empowering somali mums research report

Empowering Somali Mums research project

Final report

September 2012

This project was supported by the Victorian Women’s Benevolent Trust — Con Irwin Sub Fund

Empowering Somali Mums Research Report

2

Contents

1. Introduction .............................................................................................. 3

2. 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 ..................................................................... 5

3. About the Melbourne Somali community ............................................................. 6

Demographics ............................................................................................. 6

Immigration history and context ....................................................................... 6

4. 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 ........................................................................................... 23

5. Current help-seeking and barriers ................................................................... 26

Where mothers turn for help ......................................................................... 26

Barriers to help-seeking from professionals ........................................................ 27

6. 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 ............................................................................................. 38

Attachment 1: Bibliography ............................................................................. 40

Attachment 2: Focus group questions .................................................................. 41

Attachment 3: Forum questions ........................................................................ 42


3

1. Introduction

In January 2012 Tweddle Child and Family Health Service engaged Red Tree Consulting to conduct

research 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 that

community. 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 in

Melbourne are a culturally, socio-economically and geographically heterogeneous community with

diverse pre-migration, migration and settlement experiences. To answer the core questions in a

generalisable 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. This

would enable identification of common concerns/issues for Somali mothers, as well as important

differences 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 small

number 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 a

sense of the broader issues, were gained from interviews and a forum with Somali professionals and

other professionals working with the Somali community, and a targeted scan of the literature. See

below for a fuller description of the research method.

Our findings have led to a number of recommendations, outlined on page 31 onwards. However, one

of the strongest themes emerging even from this small-scale research project is that of diversity

within community: of experience, social connectedness, resources, circumstances, values, attitudes,

knowledge and practices. Thus, care should be taken not to generalise about the needs of Somali

mothers and families. The recommendations address a range of differing needs; we further

recommend that any model that Tweddle develops in response to these recommendations be trialled

and evaluated for their relevance and effectiveness for the whole Somali community in Melbourne.


4

2. Method

Planning and background research

We developed and submitted a draft work plan, and conducted background research on Tweddle’s

current parenting support model and approach through interviews with three key Tweddle staff:

Kerrie Gottliebsen, Cammy Naidoo and Brigid Jenkinson.

Literature scan

A literature scan was conducted. As a way of reducing project costs, Tweddle and Red Tree agreed

that we would review the most relevant research for incorporation into this report, rather than

conducting a full literature review.

The literature scan was conducted using a several popular health and social science academic

databases. We began with the two search terms, Somali and Australia, and combined them with a

series of third search terms which included: children, infants, babies, parenting, Post Natal

Depression, post partum, breastfeeding, service seeking, maternal and child health, early childhood

and sleep. The bibliographies of the most relevant references were checked for other relevant

references.

References were eliminated if they did not directly engage with or offer substantive content on

parenting issues — the experiences, beliefs and practices of Somali mothers in particular, and Somali

families generally. However some references on the settlement experiences of Somali women in

Australia were included, as they offered important background information. The process of

eliminating 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 term

Australia. These searches yielded many more references.

Again, references were eliminated that did not directly engage with or offer substantive content on

parenting issues, experiences, beliefs and practices of Somali mothers in particular and Somali

families generally. The most relevant literature came from European or North American countries

where 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 professionals

working with Somali families (see below); this interview process was invaluable for building up a

picture of key issues and support needs of Somali mothers and families, and helped us to focus our

reading. See Attachment 1 for a select bibliography (published and unpublished documents).

Somali cultural consultants

We worked with two Somali cultural consultants for this project. Their primary role was to engage

Somali mothers for the focus groups, and as such they each have strong connections in the target

geographic communities of North Melbourne and Flemington. The cultural consultants also provided

contacts for the research with professionals, and gave information about the community and its

needs that contributed to both the conduct of the research and its findings.

Research with health/welfare professionals and Somali people active in their communities

Our next step was to seek out, contact and interview by phone a number of health and welfare

professionals working with the Somali community (most of whom were themselves Somali women

and mothers), and Somali people active in their community, including in leadership roles. The latter

were harder to engage, although some of the Somali workers we interviewed clearly have seniority

and leadership roles within their community.


5

We organised a discussion forum with Somali workers and others active in their community (see

below) and sent invitations for the forum to all of Melbourne’s Somali community organisations; we

also had phone contact with a number of people from those organisations. However, those people

active in their community who engaged most were those whom we contacted in their professionals

role and/or their associates.

We spoke with 27 professionals for the research: 12 Somali workers, four other Horn of African

workers, and 11 workers from a range of other backgrounds. We prioritised Somali workers, as well as

those whose services are most relevant to Tweddle’s, including Maternal and Child Health nurses in

the target communities, a GP with many years’ experience working with and conducting her own

research with Somali people, parenting support workers, housing support workers, Neighbourhood

Renewal workers and family services staff and management in municipalities with significant Somali

populations. 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 are

part-time, most we spoke with have quite a heavy case-load, and almost all Somali workers we

interviewed combine work with parenting. It took several phone calls to make contact with most

workers, and to arrange and conduct 20 to 40 minute phone interview. Yet we persisted, as this

process enabled us to gather some rich information about the beliefs, practices, challenges and

support 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 and

people active in the Somali community, and attended by seven Somali people, and by Tweddle staff

Kerrie Gottleibsen and Janis Shoesmith.

Focus groups with Somali mothers

Our intention was to hold four small focus groups in two locations, with each group comprising six

mothers, to maximise the potential for indepth discussion. However, there were difficulties with

engaging 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. Each

group comprised 14 women, including the Somali cultural consultants (see below) who both

participated in the discussion in a personal capacity. Despite the groups’ size, a number of women

were able to share their experiences and views, and the discussions proved a useful way to confirm

and deepen our learning from other sources.

The very different demographics of the two focus groups also provided a good illustration of the

diversity of the community, and the differing experiences women often have of parenting, based on

factors including their age, migration history and social connectedness. Both community consultants

utilised their individual community networks to recruit participants to the groups, as a result of which

there might also be differences between these participants and other sub-groups amongst the Somali

residents of North Melbourne and Flemington.


6

3. About the Melbourne Somali community

Demographics

We were only able to obtain limited demographic data from the 2011 census, as basic data from this

latest 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 on

the 2006 census figure of 2623. The number of Victorians who spoke Somali at home (which includes

many born in Australia or elsewhere) was 5613 in the 2011 census, a 32.4% increase on the 2006

figure of 4240.

At the time of writing, 2011 census information was only available about the top 20 CALD

communities in Victorian local government areas (LGAs), none of which included the Somali

community. The 2006 census showed that 46.8% of Somali-born Victorians lived in the western

metropolitan region or Melbourne City LGA. Overall, Somalis were concentrated in the LGAs of

Moonee 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 2006

census data showing a median age of 29, compared to 37 for the total population; 24% were aged 18

years 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%, compared

with 18.7% of the total Victorian population. The percentage living as a couple with children was

51.8%, compared with 47.9% of the total Victorian population. The percentage living in sole parent

households was 29.3%, compared with 10.5% of the total Victorian population. The percentage living

alone or in other circumstances was 11.4% of the Somali population, compared with 22.9% of the

total 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 2006

figures were obtained from the Victorian Multicultural Commission website, at:

• www.multicultural.vic.gov.au/images/stories/pdf/somaliafs-24apr08.pdf

• www.multicultural.vic.gov.au/images/stories/pdf/somalia-2006-census.pdf

Immigration history and context

The ‘good times’ prior to civil war

Somali people in Melbourne come from a range of socio-economic backgrounds prior to the civil war

in Somalia, which began in 1991. Prior to the civil war, some older women we spoke to had had very

comfortable lives in Somalia, especially some of those who had been city-dwellers. Others had lived in

rural areas, including one woman who referred to herself as having been ‘a nomad’, and having had ‘a

hard life’ in comparison with those from Mogadishu or other cities. This diversity is confirmed in Celia

McMichael’s research with Somali women in Melbourne, which also revealed the range of women’s

support and family networks in Melbourne, with some women having extensive family here and some

living alone and unsupported (McMichael and Manderson, 2004).

A number of older women we interviewed spoke nostalgically about the ‘good times’ in Somalia prior

to the civil war, when there were accessible public health facilities, people lived in extended families

and communities with a strong ethic of mutual support, children could play outside in safe, familiar

neighbourhoods all day, and cultural traditions like the 40 days confinement were observed and


7

celebrated. These ‘good times’ were contrasted with women’s experiences of trauma, displacement

and loss in the civil war (although these experiences were not discussed) and with their struggles as

refugees and since resettlement.

Civil war and trauma

Somalia, in the Horn of Africa, is a coastal country bordered by Kenya, Ethiopia and Djibouti. It has a

population of 9.5 million, although many Somalis live outside the national borders established by

colonial and other powers. Almost a third of Somalis live in Djibouti, in the Ogaden region of Eastern

Ethiopia, in the Northern Frontier District of Kenya and in other eastern African countries; there have

been conflicts between Somalia and its neighbours over these territories at various times in the

country’s history. In the past 20 years, many thousands of Somali people have now settled in Western

countries 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 in

1991 and outbreak of civil war. Within a year of that event, almost half of all Somalis had died or

faced starvation, and hundreds of thousands had fled their country (BBC country profile). Many

attempts have since been made to establish government and reconcile warring clans. In 2011, the

worst 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 strong

feature of pre-civil war Somalia. Many older Somalis speak of a strong sense from the pre-civil war

times 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 to

be very private about their traumatic experiences in the civil war (Johnsdotter et al, 2011), and will

not discuss them except with those they trust deeply. However, it is important for service providers

such as Tweddle to have some awareness of the level of trauma that many experienced. Communities

were splintered and many people experienced terrible violence, loss and displacement: homes and

property lost, two thirds of women exposed to rape, adults and children witnessing family members

killed, and many experiencing mock executions and other torture.

Service providers need to understand the impacts that such experiences can have on people’s

emotional wellbeing, on their parenting, and on their children as they grow to adulthood and

parenthood (De Haenea et al, 2010). This provides an important background to Tweddle’s work with

Somali mothers, as discussed below under ‘The impacts of refugee experiences’, although clients

might never disclose or discuss their experiences with staff.

Some studies suggest that it is more productive for people who do need to talk about their

experiences to do so within a community of people with similar experiences (Guerin et al, 2006, cited

in Johnsdotter et al, 2011). Tweddle staff should also be prepared to offer clients referral to specialist

agencies 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 trauma

during and after conflict, and a wide range of responses to those experiences; there is diversity within

any 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 example

stating 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, and

might have been affected by their own early experiences and/or by being raised by parents or other

relatives or caregivers who have experienced trauma. Some — especially those with good extended

family support, community connections and resources – will be less affected by these issues.

High-quality training is available for service providers in this area.


8

Refugee journeys and recent arrivals

Somali people in Melbourne have come here via many different journeys. Many spent years in

refugee camps in countries such as Sudan and Egypt. Almost all have come as refugees under the

humanitarian program, including those who came through family reunion and sponsorship. A number

of women came under the ‘Women at risk’ program, for women who have lost their male relatives

and as such, are at high risk of persecution, whether in Somalia or in refugee camps elsewhere. The

peak period for arrival from Somalia was 1994 to 1998, when about half of the current Somalia-born

community 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 continue

to arrive through family reunion, and some minors under Orphan visas, to be cared for by Somali

guardians/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 the

family they are joining, others will have no relations here. They described how vulnerable these

newer arrivals can become as a result of language barriers, economic pressures, social isolation and

the 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 resettlement

Programs such as sponsored immigration and family reunion are based on the assumption that

support for newly-arrived people will be provided by pre-established communities, ethnic

organisations and informal networks (McMichael & Manderson 2004). Many studies have shown such

networks 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, at

least in the early years of Somali resettlement in Melbourne, the effectiveness of such networks was

limited, in part because the ‘community’ comprised relatively low numbers of people scattered across

the metropolitan region. In Somalia, people had strong neighbourhood communities; connecting with

people 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 a

greater or lesser degree. The significance of these has diminished over time, according to some

Somali workers interviewed, although other interviewees reported that these clan structures remain

significant, to some extent, in who will access particular support services.

In 2004 McMichael and Manderson reported that divisions along clan and status lines were

significant, but less of a cause of social isolation than the fact that Somali people here did not know

each other as they had known their neighbours at home, and that everyone was ‘just struggling on

their 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; financial

stress; transport and language barriers; experiences of racial discrimination by services (Australian

Human Rights Commission 2010) and in the broader community; poor quality, unsafe and inadequate

public housing; and long hours in low-paid work such as taxi-driving and manufacturing for men, and

childcare or aged care for women.

McMichael and Manderson reported that people’s capacity to help each other can also be limited by

the responsibility for remittances; for regularly sending money to family in Africa. One non-Somali


9

worker we spoke with also referred to the level of debt that many families incur by borrowing the

funds needed to bring family members to Australia.

Khat: a health/family issue identified by Somali women activists

A recent Australian study by Douglas et al found that the legally available drug khat is widely used by

Somali men and by a very small number of Somali women. Khat is ‘usually chewed in prolonged

sessions, producing mild psychostimulant effects such as increased energy, enhanced mood, reduced

appetite and reduced sleep.’ (Douglas et al 2011). The authors report found that excessive use of khat

can have the following effects:

Central nervous

system:

Dizziness, impaired concentration, insomnia, headaches, mydriasis, conjunctival

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 factors

Dependence: 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 use

Cardiovascular

system:

Tachycardia, arrhythmias, palpitations, hypertension, vasoconstriction

Ischaemia, infarction, pulmonary oedema, cerebral haemorrhage (all

uncommon)

Exacerbation of pre-existing cardiac conditions

Respiratory system: Tachypnoea, dyspnoea

Gastrointestinal

system:

Dry mouth, polydipsia, periodontal disease and dental caries

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

obstetric effects:

Spermatorrhoea, impotence, altered libido

Low birth weight, stillbirth, impaired lactation

In a 2009 literature review for the Centre for Culture and Ethnicity, John Fitzgerald reports ‘an

emerging consensus among international health authorities that khat has a low abuse potential’, and

that harms are associated with ‘excessive use’ rather than use as such. He concludes the available

literature suggests that although the importation of khat in Australia has increased, evidence of harm

is minimal (Fitzgerald 2009).

However, concerns have been expressed among a significant number of women in the Somali

community about khat. The East African Women’s Foundation, of which Somali women are an

integral part, lodged a parliamentary petition of 1087 signatories to the federal House of

Representatives 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 the

Foundation, told the Australian newspaper in 2008, ‘Each month, we see women walking into our

centre saying khat is destroying their family’. She also described the effect of khat misuse on her own

family: ‘He chewed it all night, then was too tired to go to work and he lost his job and would spend

what little money we had on khat. My family broke up because of khat.’ (www.theaustralian.com.au/

news/somali-women-demand-action-on-legal-drug/story-e6frg6of-1111116989658). Khat has been

an issue of disagreement within the community (Fitzgerald 2009), with some community members

seeing it as unproblematic or even beneficial to the users health (Douglas et al 2011).


10

Khat is likely to be of limited relevance to Tweddle, however service providers should be aware that

khat abuse by men may, on occasion, be one of the many pressures on Somali families accessing

Tweddle’s services. Very few Somali women also reportedly use khat; if a Somali woman accessing

Tweddle’s services is using khat excessively, then symptoms of this — such as impaired lactation or

sleep disturbances — might make it a factor in her presenting issues. However, it is important to note

that khat abuse among women is very rare, and such symptoms are much more likely to have more

common 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 is

unlikely that families accessing Tweddle’s services would speak about it. Many khat users reported

visiting their health professionals for treatment of adverse effects of khat use without disclosing that

use. Douglas et al also found many users were unaware of the effects of excessive use. If a Tweddle

worker suspects khat abuse could be an issue in a family, they should raise it sensitively, and only if it

is directly relevant to their work with the family, and they have develped a rapport with that family.

Protective factors and positive developments

In two decades of Somali resettlement in Melbourne, many religious, cultural, community and

welfare organisations and businesses have been established. These — along with programs such as

playgroups, women’s groups and homework clubs — have helped to create and strengthen

community networks and assisted many people.

McMichael (2002) also discusses Islam as a critical source of solace and support for many Somali

women in Melbourne. Both McMichael and O’Mahoney & Donelly cite range of studies point to the

role of religious faith and practice as protective factors for women’s health, including post-partum

mothers. 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 studies

identified cultural traditions such as ‘the 40 days’ as alleviating factors for postnatal depression, and

another study’s findings that greater religiosity was associated with a decreased risk of postnatal

depression (Dankner et al 2000). The altruism and ethos of mutual care within Islam continues to

benefit 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 amongst

Muslim people are far from monolithic; for example, McMichael discusses variations amongst the

Somali women she interviewed in practices such as veiling, prayer and responses to ill-health, for

example whether women are more likely to seek assistance from medical services and/or engage in

traditional healing practices such as Qu’ran reading.

A recent positive development for Melbourne Somali women is the entry (supported by targeted

training 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 the

past few years, this development has given many Somali women greater financial independence, and

additional money to spend on their children’s education and other needs. This development also has

implications for the way service providers such as Tweddle might reach out and offer support and

information to Somali mothers, as discussed in Chapter 6.


11

4. Practices, beliefs and pressing issues

Somali family structures

We interviewed Somali women with a very diverse range of family structures, ages and number of

children. A few younger women had no children yet. A few had one or two, and many had three or

more. The largest number of children amongst the 24 women interviewed was seven (in the case of

two older participants who had had their children in Somalia); the largest number among those who

had had their children in Australia was five. A number of interviewees referred to the high value given

to 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 mainly

breastfeeding, withdrawal or abstention to minimise the chance of conception. However, a GP who

has worked with Somali people for years commented that while that was generally the case, recently

she 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 female

relatives, in supporting mothers and participating in the raising of children. For those women who had

relatives in Australia, this kind of support continued to be important, although it was perhaps limited

by 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 or

children without any support from grandparents or other relatives. One mother said that although

she had come to Australia with some relatives, there were none amongst them who could teach the

new 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 – perhaps

from 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 the

fact that some Melbourne Somali women do not live with their husband full-time. Sometimes this is

because their husband is often overseas, although some interviewees referred to women whose

husbands 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 young

mothers who had had a child ‘out of wedlock’ and had experienced stigma within their community

and homelessness as a result. In contrast, other Somali workers said it was very rare for Somali

women to have children out of wedlock, and it was more likely that most were married, but did not

live 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 explained

that 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 of

reactions 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.


12

The (sometimes) changing role of Somali fathers

Many interviewees referred to the traditional division of labour as the mother as active parent and

father as breadwinner; this division was not problematised in the Somali context, because mothers

are so well supported by extended family and community. Yet in Melbourne, this broad support is

simply not available to most women, or is only available to a very limited degree; interviewees

discussed that some Melbourne Somali fathers were recognising this, and responding by taking more

of an active role in parenting their children. However, in families where this was not happening, there

were 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 Somali

community described a recent trend in which fathers were increasingly at home during the day with

their young children, because they were unemployed, underemployed or worked nights, while their

wives worked during the day. Many Somali women are becoming family day care providers because it

allows them to care for their own children and others, but others are gaining employment in other

caring 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 men

that was beginning to discuss this changing role for some men; it is possible that there might be some

role for services like Tweddle in supporting fathers of young children affected by this change. If

Tweddle 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 a

specific physical, cultural, social and economic environment. This environment will have varied, of

course, 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, social

and intellectual development – was shared in a very real, daily sense across close-knit extended

families and neighbourhood communities.

A key learning from this research is the impact on Somali children’s development of being raised in a

very different environment, here in Australia, from the environments in which Somali parenting

beliefs and practices developed.


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 have

experienced 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 teaching

mothers the range of skills and knowledge required to care for their young children. This was seen by

many as a loss for many new Somali mothers living in Melbourne, in that those without older relatives

here 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 and

settle their baby, how to deal with common maternal and infant health issues, and the needs of

infants 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 community

on becoming a mother, despite her lack of family members in Australia. Yet the challenges of

resettlement are such that most people in the community don’t have the capacity to offer significant

day-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!


14

As discussed, women’s and children’s experiences of family, household and community prior to the

civil war in Somalia were typified by support from extended family. A range of important cultural and

religious practices underpinned a strong ethos of mutual support, assisting people in need, and

celebrating and supporting mothers. The older women in one focus group discussed how the

traditional 40 days confinement helped with healing from birth and establishing breastfeeding by

ensuring that women had no responsibilities other than resting and feeding their baby. An older

participant who had her children in Somalia described how confinement would finish with ‘the

decoration, a new dress, taking us to our homes. It’s like a wedding! [But] now we are refugees, it

doesn’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 Somali

women’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. As

discussed, social isolation and lack of support are highly significant factors for Melbourne Somali

mothers. Indeed, one Somali worker who provides parenting support for women in their homes cites

these 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 various

aspects 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


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 to

these risk factors, but our informants raised a range of common pressing issues for Somali mothers

that 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 loss

of/separation from family members in the civil war. Somali women also experience a number of other

risk factors identified in studies cited by O’Mahony & Donelly in relation to immigrant women’s

mental 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 women

from cultures that support and value mothers can be further ‘exacerbated’ by the loss of those

practices and supports. Thus, ‘many find themselves without a support net where normally they

would have found recognition, nurturing and assistance within their culture’ (2010).

The impact of refugee experiences

In addition to the generalised risk factors for PPD listed above, O’Mahony & Donelly cite risk factors to

immigrant women’s mental health identified in a range of studies. These include ‘marginalization and

minority status, pre-migration experience, intolerable memories, socioeconomic disadvantage, poor

physical 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 by

many Melbourne Somalis, and how critical it is that service providers understand and acknowledge

this, 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’s

experiences as mothers. Instead, we highlight findings from O’Mahony & Donelly and another

international literature survey by De Haenea et al (2010) on the impact of refugee experiences on

parents and children. The latter survey cites a growing body of research identifying the refugee

experience 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 family

separation, 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, ‘traumatic

responses, prolonged grief, and chronic exile-related distress interfere with stabilization and recovery

in the host society’ (Bala, 2005).


16

De Haenea et al’s review includes studies on the mental health outcomes of refugee children and

adolescents, which reveal ‘patterns of anxious, post-traumatic and depressive symptomatology’ (Fazel

& Stein, 2002; Heptinstall, Sethna, & Taylor, 2004; Montgomery & Foldspang, 2005); it is likely that

amongst young mothers who might benefit from Tweddle’s services are many who came to Australia

aged from middle childhood to early adolescence, with a parent or parents or other caregivers. Other

studies 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 be

appropriate health responses. They concluded that ‘participants described a morbid unhappiness

comparable to PPD; however, concerns were raised about the cross-cultural equivalence of PPD, and

whether it was an illness remediable by health interventions.’

The relevance or otherwise of the concept of postnatal depression was discussed at some length with

a number of informants. The answers were complex and varied, but broadly in line with the first parts

of O’Mahony and Donelly’s conclusion; that is, that there is an equivalent concept, at least in

recognition of symptoms of emotional distress in mothers of young children, but terms such as

postnatal or postpartum depression were less likely to be culturally relevant, and should be used with

care or avoided by service providers due the stigma associated with traditional Somali conceptions of

depression 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 community

members 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 mental

health 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 some

in her community might link symptoms of postnatal depression and traditional conceptions of mental

illness 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.


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 postnatal

depression in a Western framework and Somali conceptions of mental illness. Many workers

suggested that it might be more appropriate to talk with Somali mothers about their emotional

distress during early motherhood using terms other than depression, as we discuss below. It is

certainly clear that service providers need to take great care and be sensitive in the language that

they use when exploring individual Somali women’s risks for and experiences of emotional difficulties

in 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 was

inconsistently supported by our research. On the one hand, we interviewed a GP who had worked for

many years with Somali people, and who had also conducted research with Somali people about

understandings of and help-seeking for mental illness, who said that most Somali informants in her

research 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’s

services 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 they

know it is available, accessible and appropriate. An appropriate approach to service provision includes

professionals using culturally sensitive language when working with/and or referring Somali mothers

and families, whether into a service such as Tweddle, or to other services from Tweddle. We spoke

with a number of interviewees about how they speak with women about their emotional difficulties

in early parenting, including during screening for postnatal depression.

We interviewed one Somali worker who routinely administered the Edinburgh protocol (EPDS) as part

of her work with families. O’Mahony & Donelly cite an Australian study (Small et al, 2003), which

found the EPDS to be a consistent, valid and ‘effective tool’ across English-speaking and non-English

speaking samples, although these authors specify that ‘careful translation processes and piloting of

translations are always necessary’ (Small et al, 2003).


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 mothers

and that of the Somali family support worker was notable. Given that the EPDS is administered

through an interview, it might be that the Somali worker was already ‘translating’ the EPDS into

culturally relevant language and concepts as she administered it in their shared language. The MCH

nurses administer the EPDS through an interpreter or in English; but it is important to note that a

literal translation of a document does not guarantee its cultural relevance, especially if there is no

equivalent word or concept in the other language. There is also a common problem with service

providers 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 try

to 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 the

centrality of their personal, long-term relationships with individual women in establishing trust, and

the 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’, or

experiencing 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 with

patients about their symptoms of emotional or psychological distress, such as ‘sadness’, ‘thinking too

much’, ‘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 pointed

out that:


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 development

Attachment and responsiveness

According to Tweddle staff interviewed for this research, the key frames of reference for Tweddle’s

work with parents are infant mental health and maternal attachment, including responsiveness to

infant 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’s

crying and long-term breastfeeding. One Somali worker emphasised the importance of mainstream

providers working within this cultural framework, and understanding that these practices are key to

Somali 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 motivated

by a strong desire to do the best for their children.

Yet research shows that the multiple pressures experienced by Melbourne Somali women (like other

refugees) are likely to compromise many women’s own emotional wellbeing, as well as their capacity

to 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 of

the experience of refugees on parental attachment and capacity to respond, in particular to their

children’s emotional needs. The studies they survey emphasise the importance of parental presence

and a supportive family environment for building children’s resilience and ‘adaptive developmental

trajectories’. 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 and

post-settlement experiences. De Haenea et al cite various research showing that grief, social isolation

and a range of stresses can lead to parental withdrawal and decreased responsiveness and/or

increased family conflict, and sometimes violence (De Haenea et al, 2010).

The loss of traditional stimulation for child development

Several Somali workers explained how traditionally, child development in Somalia was stimulated and

supported by raising children in a close, safe neighborhood community, in which children played

together 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


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 to

play with the children’.

A few Somali workers highlighted the number of Somali children exhibiting speech and learning

delays, arising, they thought, from the loss of this rich traditional environment for play, learning and

development, and the challenges of parenting in often overcrowded housing and unsafe

neighbourhoods.

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 children

organised sport or other activities, although this is changing for women who have entered family day

care and other paid employment. Nonetheless, Somali workers cited a range of problems arising from

the 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 behaviour

A number of workers referred to problems with children’s behaviour, arising from the loss of input

from 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 problem

with managing children’s sleep. Many families make frequent use of television, which can potentially

exacerbate 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 their

children in an Australian context. Several also referred to anxiety within the community about

whether 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 about

one or two cases early in the history of Melbourne’s Somali settlement, in which one or more older


21

children were removed from their families, reportedly because of their child had disclosed their

parents’ 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 address

people’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 community

is supported by a Swedish study (Johnsdotter et al 2011), which explores how the spread of verbal

information through community networks in the Swedish Somali community influenced people’s

health choices. One example cited in that study was how women shared information about which

maternity hospitals were less likely to perform caesarian births. Another was the low vaccination

rates in the Swedish Somali community, due in part to the widespread credence given to the

discredited link between the MMR vaccine and autism in that community. The authors cite another

factor in low immunisation rates for Swedish Somalis, which is that children born in Somalia or in

refugee camps had not had access to immunisation (2011). It is unclear whether vaccination is an

issue for Melbourne Somali children; the MCH nurses interviewed reported good rates of vaccination

amongst their Somali clients.

Parenting discussions and debates

One Somali worker we interviewed explained that conflict would sometimes arise between parents

and 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 the

expectations 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 about

approaches 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 from

Somali, Vietnamese and Anglo backgrounds identified that Somali parents tended to be more positive

than parents from the other groups about reasoning with children as an approach to responding to

children’s challenging behaviour, and less positive about the use of parental power in the same

situation (Wise and da Silva, 2007).


22

One Somali worker we interviewed who had run a Somali mothers group for many years said that

participants 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 great

interest to Somali mothers, and that women would often welcome new ideas about approaches and

strategies 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 ‘emotion

coaching’ strategies — has been run by two different organisations we heard about for Somali/African

parents, and was reportedly very popular. Another organisation whose staff we spoke with was

planning to incorporate Tuning in to Kids into the upcoming program for their mothers group, as part

of 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 settling

We asked all of our informants about the practices of Somali mothers and families around children’s

sleep. Responses pointed to a diversity of practices and beliefs in the community, the impact of

housing on shaping the way mothers manage their children’s sleep, and again, the power of key

stories (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.


23

Somali workers asked about the knowledge of safe co-sleeping in the community identified practices

such as sleeping with the baby against the wall, and placing pillows in ways intended to protect the

baby, presumably from the parent rolling onto them. The MCH nurses we interviewed identified SIDS

Foundation resources on sleeping with a baby as important sources of information for advice to

families on this issue.

When we asked Somali mothers in the focus groups if they co-slept with their babies, the answers

ranged from ‘yes, always’ to ‘no, never’. Many indicated that they used a combination of settling the

baby in a cot or bassinet, and bringing them to bed when they woke repeatedly and would not

resettle.

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 were

experiencing with helping their children to sleep, and getting them into a regular routine around naps

and bedtimes. Some identified this as a key problem for families, especially for dealing with the

children’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)

Breastfeeding

Traditionally, breastfeeding is very well supported in Somali culture and by Islam, which instructs

mothers 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 strong

traditional support for Somali mothers to breastfeed, including through working conditions in pre-civil

war Somalia that would be the envy of many Australia women workers: four months’ paid maternity

leave, and ongoing reduced hours for lactating women. Somali workers also described how

breastfeeding was often used to assist with child spacing by reducing ovulation.


24

Some informants alluded to a range of traditional cultural beliefs that Somali women have in relation

to 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 with

breastmilk that they believed had been ‘in the breast’ for several hours (if the baby had not fed for

that long), believing that milk would ‘spoil’ in the breast and make the baby ill (2010). However, there

was 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 that

breastfeeding is acceptable to women and their social support networks, and that most women

breastfeed on demand, although the study also found frequent supplementation of breastfeeding

with water, animal milk or solid food (as the baby gets older), reflecting a widespread belief amongst

Somali 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 amongst

Somali mothers in Melbourne, with many breastfeeding and nursing to sleep ‘well into the second

year’. Yet many Somali workers reported a significant decrease in the length of time that Somali

mothers in Melbourne were tending to breastfeed, compared with traditional practices, or even with

the 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 be

able to feed their baby. One cited a lack of time for mothers with older children, quoting a friend who

was 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 teaching

mothers 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 by

several Somali workers as a reason that mothers would give for ceasing to breastfeed. Steinman et al

and one of the Somali workers interviewed linked the combined use of bottle and breast (reportedly

quite common practice in the Somali community) with some maternity hospitals’ practice of

introducing formula before mothers’ milk had ‘come in’.

Asked who would help mothers with breastfeeding problems in Somalia, women who were city

dwellers 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 traditional

remedies 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.


25

Second mother: I had problems with my nipples, it was inverted and hard. I had to use some

traditional herbal medicines. I was taken to an obstetrician, he gave me some medicines, and they

pump out my breast. Then my mum applied some medicines, and the duct opened. Then I felt

relief.


26

5. Current help-seeking and barriers

Where mothers turn for help

When I was at the hospital, the nurse showed us how to give her a bath. My husband learned first,

and then I got the hang of it. The nurse used to visit my twice a week at home. This was helpful,

because I could ask her. She could also tell me if my other children were alright. But in the end she

would only stay a short while, then leave. Then I was on my own. (Somali mother)

From my experience, the MCH nurse is where parents go to [for help]. Services need to explain

that [getting help] is for the benefit of the baby, that no sleep will make the baby and the mother

stressed. (Somali worker)

Our Somali interviewees, both workers and mothers, reported fairly consistently that the main

sources of support for Somali mothers in Melbourne who need assistance are:

• family members, for those who have family in Melbourne. Thus, the younger women we spoke

with who had come with family were more likely to have family support, although this was not

always the case

• other Somali community members to some extent, although this was also limited by the

geographic dispersal of the community, and that most people were studying, working, caring for

their own families and dealing with the other challenges of resettlement

• Somali and other Horn of African workers such as those we interviewed, who included: workers

in the FARREP program based at the Royal Women’s Hospital, women’s health and community

health services; settlement workers; social workers in community health; and family support and

youth workers in community health and in family services within local government

• universal services, especially Maternal and Child Health, although as one mother reported, ‘not

everyone goes to maternal health’.

The MCH nurses we interviewed confirmed that they had generally fairly good engagement from their

Somali clients, and that this was often maintained over time. They did, however, emphasise the

amount of work that they did to support mothers’ long-term engagement (see below).

A number of interviewees also emphasised the role of GPs in community health services. Somali

workers interviewed reported that Somali people tended to go to GPs working at the community

health service nearest to their homes, rather than seeking out a particular bi-lingual GP, as is the case

in some immigrant communities.

Several workers discussed having referred women to breastfeeding support services located at

maternity hospitals, and a couple of workers had successfully referred Somali clients to Tweddle. One

had tried to refer a several clients to Tweddle, but these referrals had not been taken up (see below

under ‘Barriers to help-seeking from professionals’).

Peer support and the solace of faith

Several interviewees discussed the positive role of Somali/African/mixed mothers groups and

playgroups. We interviewed one worker who had run a fortnightly mothers group for seven years,

which had become an ongoing source of community connectedness for some, even after their

children were all at school, or if they moved out of the area:

The good thing about this group is it becomes a social group, and women will get in contact with

each other outside the group. When one has a baby, they go and help the mum, and will also look

after each other’s kids. Do things outside of their group. Most don’t have families in Australia. Even

if they move out of [the local area], they will keep in touch through school holiday activities, like

we have a regular barbeque in a park. (Somali worker)


27

Another worker described how playgroups tended to ‘come and go’ depending on whether there is an

energetic ‘leader’ amongst Somali mothers attending who engages many of the other Somali mothers

in her community. The MCH nurses and some other non-Somali service providers reported a recent

decrease in numbers for some playgroups associated with their services; this might be related to a

rise in the number of Somali mothers entering paid work.

The GP interviewed also discussed her understanding that some Somali people still seek help from

community and religious leaders. In her research, Somali informants were asked where a woman in

Somalia who experienced symptoms that might be labelled postnatal depression in a Western

framework would go for help:

They said, ‘She would go to her community, to an Elder or religious leader, or a traditional healer

to get help. But here in Australia we don’t have traditional healers, so we often feel really lost.’

Sometimes she might go to a GP, especially if she is not sleeping, or there is some physical

complaint, like tiredness, trouble sleeping, no energy.

The problem is that in Australia, the community is much less cohesive than in Somalia, and there is

not necessarily community capacity to support people. There are religious leaders and people still

come to see them, but they don’t have the same Qu’ranic readings they used to have. In Somalia if

someone had a mental health problem, you’d set aside a day, you’d have religious readers, have

food, have special Qu’ranic readings. But because everyone is busy and struggling and physically

distant from each other here, they don’t seem to be able to run those things as often or as well.

Women’s private practice of their faith continues to be a source of solace to many, as explored in

McMichael (2002 and in Johnsdotter et al (2010), and as referred to by the MCH nurses (see page 18).

Barriers to help-seeking from professionals

The literature identifies two main types of barriers to migrant women’s access to post-natal care:

those that are practical in nature, and those that are culturally determined (O’Mahony & Donelly

2011; Teng et al 2007). Practical barriers include language difficulties (including lack of use of

interpreters), unfamiliarity with how and where to access health care services, low socio-economic

status and childcare issues (Neufeld et al. 2002, Steele et al. 2002, Wu et al. 2005). Culturally

determined barriers cited in the literature include fear of stigma and lack of validation of depressive

symptoms within the family and ethnic community, as discussed on page 16, and a reluctance to talk

about personal problems or seek help outside the family or community (O’Mahony & Donelly 2011;

Teng et al 2007).

We would also add the barriers of the community’s perception that Somali parenting practices and

beliefs will not be respected; that services will primarily support and promote practices that are

specific to Western culture and that clients’ cultural and language needs will not be provided for.

Use of interpreters

According to a major recent report by Foundation House (2012), services including maternity services,

MCH and Nurse on Call are less accessible for women from CALD backgrounds due to language and

cultural barriers. The provision of professional interpreting services is a key access strategy for CALD

communities. DHS language service policy states that clients who are not able to communicate

through written or spoken English should have access to information in their preferred language at

critical points in service delivery. The policy also states that interpreters should be professionally

qualified, and family members should not be used as interpreters.

Despite this, using family members or friends as untrained interpreters is reportedly a common

practice in maternity services and MCH. (Foundation House 2012) The Foundation House report goes

into some detail about the reasons, other than that it is DHS policy, to use qualified interpreters,

which it summarises as follows:

Good communication between a health practitioner and a client during a clinical consultation is

essential to ensure the safety, quality and effectiveness of care. When interpretation is required,

qualified interpreters should be used as they are less likely to make errors and any errors made are


28

less likely to be of clinical consequence. Accredited qualified interpreters operate under a code of

professional ethics to ensure their services are impartial, confidential and their level of skill is of a

sufficient standard. The use of qualified interpreters in health consultations improves quality of

care; improves client safety; promotes access to health care; reduces unnecessary health

expenditure; reduces stress on families; and minimises risk of legal complications.

The report identifies a number of barriers to the use of interpreters by professionals. A key barrier is

that many health practitioners might overestimate their clients’ proficiency in English.

In a Victorian study, 37% of GPs reported they did not use a qualified interpreter because there

was no need, but the accuracy of their assessment is questionable as 9% of the population in the

catchment area where the GPs worked had poor proficiency in English … Even when clients use

every day English, their language skills may be insufficient for complex communication in the

health setting as a result of: their capacity to express themselves; their understanding of technical

medical language and explanations, which may compromise understanding of the medical

assessment, diagnosis, treatment and care.

In addition, as one Somali worker we interviewed pointed out:

These are mums who are really at the end of their tethers. They are not working on a rational level.

I don’t care how much English they have, when they are sleep-deprived and upset, they won’t take

anything on board if it’s not in their first language. Even people’s accents become stronger than

usual when they are vulnerable and emotional.

According to the Foundation House report, sometimes professionals will defer to what they presume

is a client preference to have family or friends interpreting. However, research suggests that the

majority of clients prefer qualified interpreters be used as they:

… ensure both basic and thorough understanding; ensure essential information wasn’t missed;

reduce anxiety; enable privacy and full understanding and to reduce embarrassment around

private or serious health issues

Where use of family members was preferred by a client, research shows this is often situational, for

example if the available interpreter is of the opposite gender, or if there are concerns about

confidentiality in a small, tight-knit community. Regardless of client preference, family members

should never be used as interpreters. Clients should also be informed of the confidentiality

requirements of professional interpreters, and of the health service provider themselves.

Other barriers to interpreter use identified by Foundation House include:

• That it is not identified at an early stage that an interpreter is needed, so appointments are made

without arranging an interpreter. Practitioners may then prefer to proceed rather than wait for

arrangements to be made. Thus, it is important to identify on intake, including exactly which

language and dialect are needed.

• Referrals from one service to another do not routinely indicate when a client requires an

interpreter, or which specific language/dialect is required; services need to include this

information in referral procedures into and out of the service

• A lack of telephone equipment in the service areas where use of the telephone interpreter

service would be needed

• A lack of or insufficient funding for interpreters in some health settings

• The time required to engage interpreters: this can be time consuming whether for clinical or

administrative staff, the latter requiring training in how to ask about the need for an interpreter

consistently. Many health practitioners believed using a qualified interpreters meant that

appointments took twice as long.

• Lack of knowledge about interpreter services by staff, including how much is funded and how to

book and use interpreter services. This lack of knowledge has been shown to directly correlate

with use of family or friends as interpreters.


29

Other practical barriers

It was our impression that few of the Somali workers or community members contacted for this

project had heard about Tweddle’s services. Many of the non-Somali workers had heard of Tweddle,

but most did not know about the range of support services offered.

Until you contacted me for this project, even as a community worker I have not heard about

Tweddle. That’s how the community are. If the community knows that Tweddle can help them, the

new mothers, how to feed the baby and how to deal with that period of time, it will be good.

(Somali worker)

Some of the women are very young. They came here when they were very young, and got married

very young. They don’t know about support services. (Somali worker)

A number of workers also identified practical problems with transport to services; some women have

access to a car, but many do not. A number of workers indicated the need to provide detailed

information for women about exactly how to get to support services, beyond an address.

A critical barrier for many Somali mothers to use Tweddle’s residential services, and possibly

Tweddle’s day stay program, is that of childcare. As discussed, many Somali mothers have a number

of children, often closely spaced. Therefore it is not uncommon for women to have at least three

children under school age, and up to five or more in total. Some women might also be raising children

who are not their biological offspring. Many women are also now working as family day care workers,

and might be caring for several children other than their own during the daytime, although this might

not be full-time work. Women with one, two or perhaps even three children would, we understand,

be able to bring them to Tweddle’s residential service. Some women with more and/or older children

might be able to have them cared for in order to come; others will be more able to attend the day

stay program, or perhaps some version of it offered over a couple of days during school hours.

Reluctance to talk about personal problems

There is a stigma about talking about your internal affairs. Most people don’t talk about anything.

They are brought up not to talk about their personal life with anyone, unless they trust you.

(Somali worker)

As discussed, many of our informants described a reluctance about talking about very personal issues,

including experiences of trauma, amongst Somali people; women are likely to talk about very

sensitive issues or difficulties they only with those that they trust deeply. Many workers described

that women were most likely to discuss serious problems with a relative, close friend or someone

with a helping or healing role in the community, although the MCH nurses described how some

women would disclose some difficulties such as family violence, if they had known the women a long

time and achieved a level of trust with her (see page 18).

However, there was a very positive response to our descriptions of the kinds of support Tweddle

could offer, especially in terms of information about infant care and children’s development, and

practical assistance with specific problems that women were struggling with such as breastfeeding,

sleep and settling or children’s behaviour. It might be that for many Somali people, these latter issues

are perceive as less ‘personal’ and sensitive than they might be by some Anglo parents, for example.

Anything to do with domestic violence or disability, or mental illness – people are very defensive in

talking about. Maybe sometimes they will seek assistance through their GP for mental illness. But

they will be open to other issues – so you can talk about things like sleeping problems, discipline of

children or breastfeeding. (Somali worker)

Indeed we found that during focus group discussions, some women appeared comfortable to talk

with us about problems with breastfeeding, settling, and emotional difficulties in the context of

parenting such as isolation and loneliness. It is important to note, however, that these discussions

took place through an interpreter, in the presence of other Somali mothers in a community setting

familiar to the group participants.


30

Nonetheless, even in the context of discussion about parenting issues, the MCH nurses we

interviewed also cautioned that they were always careful not to criticise the Somali mothers they

work with (or indeed any of their clients):

Once they realise that you’re not there to criticise them, and you’re supportive and you care about

them … they’re actually glad to have someone say, ‘How are you, I’m concerned about you, I want

to know if you’re feeling okay, and how’s your wee going’, and all that stuff.

This has implications, then for the way that Tweddle describes and promote its services to the

community, and how staff might talk with Somali clients at intake, assessment, during support

services and when referring them to other services.

Experiences and perception of service providers

There are a range of issues across the community. A high rate of youth crime, and Child Protection

being involved. I understand where the community is coming from in not opening up and seeking

assistance. This community has been traumatised in several ways before they come here, and now

they [feel like they] can’t handle their kids. (Somali worker)

As discussed, many of the Somali workers and community members we interviewed expressed an

interest in the support services Tweddle might offer to women experiencing difficulties in early

parenting. However, several also raised the issue of some community members’ reluctance to seek

assistance from mainstream service providers. In some cases, this might stem from shared stories and

fear about services like Child Protection, or in less than positive experiences in their physical

community of interactions between their young people and police.

Manderson and Allotey (2003) also found that stories of contradiction, conflict and poor outcomes

from community members’ engagement with health care services are powerful in the Somali

community, fuelling people’s suspicions of service providers. McMichael and Manderson reported

that their interviewees referred to stories about the efforts of doctors to ‘inhibit them from bearing

children’, and the attempts of Child Protection workers to take their children from them (2004).

In 2009, Vichealth developed Building on our strengths, an evidence-informed framework to guide

future practice, programs and policies to address race-based discrimination and promote diversity. It

cites evidence that CALD and Aboriginal Victorian continue to experience race-based discrimination,

including by service providers. Thus, it is critical that Tweddle continue work to ensure its programs

are culturally sensitive, improve the skills of its staff in working in cross-cultural contexts, and

communicate to potential clients from the Somali and other communities that their cultural needs

will be met should they access Tweddle’s services.

As we discuss in ‘Promotion of the service’, below, one barrier to Somali women’s access to Tweddle

services is that some potential referrers do not know about Tweddle’s services, or perceive them as

being culturally inappropriate for Somali mothers. For example, Tweddle’s approach was

characterised by one MCH nurse we interviewed as ‘controlled crying’, which was cited as a reason

that they would not refer Somali mothers to Tweddle. In response, the interviewer informed the MCH

nurses that Tweddle’s approach had changed, and could now be characterised as supporting parents

to respond to the needs of their baby, in the context of their own practices, for example around sleep

and settling. This news was welcomed by the nurses, pointing to a need to communicate this change

in Tweddle’s approach to potential referrers.


31

6. Implications for Tweddle

In our interviews with Somali mothers and Somali workers, there was a widespread perception that

the services that Tweddle provides would be of interest and assistance to Somali mothers, as long as

they were provided in a culturally sensitive way.

When I first knew about your service I used to work with a woman who had one baby, and then

another one soon after. So she was having difficulty holding her two babies, and she had another

four kids at home. But she said, ‘No, I don’t’ want to go somewhere and leave my other kids at

home’. I wanted her to get help, because she was not sleeping well. Eventually she came here and

she stayed two days, and it helped her. (Somali worker)

This report has commented in a number of places on the implications of our findings for Tweddle’s

services and service promotion. Below we summarise these comments and our other

recommendations.

Service promotion

As mentioned, we found that Somali mothers and Somali health and community workers knew very

little, if anything, about Tweddle, suggesting a need for targeted promotion of Tweddle's services to

the community. We also found that there were a number of organisations, workers and services

where Somali mothers tend to turn for assistance, which present some clear targets for promotion. It

will be particularly valuable to continue engaging with Somali workers, because they are able

promote Tweddle’s service in culturally relevant way, and will be an important source of referrals.

Also, many Somali workers are trusted, known figures in the community and are a central point of

contact for any issue that arises in the community. If Somali workers recommend a service, this can

give the service legitimacy among the community.

We recommend that Tweddle consider development of a promotion strategy targeting the Somali

community. This strategy should:

1. Actively engage Somali workers

This could include regular contact between workers, for example through phone contact and

exchanges of service information. It might also take the form of an annual exchange, where Somali

workers are invited to Tweddle for a lunch and tour of the service, and Tweddle staff explain how

they work and the kinds of strategies they offer to mothers/families. In turn, Somali workers could

give Tweddle staff direct insight into how the community might engage with these services, building

on the dialogue begun through the professional forum. Direct, personal interactions between

Tweddle staff and Somali professionals would be very valuable in supporting referrals and ongoing

engagement between Tweddle and the community.

2. Provide speakers to playgroups and other Somali/mixed women’s groups

It is important to talk to women [in groups] about your program, explain your role and keep

reminding them. Somali people are oral people – they talk to each other. There is a ripple effect.

(Somali worker)

As stated, playgroups and mothers groups — whether Somali only, mixed Horn of African or mixed

migrant groups — continue to be valuable sources of support and information to many Somali

mothers of young children. During our research, some workers who facilitated groups expressed

interest in Tweddle speaking to their group, either one-off or as part of a regular calendar. There is

also the potential to visit other groups and venues where Somali women gather, like sewing groups.

This strategy could target mothers of young children directly, as well as older women who might

promote the service to their daughters/daughters-in-law.


32

3. Actively engage MCH nurses and community health GPs in targeted LGAs

As noted, MCH nurses and community health GPs are the key health care providers for many Somali

mothers and families, especially in areas where there are larger numbers of Somali people.

We recommend that Tweddle send these professionals service information (including in Somali and

other languages other than English), which includes information any outdated perceptions these

potential referrers might have about Tweddle’s approach to issues such as sleep and settling.

4. Promote through Somali family day care networks

The large number of Somali women engaged in family day care work provides a potential opportunity

for promotion, potentially benefiting the other children in these mothers’ care, especially by giving

them information about child development and play. Some Somali family day care workers are

employed through local government services, but a large number are employed by Somali-run family

day care businesses, who are also the training providers for their staff.

5. Produce appropriate service information

Service information is a key part of promotion to and supporting referrals from any community.

However, Somali cluture is an oral culture, so all written material should always be accompanied by a

verbal explanation; indeed the written information is best seen as a ‘back up’ to the verbal

communication. In addition, not all potential Somali clients are literate (although many are), whether

in Somali, English, Arabic or any other language. Referrers would ideally offer Somali women

Tweddle’s information in both English and Somali, and/or offer to go through the information with an

interpreter (if the client is unable to read either language).

We recommend that Tweddle consider how its service materials might be adapted to the needs of

Somali mothers, including:

• focussing on practical problems and practical support that Tweddle can offer; the use of

examples or scenarios can be very valuable in this

• explaining costs and how to access Tweddle services (assuming limited knowledge of the system)

• steering away from using labels like depression’, and focusing on feelings, symptoms and

experiences

• explaining how clients’ cultural needs (for example, halal food and space to pray) will be met

• producing materials in very “plain English”, avoiding jargon, acronyms and idiomatic expressions

• using this plain English version for translation into Somali (and having this translation checked by

a Somali worker to ensure its cultural relevance.

6. Support positive community engagement

Word of mouth works very easily in the community. If I go to Tweddle, then say [what I learned

there] really works, and tell the next person, the whole community will go.’ (Somali worker)

Word of mouth promotion is very powerful in all immigrant communities; many of our informants

emphasised this characteristic of the Somali community. This will work to Tweddle’s benefit in that, as

one worker said, one woman who has a positive experience of Tweddle’s services will ‘bring another

five or six in the door’. However, as she also cautioned, a negative experience or perception from one

woman can similarly translate into a negative community perception of the service.

This, we suggest, makes it important that Tweddle has implemented those actions needed to ensure

its services are culturally responsive before promoting them widely to the community. We also

recommend that Tweddle staff maintain a strong collegiate relationship with key Somali workers,

from whom Tweddle can obtain regular feedback on referrals and any other issues that might arise in

the community about Tweddle’s services. This might, for example, include making the exchange

suggested above an annual event.


33

First point of contact, waiting lists, intake and assessment

The community is very oral-oriented, so word of mouth is very important. They prefer information

in their own language, but 15 to 20% are illiterate. Even very young women, around 45% would

need an interpreter. (Somali worker)

Once Tweddle becomes better known in the Somali community, some women might begin to self-

refer. However, it is likely that many will continue to be referred through Somali workers, MCH nurses

and other health and community service professionals.

We recommend that procedures are in place for taking calls from people who speak limited or no

English, and that Tweddle ensure that those staff who are likely to be the first point of contact for

potential clients have had training in how to use an interpreter. Valuable training is available for front-

of-house staff, which includes the skills needed to book and work with a telephone or onsite

interpreter, how to brief an interpreter, how to phrase questions through an interpreter, and body

language/eye contact when working with an interpreter.

Referral, intake and waiting list procedures that require potential clients leave a message or to

answer phone messages from people they have not spoken with previously are likely to be ineffective

with Somali women. Reception or other staff responsible for making contact with women will need to

keep calling, and to use an interpreter if needed (see below).

If possible, intake and assessment should be face to face, through an interpreter when needed. When

staff are making times with women to come in, we recommend that staff send SMS reminders about

appointments, and phone reminders on the same day. It is also important to provide detailed

information about how to get to Tweddle using public transport.

Additional time might also be required for assessment, including for working with interpreters and for

explaining the service system to clients for whom staff are making referrals; many migrants have a

very limited knowledge of the Australian service system, and what kind of assistance different

services offer, how they might be relevant to them, and how they are accessed.

Support might be needed to assist staff to talk with women about their experiences and issues in

ways that are culturally relevant, including avoiding jargon or idiomatic expressions, and language

that might be sensitive for some women (see page 17). This includes assisting staff to understand the

different cultural framework women might have for understanding their experiences, for example

those which might be considered symptoms of postnatal depression.

We recommend that Tweddle consider whether some assessment tools need adaptation to make

sense to women in their cultural context (see discussion of the EPDS on page 17). For specific

assessment tools, it might be worth Tweddle staff seeking advice from Somali workers who use them

in their work with Somali women about how they have done this.

Use of interpreter services

As discussed, the use of interpreters is important to the provision of quality care. It is also required by

Victorian Government policy, as this extract from the DHS Language Services Policy outlines:

All departmental programs and funded agencies must have policies and procedures in place

to meet three minimum language services requirements.

Requirement 1

Clients who are not able to communicate through written or spoken English have access to

information in their preferred language at critical points. That is, when they:

• need to be informed of their rights;

• need to give informed consent; and,

• need to be advised of critical information relating to their health and wellbeing and/or

participate in decision making related to medical and other human service matters.

Requirement 2

Language services are provided by appropriately qualified professionals.


34

Requirement 3

Persons, including family members, under 18 years of age are not used as interpreters.

It is, of course, the decision of Tweddle clients as to whether they want to use a qualified interpreters,

however it the responsibility of staff to ensure that communication is effective. Duty of care

requirements have not been met, for example, if safe co-sleeping methods have been explained but a

client does not have the English comprehension to understand, regardless of whether she preferred

not to use an interpreter. Sometimes women are happy to use an interpreter if the staff member

explains that this is needed to ensure that the service has met its obligations, and the women is also

assured that the interpreter will keep the session confidential. Sometimes it is useful to ask the

interpreter to explain the code of conduct by which she is bound at the beginning of the session.

It is always critical to book a female interpreter. We received feedback that the topics discussed by

Tweddle are not culturally acceptable for a woman to discuss in front of a man. However, we found

during the project that female Somali interpreters for face-to-face interpreting are quite scarce, and

difficult to find at short notice. Thus, we suggest that a regular booking might be useful, with

women’s appointments and day stay programs organised around that booking.

It is also important to use professional, NAATI-accredited interpreters. Family and friends should

never be used as interpreters, even if a woman insists that they used. It can be suggested tactfully to

the woman that it is better that her friend or family member be able concentrate on supporting her,

rather than on interpreting, and that DHS policy prohibits the use of family and friends as

interpreters. Nor should other Somali professionals who might be supporting the woman — such as

local government family support workers — be asked to intepret for her, unless they are also NAATI-

accredited and it is in their job description to provide interpreting for clients.

Service types

The Somali community would like to see practical support. They would like to go overnight, or a

couple of nights, and see what other mums are doing, how they are coping. Also, for the worker to

go through the intervention step by step. Some of the mothers are really stressed, and can get very

overwhelmed by panic, anxiety, you name it. For some clients they might like to have in-home

visiting, but sometimes overcrowding means the environment is not suiting. (Somali worker)

An overnight program could be good for some women, but there would have to be childcare for

the other children. When women in the community have a baby, they don’t even stay the three

days at hospital, because there is no one else to care for the other children. (Somali worker)

Somali women interviewed expressed interest in the full range of Tweddle’s support programs. The

residential program was seen as a positive possibility for many women, although a number of

interviewees expressed a concern that women with larger families and older children would not be

able to access such a service because of childcare concerns.

Some women thought that if Somali women could leave their older children with a relative or friend,

they may welcome coming to a residential program, as it would offer them needed respite and an

opportunity to focus on their youngest child. This has a precedent within Somali culture in that as part

of the 40 days confinement, mothers of new babies are supported by other women to rest and

concentrate on the needs of their baby. However, as discussed, some women do not have the kind of

support networks to make this possible in Melbourne.

Some interviewees thought that women would probably want to bring all of their children with them

if they participated in a residential program, while others felt that the logistics of bringing a big family

into Tweddle would be daunting for some women, who might prefer to participate in a day stay or

home visit program only. It should of course be remembered that not all Somali women have many

children. Younger women are having are first time mothers in Australia and some women are

reportedly choosing to have smaller families.

One interviewee also suggested that a full day stay program might be difficult for some women to

access, once children are home from school. Thus some women suggested that ‘day stay’ type


35

support could be provided over a couple of days, or that in-home support, if available, might be more

appropriate.

Being culturally responsive

A culturally relevant approach

Sometimes it is about going in, we ask what is the issue for mums, what they have tried, what do

they feel comfortable with. We problem solve it with them. We work with the way that parents

have, for example about getting kids to bed, and just maybe move it earlier and earlier. If you put a

foreign idea, the family is just going to fall off the rails again. (Somali worker)

Much of this report has explored the complexity of how a service provider like Tweddle might work

with Somali women from an understanding of their cultural beliefs and practices, refugee experiences

and the many and varied pressures of resettlement. If staff practice is not culturally responsive or

appropriate, Tweddle is unlikely to hear about it from clients, as this Somali worker points out:

You need to find out what works for the mums. If you import something that comes from another

frame of mind, they will be very polite. But they are not going to come back, and they will tell other

mums ,’That place, they are so cruel’. You need to make sure mums feel comfortable. Then that

woman will bring another five or six in the door.

Our understanding of good practice for a service like Tweddle is that service providers would begin

with engaging the client, and understanding how they see the issue and potential solutions. This task

is more difficult, but all the more important when working with clients from CALD backgrounds. Staff

need to be aware of and reflect on their own assumptions and cultural values, and how they might

differ from those of the Somali women they work with. If a staff member is unsure about the relevant

cultural practices or beliefs in relation to a particular issue that might arise, the most direct way to

find out more is to ask the woman herself. Professional development can also be very valuable.

Interviewees suggested that many women will be open to new ideas and strategies, but not all. When

staff introduce new ideas to Somali clients, it will be important for them to explain them clearly, and

offer them in a way that makes sense to her, given her cultural context.

One interviewee emphasised the need to offer information and options to Somali clients (including in

their own language) rather than ‘pushing them’ to take action.

They don’t mind the information, but they don’t like services pushing them, or interfering with

them. In Somali we say that [if you do that] you are ‘sniffing’. If someone says, ‘I don’t want to

wake up, I’m tired, I don’t want to take care of myself’, then, you could explain the symptoms of

stress and depression to them. If you confront or push that person, and tell them to take action,

they won’t like it. If you provide the information, offer them choices in their own language, and

assure them about confidentiality, then they would think about it.

Professional development

This report provides some background information for staff about working with Somali clients. We

also recommend that any Tweddle staff member who is likely to have contact with Somali clients or

potential clients should be given access to professional development to enable them to work skilfully

in a cross-cultural context, and with the Somali community in particular.

We recommend that staff be given access to four types of training:

• How to work with interpreters, available through OnCall

• Information about the Somali community in Melbourne, their history of migration and Somali

culture, available through the FARREP Program at the Royal Women’s Hospital

• General cross cultural skills relevant to Tweddle’s core business, available through the Victorian

Transcultural Psychiatry Unit. Although the VTPU focuses on mental health services, they provide

excellent training on working cross-culturally around emotional and psychological issues, and

recently offered training in perinatal mental health in CALD communities. They could also tailor a


36

program to Tweddle’s particular needs. The Centre for Culture, Ethnicity and Health offers more

generic cross cultural training in cross cultural skills at both an individual and organisational level

• Working with clients who have experienced torture and trauma, available through the Victorian

Foundation for the Survivors of Torture. The VFST offers tailored professional development

programs as well as set courses, with a particular focus on counselling with survivors of torture.

Culturally accessible policies and practices

In addition, Tweddle should of course continue to meet Somali and other Muslim clients’

cultural/religious needs by providing halal food and space for prayer. It is also important that Tweddle

communicate their attention to this aspect of their service in all their service information. This will be

very reassuring to potential clients.

We discussed at some length the question of whether programs needed to be women only, and

whether the presence of fathers from other families would affect whether some Somali women felt

comfortable using the residential service, in particular. Answers on this question were mixed. Three

Somali workers said that a women-only program would be best, or that some women might hesitate

to access a program where there were men present.

They need to set up a service that is women only. Sometimes women might bring partners or

husbands, but very rare. This is the tradition in the culture. But if women are uncovering [their

head] they might be uncomfortable with men there. (Somali worker)

Most answered that women would be comfortable with men being present, provided that everyone

wore appropriate clothing (pyjamas were fine, provided that everyone’s clothes were modest), and

that every family had their own private bedroom, which would also be used for prayer which would

be where women would feel free to be uncovered. Women would wear hijab (headscarf/covering) in

spaces where men were present.

In addition, it is important to remember that the way that people prefer to learn is culturally

informed, as well as varying according to the individual. If Tweddle’s approach is generally to support

direct support and learning with written materials, we suggest that this might be less effective with

Somali clients, who tend to prefer verbal information and discussion (even professionals, according to

one Somali worker) and who sometimes have low literacy.

One Somali worker also gave feedback about a client she had recommended to Tweddle who felt

overwhelmed by all the information she received in one session (presumably in day stay):

One of my clients went to Tweddle, but she preferred to stay for a couple of days rather than have

all the information in one session. She told me that in one session, ‘I was bombarded with all this

information. I prefer to practice, and have information over time in a practical way’.

Breastfeeding support: an example of cultural responsiveness

This issue provides a good example of the importance of culturally responsive support for mothers, in

part because there is good literature on cross-cultural practice in this area, and also because support

for breastfeeding is so strong in Somali culture and Islam.

It would be great if Tweddle can understand what the culture believes about breastfeeding, and

then it can be a resource for other professionals about breastfeeding. Learning each other and

valuing everyone’s culture is important. Yes we are different to Australian culture, but there is a

good part of that [mainstream Australian] culture we can get from them. But our cultural

perspective is still important. (Somali worker)

All of the Somali workers we spoke to emphasised the openness of Somali women to seeking

assistance with breastfeeding if needed. One often referred mothers to lactation consultants within

her service and two had referred women to Tweddle in previous years. Many cited the willingness of

most Somali mothers to seek assistance from MCH nurses (and GPs in community health services,

although not specifically for breastfeeding), although one Somali mother said that ‘not everyone goes

to the nurses’. A number of Somali mothers interviewed referred to seeking professional help for

breastfeeding, including from the maternity hospital and MCH nurses, and from older Somali women,


37

including relatives or others in the community. In some services, this advice from Elders in the

community was incorporated into the support provided:

Across the culture, we believe in the mother breastfeeding. Some of the young mothers prefer to

just breastfeed very short. Most are keen to breastfeeding for along time. Cultural influence took

over, and there are really keen to do breastfeeding. We run breastfeeding support in my

organisation, mainly through Elders teaching them. (Somali worker)

Steinman’s study of Somali mothers breastfeeding practices in the US emphasised the need for

breastfeeding support and promotion to be based on an understanding of Somali immigrants cultural

context and life circumstances (Steinman et al, Mulford 2008). Steinman cites other studies that

demonstrate the effectiveness of breastfeeding support interventions that are culturally specific in

other migrant communities.

Drawing on Steinman’s findings and information from our informants, effective support for Somali

mothers to breastfeed might include:

• an understanding that most mothers are probably breastfeeding and supplementing with

formula

• acknowledgement of the multiple stresses on women that can make breastfeeding difficult

• seeking to understand and address women’s beliefs (including any misconceptions) about

breastfeeding in a non-judgemental way

• acknowledgement of the cultural and religious significance of breastfeeding for Somali women

and in Islam

• engagement with the traditional beliefs and practices around breastfeeding

• emphasis on the protective benefits of breastfeeding for sickness and allergies

• emphasis on the role of breastfeeding in child development and attachment

• emphasis on the role of breastfeeding (and its limitations) as a contraceptive

• how to express and store breast milk safely

• how to recognise the evidence of sufficient supply

• strategies for increasing supply, including the impact of missing feeds/supplementation.

A Somali worker or program

We asked most of our informants about whether it was important to have a Somali worker as part of

a program to support Somali women. Two said that this was not important, but most indicated that

having a Somali worker would be very valuable:

Having a Somali worker will help for two reasons. The women feel reluctant to talk about issues,

it’s a big barrier. They will like to see someone from the Horn of Africa who is in the field, and has

expertise. It’s a big advantage to be able to ask questions and get extended information, and for

the community to know where she is, and contact her if they have questions. (Somali worker)

It is good to have a Somali worker. This makes women feel confident, if they have someone

speaking their language. Also trusting. They are more likely to come in [and seek help]. People

don’t mind if [a Somali worker] comes from a different group within the community. They need to

have the right language, Somali and English. They need to be Somali. Some people speak Somali,

but are not Somali, and don’t understand the issues. (Somali worker)

We asked several interviewees about whether it made a difference as to which group or clan a worker

was from, as to whether community members would go to her. We heard from one non-Somali

worker that this was important, but several Somali workers told us otherwise:

It used to be an issue where people would not go to someone form another group within the

community, but this is changing, as long as we don’t talk about the groups and clans and what

happened in Somalia. Soon after the war it was life that, but we have been here a long time, they


38

have had to face the reality of their lives here, and realise how important it is to have someone

from their culture alongside the other professionals. (Somali worker)

It is clear form this and previous research that employing a worker from the Somali community would

be the idea in terms of access and culturally responsive support. Another approach that many services

have implemented successfully is to employ a worker whose brief is access and equity, and whose

role might include, for example:

• quality assurance around access and equity across the service, and ensuring a whole-of-

organisation approach to working in cross-cultural contexts

• monitoring and training for staff around working in cross-cultural contexts

• active service promotion to CALD workers and being a contact point for CALD communities

• community education to CALD communities

• being the first point of contact for CALD potential clients, and becoming the ‘bridge’ into the

client’s assessment, for example by booking their assessment and organising the interpreter.

A staff member in such a role would need to be highly skilled in cross-cultural work, experienced in

similar roles, and attuned to the subtleties of issues that can arise for refugee and other CALD clients

in a range of ways in the context of service provision. It would be ideal if the worker was from a CALD

background.

Other issues

Long-term engagement

A number of interviewees discussed the importance of service providers taking a long-term approach

to their efforts to engage with and support particular cultural communities.

Tweddle needs to understand that this is a long-term thing. They won’t be able to set up the

service and just get the numbers straight away. It’s about building a relationship. You have to go to

people in the community, wherever they are. You can’t just make an appointment and expect

them to turn up. And you really have to be there long-term. Somali people don’t operate in the

wider system. It’s word of mouth, just like with Aboriginal people. (Non-Somali worker)

Workers also emphasised the value of trying different approaches, and reflecting on their success or

otherwise in engaging the community.

If you say, ‘Oh I’ll put in a Somali worker for one year,’ people will come for a year and then it’s

finished. You need a plan to keep it going, to provide that ongoing support to families. The Council

is really good about access and equity for vulnerable families. They are supporting pilot ideas, once

they find the money. It’s been great that we’ve able to try different things. (Somali worker)

This worker also discussed the success of co-locating many of their family support services in one

place – a primary school which is attended by many in the local community – and providing regular

‘drop in’ times, and childcare to enable mothers to engage with services.

From our interviews with Tweddle staff, we understand that the number of referrals to the

Vietnamese day stay program were lower than hoped. Many of the interviewees for this project

referred to the need to build up CALD communities’ engagement with program over time, especially

given the importance of word of mouth. Some of the most successful programs we heard about

through the research were those that had been running long-term, such as a mothers/playgroup

which had been running for seven years.

The MCH nurses we interviewed also shared their observations of the importance of longevity to

service success, including with playgroups run by other services, and programs that they have run

themselves:

First MCH nurse: The Wingate [mixed CALD playgroup] is quite popular. Its been running for longer,

and I’ve now got Flemington families coming up to the Wingate one.


39

Second nurse: Programs take time to build, but often things come and go, or finish after a year.

What people need is a bit of continuity and structure. For example, when we changed days, we had

people turning up [on the former day]. Somali people don’t work off calendars the way

[Westerners] do. It’s word of mouth, and they have to remember. It’s really difficult for them to

remember if programs are held at a different time, if that information is not implanted.

So it has to be a really regular time, and program attendance will build up over time. Things will

just finish after a year. We have started an early literacy book club for babies. We’re getting two or

three families at the moment, and plan to run that all year. If we’re getting a regular 4 or 5 to each

session, we’ll run it next year. You have to start with small steps.

Flexibility

A number of interviewees, including the MCH nurses above, mentioned the importance of supporting

Somali people’s engagement with their service through the use of reminder phone calls and text

messages. A number also noted that community members are also fairly likely to come early or late to

appointments.

Confidentiality

A number of interviewees, Somali and otherwise, mentioned the need to explain organisational

policies around confidentiality and privacy to Somali clients, and what they mean to how support is

provided and information about them stored and shared with other services:

As a social worker, I explain to Somali clients [my organisation’s] privacy policy. That is not part of

our cultural background. I explain that it’s a really serious issue.

[Its important to] assure Somali people about confidentiality. If they know there is confidentiality,

and which service to go to, then they might seek help.

A gateway to other services

It is particularly important, when working with clients from migrant (especially refugee) communities,

to ensure that they are connected to the other services and supports that they require. As noted, this

should go beyond the provision of written information to include verbal explanations of services you

are offering referrals to, and what support they can provide.

New mothers will often be linked to MCH because MCH receive notification of new births and initiate

contact, however MCH nurses do not always ensure that mothers have all the supports they need or

are entitled to. This Somali worker, speaking of Somali women who immigrate to Australia to marry

Somali men living here, said:

[These women], because they are new mothers, might not integrate into the wider community, or

even the Somali community. They come and they end up under the roof of that husband who

brought them here. Getting out and knowing the community takes time. The first person they

meet is the MCH nurse, but she nurse provides limited information. So, when you see someone

who is new to the country with limited English, you should always connect them with the other

services in the area. If you don’t provide that assistance, you are not helping that person much.

Thus, even if a Somali client is linked into her MCH service, it is important that Tweddle staff bear in

mind the likelihood that CALD mothers of young children – especially those who are recently arrived –

are likely to not be well linked into health and community support services, and offer them

information about and referral to a range of other services, depending on the family’s needs.


40

Attachment 1: Bibliography

Atwell, R., M. S. Gifford M. Sandra, et al. (2009). "Resettled refugee families and their children's

futures: Coherence, hope and support " Journal of Comparative Family Studies 40(3): p. 677-697.

Australian Human Rights Commission. (June 2010). In our own words: African Australians: A review of

human rights and social inclusion issues, Australian Human Rights Commission.

Bailes, M. J. (2005). Mental illness and help seeking concepts and attitudes in the Somali community in

Melbourne. Department of Psychiatry, University of Melbourne.

De Haene, L., H. Grietens, et al. (2010). "Adult attachment in the context of refugee traumatisation:

The impact of organized violence and forced separation on parental states of mind regarding

attachment " Attachment and Human Development 12(3): p. 249-264.

Douglas, H., M. Boyle, et al. (2011). "The health impacts of khat: a qualitative study among Somali-

Australians." Medical Journal of Australia 195(11-12): 666-669.

Johnsdotter, S., K. Ingvarsdotter, et al. (October 2011). "Koran reading and negotiation with jinn:

Strategies to deal with mental ill health among Swedish Somalis." Mental Health, Religion and Culture

14: (8) 14(8): 741-755.

McMichael, C. (2002). "‘Everywhere is Allah's Place’: Islam and the Everyday Life of Somali Women in

Melbourne, Australia." Journal of Refugee Studies 15(2): 171-188.

McMichael, C. (2003). Memory and resettlement : Somali women in Melbourne and emotional

wellbeing Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne.

McMichael, C. and L. Manderson (2004). "Somali women and well-being: Social networks and social

capital among immigrant women in Australia." Human Organization 63(1): 88-99.

O'Mahony, J. and Donnelly, T. (2010). "Immigrant and refugee women's post-partum depression help-

seeking experiences and access to care: A review and analysis of the literature." Journal of Psychiatric

and Mental Health Nursing 17(10): p. 917-928.

Raine, R., M. Cartwright, et al. (2010). "A qualitative study of womens experiences of communication

in antenatal care: Identifying areas for action." Maternal and Child Health Journal 14(4): 590-599.

Renzaho, A. (2011). "Parenting, family functioning and lifestyle in a new culture: the case of African

migrants in Melbourne, Victoria, Australia." Child and Family Social Work 16(2): 228-240.

Robertson, C. (2006). "Somali and Oromo refugee women: trauma and associated factors." Journal of

Advanced Nursing 56(6): 577-587.

Steinman, L. (January 2010). "Understanding infant feeding beliefs, practices and preferred nutrition

education and health provider approaches: an exploratory study with Somali mothers in the USA "

Maternal and Child Nutrition 6(1): 67-88.

Wise, S. and L. da Silva (2007). Differential parenting of children from diverse cultural backgrounds

attending child care. A.I.F.S, Commonwealth of Australia. Research Paper No. 39.

Victorian Health Promotion Foundation (VicHealth), Onemda VicHealth Koori Health Unit (University

of Melbourne), McCaughey Centre: VicHealth Centre for the Promotion of Mental Health and

Community Wellbeing (University of Melbourne) and the Victorian Equal Opportunity and Human

Rights Commission 2009, Building on our strengths: a framework to reduce race-based discrimination

and support cultural diversity in Victoria: summary report, VicHealth.


41

Attachment 2: Focus group questions

Introduction and consent

• Introductions.

• Explain why we are running the groups.

• Explain how the information will be used.

• Ask participants to sign a consent form.

Warm up questions

• How long have you been in Australia?

• How many children do you have? What are their ages? Where were they born?

Pressing issues in early parenting

• Thinking back, what was life like for you after your youngest child was born?

• What were the things you most enjoyed about this time?

• What were the hardest things about this time?

• Did you have trouble with breastfeeding? Healing from birth? Getting your baby to sleep? Crying

a lot, or feeling very tired, sad or needing more support?

• Did anyone help you with these things?

• What kind of help was useful?

• Did you have any support from workers? What kind? If you didn’t have support, would you feel

comfortable to?

• Did you have trouble with your children as older babies, toddlers or pre-schoolers? What kind of

trouble? What did you do? (PROMPT: sleep and behaviour, esp ask about sleep)

• Did anyone help you with these things?

• What kind of help was useful?

• Did you have any support from workers? What kind? If you didn’t have support, would you feel

comfortable to?

• IF WE HAVE TIME: What do you think are the most difficult things for other women in your

community in parenting babies and young children?

• What kind of support have other women in your community found helpful?

Service access and help seeking

We will describe Tweddle’s services and the way in which these services are delivered -day stay,

residential, community based or in-home services.

• At the moment not many Somali women use these services. Why do you think this is? What

might make it difficult for Somali women accessing these services?

• Would this kind of service have been useful to you? Why? Why not?

• Do you think women from your community would use a residential service? Why/why not?

• What about day stay? What about in-home support?

• Would women from your community prefer to attend a day stay or residential service with other

relatives/friends? Who?

• What kinds of things would help your community to access the service?


42

Attachment 3: Forum questions

Community profile

Somali people have been coming to Australia for more than 15 years.

• Can you tell us a little about who is arriving now?

• How might the needs of newly-arrived people differ from those who have been here longer?

When the community first migrated to Australia, people often talked about tribal differences in the

community and the history of conflict between the different groups or clans.

• Are those differences and that history still as powerful today as they were then?

• Does a service need to take these into account in working with the community, for example when

they employ a worker, engage an interpreter, run information sessions or promote services?

Family structure and context

Some Somali professionals have told us that a major issue is the lack of extended family and

community support for mothers in Melbourne, compared with in Somalia.

• Who tends to look after children in Somali families living in Melbourne? What support might

women with a new baby have from family or community? What about in raising older children?

• Is this different from the way things were traditionally done in Somalia?

• Is the role of Somali fathers in Australia different, or changing from traditional roles?

• Do mothers support each other or care for each other’s children? Do many use Somali-run family

day care? Are there other, more informal community support structures for mothers and

families?

• Some Somali professionals have told us that there is a high rate of parental separation, or partial

separation, in the community. How is this affecting mothers and families?

• Some Somali professionals have told us that there are a number of very young women becoming

sole parents. What kind of issues are these young women facing?

• Some Somali professionals have told us that traditionally, mothers would learn about pregnancy,

birth, breastfeeding and child-rearing from relatives and Elders. How has being in Australia

affected how new mothers learn these things? Is there a role for those relatives and Elders who

are here?

Environment

Some Somali professionals have told us that economic and environmental issues are having big impacts on mothers, children and families.

• What is the impact of housing on mothers and families?

• What is the impact of employment/unemployment (of mothers and fathers) on families and

children? How is it affecting who cares for children?

• What other key economic or environmental issues are there for mothers and families? For

example, access to education, public transport, language services, private outdoor spaces?

• Are people in the community experiencing high levels of racism in public spaces? Is this affecting

whether, where and when mothers are willing to go outside of their homes with children? How

else does racism impact on mothers and families?


43

Beliefs, attitudes, practices and problems

Within any community and culture, there will be a range of beliefs and practices – it is important to know about these. We are interested to understand where there are differences between Somali cultural beliefs and practices, and those arising from Islam. We also want to know how practices have changed, and are perhaps still changing for Somali people in Melbourne.

Post-birth, early infancy and postnatal depression

• What are some traditional practices and beliefs around post-birth and early infancy?

• Are women in Melbourne maintaining these? How are they changing?

• What are traditional practices around the role of fathers with a new baby? Is this changing?

• What traditional beliefs or practices are there about the mother’s health and emotional state in

the weeks following birth?

• How do people in the community think or talk about emotional and health impacts of having a

new baby e.g. ‘third day blues’ (effects of post-birth and breastfeeding hormones), lack of sleep,

healing from birth, and forming of attachment to the baby?

• Is there a cultural concept that is similar to what Western medicine calls postnatal depression,

which might be experienced in the months following birth? What is seen as the appropriate

response? What are community attitudes towards seeking professional help for this?

• Are community attitudes changing, in relation to people’s willingness to seek professional help

when parenting is more difficult than expected, or mothers are having a hard time?

Breastfeeding

Some studies and many Somali professionals have told us that breastfeeding is very important in Somali culture, and in Islam.

• What are the main traditional practices and beliefs around breastfeeding? For example, how long

women should breastfeed, how often, when (on demand, in a routine, through the night)? What

beliefs are there about when and how women should night-wean, day-wean, or fully-wean?

What if the baby or mother is sick, or if the mother becomes pregnant? What other beliefs and

practices around breastfeeding is it important for Tweddle to understand?

• If women are experiencing problems with breastfeeding, whom do they tend to turn to for help?

What kind of advice is given?

• Do women tend to seek professional help if they experience problems with breastfeeding?

If so, where from? What are women’s attitudes to seeking professional help about it?

Sleep, settling, responsiveness and attachment

A key area of assistance for Tweddle’s programs has traditionally been sleep and settling. They are keen to understand Somali practices, and to offer support in the context of these.

• What are some of the traditional beliefs and practices about sleep and settling for babies,

toddlers and older children?

• Do mothers and babies traditionally co-sleep? Until when? Do they co-sleep with fathers? Other

children? Are there circumstances in which they would not co-sleep?

• Are parents maintaining these practices? What is the impact of housing (or other issues) on

them? Are parents experiencing criticism about them from health practitioners or others?


44

• What knowledge do parents tend to have about safe co-sleeping e.g. in relation to firm/soft

surfaces, coverings, children sleeping together, or with adults affected by drugs or alcohol?

• How are babies’ sleep and other needs traditionally managed during the day and night? Do they

tend to have bed times and nap times? How are they ‘resettled’ at night and during naps? Are

there any practices that relate to babies being put into routines for sleeping, feeding, changing or

other activities (‘tummy time’, carrying, play or other stimulation)?

• What beliefs and practices are there about babies and crying? Do parents regard different kinds

of crying as indicating different needs (milk, sleep, change, comfort etc)?

• Are babies traditionally carried and held? Until what age? Are women in Melbourne maintaining

these practices? Or are they using prams, or not going out with their babies?

• How are babies traditionally clothed and wrapped? For sleep? During the day? What are beliefs

around how warm or cool babies and young children should be?

• What traditional beliefs and practices are there around playing and interacting with babies and

young children? Are these being maintained in Melbourne?

• What do you think mothers might tend to find most difficult about sleep and settling? If women

are experiencing problems with sleep and settling, who do they turn to for help? What advice is

given? What are women’s attitudes to seeking professional help about this?

Child development, behaviour and childrearing practices

• What are key traditional beliefs about the role and place of children in the family and

community?

• What are key beliefs and practices about raising children, including responding to children’s

emotional needs and ‘difficult’ behaviour?

• What are key beliefs about child development, e.g. when children are expected to be able to

walk, talk, feed and dress themselves, socialise with other children, take part in family and

community events, behave in certain ways in public?

• Are parents’ attitudes and practices in relation to childrearing changing? How?

• What do you think is the most important area that Somali parents need information about, with

regards to child development and childrearing?

• If women have concerns about their children’s development or behaviour, whom would they turn

to for help? What kind of advice is commonly given?

• Do women tend to seek professional advice on about child development or behaviour? If so, who

from? What are women’s attitudes toward seeking professional help about these issues?

Access barriers and providing culturally responsive support

• Is Tweddle generally known to the community, and/or workers? What is the general perception

of their services?

We will provide a brief description of Tweddle’s day stay, residential, community-based and in-

home services.

• What might be the barriers for Somali mothers/families accessing these various services?

• Are any of those services more likely to work for Somali mothers/families? E.g. group-based, in-

home, day stay or residential? Are there other types of services that might work better?


45

• What are the key aspects of service delivery needed for Somali mothers/families to access these

services, e.g. interpreters, women-only space, privacy, prayer space, halal food, childcare,

availability of after-hours support, regular times that a service is available, in-home support?

• Is it important to have a Somali worker involved? What else is important about the worker/s

skills, background or capacity?

• Can you give examples of how primary health and community services have successfully engaged

the Somali community and Somali mothers/families in the past, that Tweddle could learn from?

• What is the most important thing that Tweddle needs to understand or do, in order to provide a

culturally sensitive service to Somali mothers, and engage this community?

empowering somali mums research report

Documents