate to mental disorders for
migrant and non-migrant women differently. This could Data sources
also differ somewhat for migrant women from different We used data from several national databases and regis-
parts of the world. Workforce participation may also play tries, linked at an individual level through a non-identifia-
an important role. ble version of a personal number. All registered residents
with at least six months of residence are assigned this
Current study personal number, in addition to Norwegian-born individ-
In the current longitudinal study, we focused on married uals. Demographic information was extracted from the
women living in Norway, aged 18-40 years, who volun- National Population Registry. This was used to identify
tarily or involuntarily have no children at baseline and no all women, their year of birth, civil status, migrant status
recent history of outpatient mental health (OPMH) ser- / region of origin, year of migration and year of any child-
vice use and followed them for up to six years. We aimed births. Education level was extracted from the Education
to answer the following research questions: 1) Do mar- Database. FD-Trygd, which contains event history infor-
ried women who become mothers have higher or lower mation relating to welfare benefits, was used to extract
odds of using OPMH services (a proxy for mental dis- information on child benefit. Information on income was
order) compared with married women who do not? 2) taken from the National Income Tax Registry. Finally,
Does the relationship between motherhood and OPMH the National Database for the Reimbursement of Health
service use differ for married migrant women compared Expenses, which contains information about patient
to married non-migrant women? 3) Does the relationship contacts, was used to extract information on whether an
individual had attended OPMH and primary health care end of 2013, the year they turned 40, died or emigrated.
services. We also censored women if their marital status changed.
Study population Variables

We used a dynamic study design where all women, aged Outcome: Consultation with OPMH services (yes/no).
18-40 years, living in Norway between 2008 and 2013 Exposure: Motherhood: (Non-mother; mothers, peri-
were potentially included. We selected all women who natal; mothers, >perinatal). This measure was based
were married at some point during the study period. on registered births in the medical birth registry. This
Migrant women had to have been living in Norway for measure was time-varying in that women were classed
at least two years prior to inclusion. This was because as non-mothers until the year they gave birth. Since the
we wanted to exclude women who had used OPMH ser- perinatal period is considered a vulnerable time for men-
vices in the two years prior to baseline to increase the tal disorder development, we also grouped women who
likelihood that use of OPMH services was related to the were perinatal (year of, or year after birth) separately
perinatal period and not a pre-existing condition. Infor- from mothers who gave birth more than two calendar
mation on women’s year of childbirth (available from years ago. Although the post-partum period is gener-
1992) and receipt of child benefit (available from 1996) ally considered up to 12 months [45], we did not have
was used to exclude women who had children prior information on the date of the birth within the calen-
to baseline (baseline was 2008 or the year of marriage, dar year. Thus, inclusion of the following year allowed
whichever came first). Women who, during the follow-up us to account for the post-partum period for women
period, received child benefit but had not been registered giving birth towards the end of the year. For example, a
as giving birth were also excluded from analysis because woman who gives birth in 2010 would be classed as peri-
it was unclear when they became mothers. Figure 1 natal in 2010 and 2011. In 2012, she would be classed as
shows a flow chart of the number of women in the study >perinatal.
population and the number and percentage of women Migrant category: Non-migrant women (women born
excluded according to the different inclusion criteria by in Norway and women born abroad with at least one
migrant category. Norwegian born parent) and migrant women (born
We included only married women due to lack of cohab- abroad with two foreign-born parents). We divided
iting information for unmarried women. Over 80% of migrant women into two categories: Western (women
unmarried women in Norway who give birth live with a from EEA countries, the UK, USA, Canada, Australia
partner [43]. Thus, most unmarried women who become or New Zealand) and non-Western (Asia, Africa, Latin
mothers have a partner, while among unmarried women America, Oceania (except for Australia & New Zea-
who do not have children, there is a greater mix of sin- land) and European countries not in the EEA or the UK).
gle and cohabiting women. Since cohabitation is almost Country composition is shown in Supplementary table 1.
as protective of mental disorder as having a spouse [44], A more nuanced distinction by region of origin was not
if we included unmarried women, we would not be able possible due to power considerations (based on the rela-
to separate the association between motherhood and tive infrequency of the outcome).
OPMH service use and having a partner and OPMH ser- Age group (time-varying): Based on year of birth, we
vice use among unmarried women. This could lead to an grouped women into the following categories: 18-24
overestimation of any positive effect of giving birth to a years, 25-29 years, 30-34 years, 35-40 years.
child or cancel out any negative effect. Thus, we selected Education (time-varying): Highest level of completed
only married women since their partner status was education: Higher education, high school education or
known. less than high school education/unknown.
However, because the rate and timing of marriage and Frequent primary healthcare attendance: This is a
giving birth is different across migrant status, select- proxy of poor somatic health as it is associated with
ing only married women results in an overrepresen- pre-existing medical conditions, unresolved health com-
tation of migrant women. As Fig. 1 shows, only 7% plaints, medication use and poorer self-reported physi-
(52,402/771,657) of all non-migrant women from the cal health [46, 47]. Frequent attendance can be defined
base sample are included in the analysis, as opposed to as the top 10th percentile of number of appointments
15% (14,410/93,025) of all Western migrant women, [48]. We calculated the average number of consultations
and 19% (23,383/125,229) of all non-Western migrant in primary care across the two years prior to baseline
women. We consider this selection issue further in the for reasons not related to pregnancy or family planning
discussion. We followed the women from baseline until or for psychological consultations (W and P chapters of
they had an OPMH consultation or were censored at the ICPC-2 codes respectively). Around 90% of women had
Fig. 1 Flow chart with sample inclusion criteria by migrant category
an average of four or fewer appointments in the two years Insurance Scheme [49] were classed as participating in
prior to baseline. Thus, we had a dichotomous variable the workforce. This cut-off has been used as an indicator
of non-frequent attenders (<=4 appointments) and fre- of stable labour market attachment in other studies [50].
quent attenders (> 4 appointments). Ongoing education (time-varying): (Yes/No) Women
Labour market attachment (time-varying): (Stable/ enrolled in education were classified as currently
No or weak) Women with a personal income (based on studying.
salary and income from self-employment) of over two Employed/studying (time-varying): (Yes / No). Since
times the yearly basic taxation amount of the National younger women are less likely to have entered the
workforce because they are still in education, we com- Results

bined labour market attachment with current enrol- Population sample
ment in education. Women who were working and/or Our total population sample consisted of 90,195 mar-
studying were grouped together as were women who ried women with 317,665 person years. Women were in
had a weak or no labour market attachment and were the study for a mean of 3.52 years (range: 1-6). Around
not studying. 58% were non-migrant women. Migrant women are
overrepresented compared to the share of migrants in
the general population because non-migrant women
Statistical analyses are less likely to be married and are more likely to have
Data were arranged on a yearly basis. In the descrip- children prior to baseline (see Fig. 1). Overall, half of
tive analyses, we divided and described the sample by women became mothers during the follow-up period
migrant category based on the final year of inclusion. We and four percent used OPMH services. In the sample
conducted chi-square analyses to see if there was a signif- including only migrants with five or more years of resi-
icant difference across the different groups on each vari- dency in Norway at baseline, non-migrants made up 72%
able. For the main analyses, we conducted discrete-time of the sample, half became mothers and overall, 5% used
logistic regression to examine the relationship between OPMH services. Overall, the average age of becoming a
becoming a mother and use of OPMH services [51]. First, mother was 29.75 years.
we ran separate bivariate analyses for each variable, then Table 1 displays the demographics of the sample by
in model one we included motherhood and migrant cate- migrant category in the last year of inclusion, both for the
gory together. In the second model, we controlled for age, total sample and in the sample excluding migrants with
education and frequent primary healthcare attendance less than five years of residency in Norway. There were
and in the third model, we added in employed/studying. significant differences by migrant category across all
To investigate if the relationship between motherhood variables.
and OPMH service use was moderated by migrant cat-
egory, we introduced an interaction term between Motherhood and OPMH service use
migrant category and motherhood while controlling for Table 2 shows the yearly odds of using OPMH services
all covariates. We ran post-hoc margin analyses and plot- during follow-up for the different models. The first col-
ted marginal yearly probabilities to visualise the inter- umn shows the bivariate relationship between OPMH
action effects. To check the robustness of our findings, services and each of the variables separately. Married
we reconducted analyses including only migrants who mothers, both in and beyond the perinatal period, had
had been in Norway for at least five years at baseline significantly lower odds of using OPMH services than
(length of stay= current year – year of arrival). For this, married non-mothers, as did both groups of married
we selected the sample from the study population in the migrant women compared with married non-migrant
same way as shown in Fig. 1, except this time, the second women. Women aged 35-40 years had lower yearly odds
exclusion criterium was increased to a minimum of five than women aged 25-29 years while women aged 18-24
years in Norway. had higher odds. Women who were not employed/study-
Finally, to investigate if the relationship between ing and women without higher education had higher
labour market attachment and mental disorder differed yearly odds of using OPMH services than those who were
for migrants compared to non-migrants and if it was employed/studying or had higher education respectively.
dependent on motherhood status, we also conducted Frequent attenders of primary healthcare had around
analyses with 25-40 year olds only, since many in the three times the yearly odds of women who were not fre-
youngest age category would still be studying. Here, we quent attenders. With both motherhood and migrant
ran a fully-adjusted model with no interaction, a model category in the model, both groups of mothers had lower
with an interaction term between migrant category and yearly odds of OPMH services than non-mothers (model
motherhood status, a model with an interaction term 1). After adjusting for age group, education and frequent
between migrant category and labour market attachment attendance (model 2), perinatal mothers in the perinatal
and then a three-way interaction term between migrant period, but not beyond, had lower odds of OPMH service
category, labour market attachment and motherhood. use compared to non-mothers. This was only a tendency
We then ran post-hoc margin analyses and plotted mar- after adjustment for whether a woman was employed/
ginal yearly probabilities for the final model to visual- studying (model 3).
ise the interaction effects. Finally, we reran the analyses In the interaction analyses (model 4), the main effect
again including only migrants who had been in Norway of motherhood was significant for both perinatal and
for at least five years. >perinatal mothers, indicating that among married
Table 1 Characteristics of the sample by migrant category (% by migrant category) a

Total sample Migrants > 5 years in Norway at baseline
Non-migrants Migrants, Migrants, Total sample Migrants, Migrants, Total with
(N=52402) Western non-Western (N=90195) Western non-Western non-migrants
(N=14410) (N=23383) (N=6895) (N=13701) (N=72998)
Mean (sd) years in 3.82 (1.86) 2.93 (1.68) 3.21 (1.82) 3.52 (1.86) 4.16 (1.53) 4.24 (1.65) 3.93 (1.80)
study
Motherhood
Non-mother 22137 (42.24%) 8882 (61.64%) 13835 (59.17) 44854 (49.73%) 3042 (46.99%) 6556 (47.85%) 31933 (43.75%)
Mother, 10497 (20.03%) 2639 (18.31%) 4053 (17.33%) 17189 (19.06%) 1062 (15.40%) 2106 (15.37%) 13665 (18.72%)
perinatal
Mother, > 19768 (37.72%) 2889 (18.31%) 5495 (23.50%) 28152 (31.21%) 2593 (37.61%) 5039 (36.78%) 27400 (37.54%)
perinatal
Used OPMH 2717 (5.18%) 354 (2.61%) 794 (3.28%) 3864 (4.29%) 300 (4.35%) 619 (4.52%) 3636 (4.98%)
services
Age group
18-24 years 3822 (7.29%) 421 (2.92%) 1583 (6.77%) 5826 (6.46%) 105 (1.52%) 796 (5.81%) 4723 (6.47%)
25-29 years 14174 (27.05%) 3330 (23.11%) 6451 (27.59%) 23955 (36.56%) 1030 (14.95%) 3408 (24.87%) 18612 (25.50%)
30-34 years 18641 (35.57%) 5162 (35.82%) 8021 (34.30%) 31824 (35.28%) 2766 (40.12%) 4779 (34.88%) 26186 (35.87%)
35-40 years 15765 (30.08%) 5497 (38.15%) 7328 (31.34%) 28590 (31.70%) 2994 (43.42%) 4718 (34.44%) 23477 (32.16%)
Education
<high 4790 (9.14%) 4352 (30.20%) 10491 (44.87%) 19633 (21.77%) 1670 (24.22%) 5490 (40.07%) 11950 (16.37%)
school/
unknown
High school 11751 (22.42%) 2984 (20.71%) 3942 (16.86%) 18677 (20.71%) 1398 (20.28%) 2763 (20.17%) 15912 (21.80%)
Higher 35861 (68.43%) 7074 (49.09%) 8950 (38.28%) 51885 (57.53%) 3827 (55.50%) 5448 (39.78%) 45136 (61.83%)
Employed/studying
No 6731 (12.84%) 5237 (36.34%) 9875 (42.23%) 21843 (24.22%) 1768 (25.64%) 4238 (30.93%) 12737 (17.45%)
Yes 45671 (87.16%) 9173 (63.66%) 13508 (57.77%) 68352 (75.78%) 5127 (74.36%) 9463 (69.07%) 60261 (82.55%)
Frequent primary 6524 (12.45%) 637 (4.42%) 1887 (8.07%) 9048 (10.03%) 433 (6.28%) 1418 (10.35%) 8375 (11.47%)
care attendence
Mean (sd) age 29.72 (4.05) 30.52 (3.88) 29.39 (4.44) 29.75 (4.13) 30.80 (3.77) 29.32 (4.38) 29.75 (4.10)
of becoming a
mother
a
the last year of inclusion is used for the time-varying variables
non-migrant women, mothers had lower odds of using model are shown in Table 3. In model 1, controlling for
OPMH services than non-mothers. However, the inter- all covariates, mothers did not have significantly lower
action term indicated the relationship was significantly yearly odds of OPMH service use, though again, there
weaker for married non-Western migrant women. was a tendency for perinatal mothers to have lower odds.
Although not significant for married Western migrant Inclusion of the interaction in model 2 indicated that
women, the odds ratios also indicated a weaker relation- for married non-migrants, perinatal mothers had sig-
ship. Plotting marginal yearly probabilities of OPMH nificantly lower odds of OPMH service use and mothers
service use by migrant category and motherhood (Fig. 2) beyond the perinatal period tended to have lower odds.
indicated that the yearly probability of OPMH service There was no significant interaction between mother-
use for both groups of migrants was similar regard- hood and migrant category, suggesting that the relation-
less of motherhood. There was a slight difference for ship between motherhood and OPMH service use was
non-migrants; with non-migrant women without chil- not significantly different across migrant category for
dren having a greater probability than both groups of married women.
non-mothers. However, the 95% intervals were slightly
overlapping. Labour market attachment, motherhood and OPMH
We repeated analyses with the sample only including service use
women who had been in Norway for at least five years For characteristics of the sample of married women
and the results of the fully adjusted model and interaction aged 25-40 years used in analyses with labour market
Table 2 Odds ratios and 95% confidence intervals for outpatient mental health service use– all married women
Bivariate analyses Model 1 Model 2 Model 3 Model 4
(n=90195) (n=90195) (n=90195) (n=90195) (n=90195)
Non-mother 1.00 1.00 1.00 1.00 1.00

Mother, perinatal 0.91 (0.85-0.99)* 0.88 (0.82-0.95)** 0.92 (0.85-0.99)* 0.93 (0.86-1.01)^ 0.89 (0.81-0.98)*
Mother, > perinatal 0.90 (0.82-0.97)** 0.85 (0.78-0.93)*** 0.94 (0.86-1.03) 0.94 (0.86-1.04) 0.88 (0.80-0.97)*
Non-migrants 1.00 1.00 1.00 1.00 1.00
Migrants, Western 0.69 (0.62-0.77)*** 0.68 (0.61-0.75)*** 0.71 (0.63-0.79)*** 0.67 (0.60-0.75)*** 0.62 (0.54-0.71)***
Migrants, non-Western 0.73 (0.67-0.79)*** 0.72 (0.66-0.78)*** 0.64 (0.58-0.70)*** 0.60 (0.54-0.66)*** 0.55 (0.49-0.62)***
18-24 years 1.53 (1.38-1.70)*** 1.31 (1.17-1.45)*** 1.30 (1.17-1.45)*** 1.29 (1.16-1.43)***
25-29 years 1.00 1.00 1.00 1.00
30-34 years 0.95 (0.88-1.03) 1.00 (0.92-1.08) 1.00 (0.93-1.08) 1.01 (0.93-1.09)
35-40 years 0.88 (0.81-0.96)** 0.89 (0.81-0.97)* 0.88 (0.80-0.96)** 0.88 (0.81-0.97)**
Higher education 1.00 1.00 1.00 1.00
<High school/unknown 1.58 (1.46-1.71)*** 1.71 (1.56-1.87)*** 1.53 (1.40-1.68)*** 1.53 (1.40-1.68)***
High school 1.54 (1.43-1.67)*** 1.37 (1.26-1.49)*** 1.32 (1.22-1.43)*** 1.32 (1.22-1.43)***
Frequent primary care attendence 2.99 (2.71-3.30)*** 2.51 (2.28-2.76)*** 2.48 (2.25-2.72)*** 2.46 (2.27-2.67)***
Not employed/studying 1.46 (1.36-1.57)*** 1.45 (1.34-1.57)*** 1.45 (1.34-1.57)***
Mother, perinatal * Western 1.15 (0.89-1.49)
Mother, > beyond perinatal * non-Western 1.15 (0.94-1.40)
Mother, perinatal*Western 1.27 (0.94-1.72)
Mother > perinatal*non-Western 1.29 (1.04-1.60)*
^p<0.10; *p<0.05, **p<0.01, ***p<0.001.
Fig. 2 Marginal yearly probability of OPMH service use by migrant category and motherhood for married women
attachment see Supplementary table 2. Table 4 shows In model 1, we found that overall, married women
the results of the fully adjusted model and three models who became mothers tended to have lower odds of
with different interactions. We controlled for age, educa- using OPMH services than married women who did not
tion level and frequent attendance in all models. Ongoing have children. This was for both perinatal mothers and
education was not significantly related to OPMH service mothers beyond the perinatal period. Again, we found
use, so we excluded this in analyses. a significant interaction between motherhood and
sea
Table 3 Odds ratios and 95% confidence intervals for outpatient mental health service u
Model 1 Model 2
(n=72998) (n=72998)
Non-mother 1.00 1.00

Mother, perinatal 0.92 (0.85-1.00)^ 0.90 (0.82-0.99)*
Mother, > perinatal 0.94 (0.86-1.03) 0.90 (0.81-1.00)^
Non-migrants 1.00 1.00
Migrants, Western 0.75 (0.66-0.85)*** 0.71 (0.61-0.84)***
Migrants, non-Western 0.62 (0.56-0.68)*** 0.58 (0.51-0.66)***
18-24 years 1.27 (1.14-1.42)*** 1.27 (1.14-1.42)***
25-29 years 1.00 1.00
30-34 years 0.98 (0.90-1.07) 0.99 (0.91-1.07)
35-40 years 0.87 (0.79-0.95)** 0.87 (0.79-0.96)**
Higher education 1.00 1.00
<High school/unknown 1.65 (1.49-1.82)*** 1.65 (1.49-1.82)***
High school 1.36 (1.25-1.48)*** 1.35 (1.25-1.47)***
Frequent primary care attendence 2.42 (2.19-2.67)*** 2.41 (2.18-2.66)***
Not in employed/studying 1.56 (1.43-1.69)*** 1.55 (1.43-1.67)***
Mother, perinatal * Western 1.08 (0.80-1.45)
Mother, > beyond perinatal * non-Western 1.11 (0.90-1.49)
Mother, perinatal* Western 1.14 (0.83-1.56)
Mother > perinatal* non-Western 1.20 (0.96-1.51)
a
Based on married women aged 18-40 and married migrants with ≥5 years in Norway; ^p<0.1, *p<0.05, **p<0.01, ***p<0.001.
Table 4 Odds ratios and 95% confidence intervals for outpatient mental health service use with interactions a,b
Model 1 Model 2 Model 3 Model 4
(n=81908) (n=81908) (n=81908) (n=81908)
Non-mother 1.00 1.00 1.00 1.00

Mother, perinatal 0.92 (0.85-1.04)^ 0.86 (0.77-0.95)** 0.94 (0.86-1.02)
Mother, > perinatal 0.92 (0.83-1.01)^ 0.85 (0.75-0.95)** 0.93 (0.85-1.03)
Mother 0.90 (0.82-0.99)*
Non-migrants 1.00 1.00 1.00 1.00
Migrants, Western 0.68 (0.61-0.77)*** 0.62 (0.53-0.72)*** 0.90 (0.78-1.02) 0.85 (0.71-1.02)*
Migrants, non-Western 0.61 (0.55-0.67)*** 0.54 (0.48-0.62)*** 0.80 (0.71-0.90)** 0.71 (0.61-0.84)***
No or weak labour market attachment 1.45 (1.33-1.57)** 1.44 (1.33-1.57)*** 1.96 (1.77-2.16)*** 2.01 (1.77-2.27)***
Mother, perintal * Western 1.27 (0.97-1.66)
Mother, perintal * non-Western 1.29 (1.03-1.60)*
Mother, >perintal* Western 1.30 (0.95-1.79)
Mother, >perintal* non-Western 1.35 (1.06-1.72)*
No/Weak labour market attachment* Western 0.41 (0.32-0.53)***
No/Weak labour market attachment* non-Western 0.48 (0.39-0.58)***
Non-mother*no/weak labour market attachment* Western 0.41 (0.30-0.55)***
Non-mother*no/weak labour market attachment* non-Western 0.49 (0.39-0.62)***
Mother*no/weak labour market attachment*non-migrants 0.91 (0.74-1.10)
Mother*no/weak labour market attachment* Western 0.51 (0.33-0.78)**
Mother*no/weak labour market attachment* non-Western 0.52 (0.39-0.71)***
Mother*stable labour market attachment*Western 1.19 (0.90-1.58)
Mother*stable labour market attachment* non-Western 1.28 (1.02-1.61)*
a
based on married women aged 25-40 years; b adjusted for age, education level and frequent primary healthcare attendance *p<0.05, **p<0.01, ***p<0.001.
migrant category (model 2). The relationship between was associated with twice the yearly odds of OPMH
motherhood and OPMH service use was significant for service use for married non-migrant, non-moth-
non-migrants but the interaction effect suggested this ers. Motherhood was associated with lower odds of
association was significantly weaker for non-Western OPMH service use for non-migrants with a stable
migrant women. The interaction was in the same direc- labour market attachment. Further, married migrant
tion for Western migrant women, though it did not non-mothers with a stable labour market attachment
reach statistical significance. Marginal predicted prob- had significantly lower odds of using OPMH services
abilities indicated that the probability of OPMH ser- compared with their non-migrant counterparts. The
vice use was similar for married migrants regardless of interaction term between mother*no/weak labour mar-
motherhood status (Supplementary table 3). In model 3, ket attachment*non-migrants and mother*no/weak
there was an interaction between labour market attach- labour market attachment*Western migrants was not
ment and migrant category. Noteworthy, the main effect significant, suggesting that the relationship between
of motherhood was not associated with lower odds of labour market attachment and OPMH service use did
OPMH service use. Further, the difference in odds of not differ depending on motherhood for married non-
OPMH service use between migrants from Western migrants and married Western migrants. However,
countries and non-migrants was not significant, indi- there were several other interactions. Plotted marginal
cating no difference in odds for these groups among yearly probabilities suggested that among married non-
married women with a stable attachment to the labour migrants, those with a stable attachment to the labour
market. Although the main effect of labour market market had around half the probability of using OPMH
attachment was strong for non-migrants, the interac- services compared with non-migrants with no or weak
tion term suggested it is far weaker for both groups of attachment, for both mothers and non-mothers (Fig. 3).
migrants. Marginal yearly probabilities indicated that For both groups of migrants however, the yearly prob-
the probability of OPMH service was not dependent on ability of OPMH service use was similar regardless of
labour market attachment for married migrant women labour market attachment and motherhood.
(Supplementary table 4). Finally, we repeated the analyses on a sample includ-
Finally, in model 4, we included a three-way inter- ing only migrants who had been in Norway at least five
action term. In this model, we combined both groups years together with non-migrants (see table 5). Our
of mothers (perinatal and >perinatal) into one cat- findings were similar indicating the robustness of the
egory to preserve statistical power and ease inter- above findings, except that there was no significant
pretation, since there was little difference in odds of difference in the strength of the relationship between
OPMH for these groups. The main effects indicated motherhood and OPMH for either migrant group com-
that having no or a weak labour market attachment pared to non-migrants (model 2). Post-hoc marginal
Fig. 3 Marginal yearly probability of OPMH service use by migrant category, motherhood and labour market attachment
Table 5 Odds ratios and 95% confidence intervals for outpatient mental health service use with interactions a,b
Model 1 Model 2 Model 3 Model 4
(n=65935) (n=65935) (n=65935) (n=65935)
Non-mother 1.00 1.00 1.00 1.00

Mother, perinatal 0.91 (0.84-0.999)* 0.87 (0.78-0.96)** 0.93 (0.85-1.01)
Mother, > perinatal 0.92 (0.83-1.02)^ 0.87 (0.77-0.97)* 0.93 (0.84-1.03)
Mother 0.91 (0.82-1.01)^
Non-migrants 1.00 1.00 1.00 1.00
Migrants, Western 0.75 (0.65-0.85)*** 0.69 (0.58-0.82)*** 0.93 (0.80-1.09) 0.91 (0.74-1.10)
Migrants, non-Western 0.63 (0.56-0.70)*** 0.57 (0.50-0.66)*** 0.81 (0.71-0.92)** 0.72 (0.61-0.86)***
No or weak labour market attachment 1.55 (1.42-1.69)*** 1.54 (1.41-1.68)*** 1.94 (1.75-2.15)*** 2.00 (1.76-2.28)***
Mother, perintal * Western 1.21 (0.89-1.65)
Mother, perintal * non-Western 1.24 (0.98-1.58)
Mother, >perintal* Western 1.20 (0.86-1.68)
Mother, >perintal*non-Western 1.26 (0.98-1.62)
No/Weak labour market attachment* Western 0.46 (0.34-0.61)***
No/Weak labour market attachment* non-Western 0.51 (0.41-0.63)***
Non-mother*no/weak labour market attachment* Western 0.43 (0.30-0.63)***
Non-mother*no/weak labour market attachment* non-Western 0.54 (0.41-0.71)***
Mother*no/weak labour market attachment*non-migrants 0.90 (0.74-1.10)
Mother*no/weak labour market attachment* Western 0.51 (0.32-0.81)**
Mother*no/weak labour market attachment* non-Western 0.57 (0.41-0.79)**
Mother*stable labour market attachment* Western 1.08 (0.80-1.46)
Mother*stable labour market attachment* non-Western 1.28 (1.00-1.65)^^
a
based on married women aged 25-40 years and migrants with ≥5 years in Norway; b all models adjusted for age, education level and frequent primary healthcare
attendance; ^p<0.10; ^^p=0.05, *p<0.05, **p<0.01, ***p<0.001.
yearly probabilities for interactions in model 3 and developing a disorder is not greater at this stage, at least
model 4 are shown in Supplementary tables 5 and 6). for married women, than it is for married women with-
out children and may, in fact be lower for non-migrant
Discussion women aged 25+ and migrant women with five or more
In our study, we aimed to determine if married women years of residence.
who become mothers have higher or lower odds of men- Among married non-migrants, mothers both in and
tal disorder (using OPMH service use as a proxy) than beyond the perinatal period have lower odds of OPMH
married women who voluntarily or involuntarily do not service use than women without children. Previous stud-
have children. Our findings indicate that although mar- ies considering mental disorder beyond the post-partum
ried mothers may appear to have slightly lower odds of period found no difference in risk of depression or mental
OPMH service use than married women who do not disorders in general between mother and non-mothers
become mothers, this difference is mostly explained by [7, 12] but neither of these studies accounted for mental
age, education and workforce attachment in analyses health selection. Compared with non-migrants, we found
with women aged 18-40 years. However, in analyses with the relationship between motherhood and OPMH use
married women aged 25-40 years and married migrants was weaker among married migrants, and significantly
with at least five years in Norway, perinatal mothers had so for women from non-Western countries. Our post hoc
significantly lower odds of OPMH service use than mar- analyses indicated that the yearly probability of service
ried women who voluntarily or involuntarily do not have use was similar for both groups of migrants, regardless
children. The difference in findings when we include of motherhood status. It is possible that motherhood is
younger women could be because previous research sug- associated with greater challenges for married migrant
gests that younger mothers tend to have poorer mental women, particularly those from non-Western coun-
health [15, 52]. Nonetheless, although post-partum dis- tries, in terms of potential lack of practical support from
orders can have serious consequences for the mother extended family, challenges in bringing up children in a
and child [3, 53], our findings suggest that the risk of country with different values and practices, difficulties
in navigating society, and the experience of discrimina- in fewer mental health benefits compared with non-
tion [27, 28, 54]. Such additional stress may cancel out migrant women. We may therefore have expected a
any protective aspect of becoming a mother on mental slightly weaker association between labour market
disorder. Since we found no significant difference in the attachment and OPMH service use for married non-
relationship between motherhood and migrant category Western women, especially among mothers, compared
among married migrants who had been in Norway more with married non-migrant women. Given how strong
than five years, it is possible that these challenges are less the relationship was among non-migrants, it is surpris-
intense for women who have been in a new country for a ing that there was not even a weak association for either
longer period before having children. group of migrants. Survey data indicates that migrant
On the other hand, previous research indicates that women who are not in the workforce are more likely to
migrant women with stays of less than five years have report mental health problems than migrant women
particularly low utilisation of OPMH services [55]. Bar- who are [62]. There are two potential reasons for this
riers to mental health service use are well-documented lack of relationship. The first relates to how well OPMH
among migrants [56, 57] and it is likely that these bar- service use measures mental disorder among migrants
riers are greatest in the first few years after arrival [58]. with and without a stable labour market attachment.
Thus, the lack of relationship between motherhood and Married migrants who are in stable employment will
OPMH service use observed for married migrants in presumably have more contact with Norwegian soci-
the main sample could indicate that OPMH service use ety, better language skills, more resources and possibly
is a poorer proxy for mental disorder among migrant better health-literacy than migrants who do not. These
women, especially those with shorter stays. Further, dur- attributes and skills may reduce barriers and lead to
ing the perinatal period, most women have more con- more appropriate help-seeking if they do experience
tact with healthcare services than prior to pregnancy a mental disorder [63, 64], particularly among women
[59, 60]. This allows greater opportunity for health pro- with longer stays. In support of this, our analyses indi-
fessionals to identify mental health disorders and facili- cated that married migrant women from Western coun-
tate access to care. Thus, the lack of association between tries who had a stable attachment to the labour force
motherhood and OPMH service use for married migrant had similar odds of service use as married non-migrant
women may be because the unmet need for mental women with a stable attachment. Married migrant
healthcare is greater among women without children, women without a stable labour market attachment
particularly those with shorter stays, than among women may, conversely, experience greater barriers and be less
who become mothers. However, investigation of the gap likely to seek help for mental disorder. Among mar-
between actual mental disorder and use of OPMH ser- ried women with no or a weak labour market attach-
vices among migrant women, both mothers and women ment, non-migrants had over twice the probability of
without children, is required, as well as a closer investiga- using OPMH services as migrant women. Thus, there
tion of the role of length of stay. may be more unidentified mental disorder in migrant
We also investigated if the association between labour women with no stable attachment compared to women
market attachment and mental disorder differed for mar- with a stable attachment to the labour market, resulting
ried migrants than for married non-migrants and by in no overall difference in service use between married
motherhood. Among married non-migrant women, a migrant women with and without a stable labour mar-
stable attachment to the labour market was associated ket attachment.
with lower odds of OPMH service use. This association The second potential explanation for the lack of
was the same regardless of motherhood. This supports observed difference in OPMH service use for married
the assumption that employment is beneficial, also for migrants by labour market attachment could be due
mother’s mental health [61]. However, labour market to selection. A Norwegian study among mothers in the
attachment was not significantly related to OPMH ser- general population indicated that poorer mental health
vice use among either group of married migrant women, predicted subsequent workforce dropout, rather than
or dependent on motherhood status. Our findings were non-workforce participation leading to poorer mental
similar, even when we excluded women with less than health [65]. This suggests that mothers with poor men-
five years in Norway at baseline (who are less likely to be tal health are selected out of work. However, labour mar-
in employment), demonstrating the robustness of this ket attachment among migrant women, especially from
finding. Africa and Asia, is lower than for non-migrant women
Migrant women, particularly those from non-West- [41]. Mothers in particular may have a stronger pref-
ern countries have on average more job insecurity erence to stay at home and care for one’s children [66].
and poorer working conditions [38]. This could result Migrants may also struggle to enter the workforce due to
lack of, or differences in, formal qualifications as well as There may be other factors that differentiate between
discrimination [67, 68]. Thus, married migrant women, married women with and without children such as own
especially mothers, who do not work outside of the home number of siblings and urban residence [71]. Our non-
may be a less selected group in terms of mental disorders migrant group is also diverse and includes 1) women
than married non-migrant women. born in Norway with Norwegian born parents, 2)
women born in Norway with migrant parent(s) and 3)
Strengths and limitations women born abroad with Norwegian born parent(s).
This study has several strengths. The relationship Future studies could consider distinguishing between
between motherhood and mental disorder has not these different groups since they may have different
been researched much beyond the post-partum period marriage and childbearing patterns as well as different
for migrant women, and in our study, we were able to use of mental health services. Finally, we only had the
look at both the perinatal period and beyond. We were child’s year, and not the date, of birth. In cases where
able to control for frequent primary care attendance OPMH service use and childbirth occur in the same
for reasons not related to pregnancy, family-planning year, we cannot determine which came first. However,
or mental health, as an indicator of general health. This exact date of birth was not available due to ethical rea-
is important as women without children report poorer sons to preserve anonymity. Nonetheless, the life chang-
general health than women in the general population ing transition to motherhood, for many, begins during
[11]. We also attempted to account for mental health pregnancy and mental disorder during pregnancy is a
selection bias into motherhood by only including mar- strong predictor of post-partum disorder [72].
ried women who had not used OPMH services in the
two years prior to baseline. However, it is possible that Conclusions
there is a larger proportion of unidentified mental dis- In conclusion, this longitudinal study shows that the
order among migrant women during these two years transition to motherhood among married women is
prior to inclusion, since they may experience greater not associated with higher odds of mental disorder,
barriers to care, particularly in the first few years after measured by use of OPMH services. Further, this also
arrival. Further, the minimum of two years of residence applies to mothers in the early childhood years. For mar-
in Norway will have led to an exclusion of some married non-migrants, women who become mothers have
ried migrant women who become mothers shortly after lower yearly odds of using OPMH services than women
arrival. who voluntarily or involuntarily do not have children.
A major limitation in this study is our inclusion of Labour market participation is associated with lower
married women only. Non-migrant women are under- odds of service use for both mothers and non-mothers.
represented in this study since a large proportion are Yet, a different picture emerges for married migrant
unmarried when they become mothers [43]. Married women; among them, there was no significant asso-
non-migrant women without children may therefore be ciation between motherhood and OPMH service use or
a more selected group in terms of health than married labour market attachment and OPMH services. Future
migrant women since, as indicated in an e-mail from research should investigate if it is selection effects, bar-
Statistics Norway in 2021, childbearing prior to mar- riers to healthcare, or both, that explain the lack of rela-
riage is less common among migrant women from non- tionship for married migrant women. Married migrant
Western countries [69]. Thus, our findings might not women in general have lower OPMH service use com-
be generalisable to unmarried non-migrant mothers. pared with married non-migrant women, regardless of
Further research should preferably include all women, whether or not they become mothers. This might indi-
but this will only be possible if information on their cate the need to improve access to mental health care.
cohabiting status is available. Unfortunately, it was not Further research and targeted interventions for reduc-
possible in this study. We were also unable to account ing barriers may be needed to bridge the gap between
for whether women who did not become mothers were need for, and use of, mental health care among migrant
voluntarily or involuntarily childless. Involuntary child- women. Migrants with short lengths of stays and who do
lessness is associated with poorer mental health [70]. not have a stable attachment to the workforce may expe-
Further, our measure of labour market attachment, rience the greatest barriers.
based on income, does not give a nuanced view of wom-
en’s work situation in terms of the type of job, number
Abbreviations
of hours or extent of permanency. Such characteristics OPMH: Outpatient mental health; EEA: European Economic Area; GP: General
could have a different association with mental disorder. practitioner.
Supplementary Information Received: 2 August 2021 Accepted: 10 March 2022

The online version contains supplementary material available at https://doi.
org/10.1186/s12888-022-03848-9.
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Straiton et al.

BMC Psychiatry (2022) 22:211

RESEARCH Open Access

The relationship between motherhood

Study population Variables

Fig. 1 Flow chart with sample inclusion criteria by migrant category

workforce because they are still in education, we com- Results

Table 1 Characteristics of the sample by migrant category (% by migrant category) a

Non-mother 1.00 1.00 1.00 1.00 1.00

Non-mother 1.00 1.00

Non-mother 1.00 1.00 1.00 1.00

Non-mother 1.00 1.00 1.00 1.00

Supplementary Information Received: 2 August 2021 Accepted: 10 March 2022

Additional file 1. References

63. Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska

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