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INTERPERSONAL Shared decision making Shared decision making between healthcare professionals and women.​ Shared decision making. Resources. Shared decision making Shared decision making between women and health professionals may be a facilitator to perinatal mental health care. "Women with postpartum psychosis discussed the need for greater consultation and negotiation in antipsychotic prescription…​ … it would have been good I think to have been listened to about the side effects…It’s just they’re managing your risk.., maybe that’s what they’ve got to do clinically, but I wanted a bit more of a human face of it really."​ ​ Evidence level: ​Low ​ ​Parts of the care pathway affected: Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Megnin-Viggars O, et al. 2015 Resources NHS England provides guidance on shared decision making.​ Recommendations We recommend health professionals participate in continuing professional development activities related to perinatal mental health including participating in high quality training. ​ To ensure there are opportunities for health professionals and women to form trusting relationships, we recommend continuity of carer across the care pathway​. Back to Interpersonal

INTERPERSONAL Trusting relationship and rapport​ The development of a trusting relationship and rapport between health professionals and women​. Trusting relationship and rapport​. Difficulties developing a trusting relationship. Trusting relationship and rapport​ The development of a trusting relationship is a facilitator to perinatal mental health care. "It’s like family, almost. You know what I mean? It’ s somewhere where you already feel comfortable.​."​ ​ Evidence level: ​ High ​ ​Parts of the care pathway affected: Deciding to consult, Assessment, Decision to disclose, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Young CA, et al. 2019 Difficulties developing a trusting relationship Difficulties developing a trusting relationship and rapport between health professionals and women is a barrier to perinatal mental health care​.​ ​ "I didn’t trust them I suppose so I didn’t tell the health visitors how I was feeling​".​ ​ ​Evidence level: High​ ​ ​Parts of the care pathway affected: Deciding to consult, Assessment, Decision to disclose, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​ ​ ​Key literature: ​ Shakespeare J, et al. 2003 Recommendations To ensure there are opportunities for health professionals and women to form trusting relationships, we recommend continuity of carer across the care pathway. A good example of this is The Tower Team based in the Tower Hamlets, London is a high-risk caseload midwifery team that works closely with the perinatal mental health team and the consultant obstetrician for mental health at St. Thomas’ hospital. The Tower Team offers continuity of care for women with severe mental illness from their maternity booking appointment, throughout pregnancy, intrapartum and for up to 28 days postpartum. Back to Interpersonal

Health Professionals Health professionals' knowledge​ Getting it right first time​ Health professionals’ attributes​ Back to Conceptual Framework

INDIVIDUAL Beliefs About Health Professionals ​Certain beliefs or understandings about health professionals can impact whether services are implemented and delivered successfully and whether women seek help and access services. Not Understanding Roles Believing health professionals won’t be interested Not Understanding Roles Not understanding the roles of health professionals and how they relate to perinatal mental health care can act as a barrier to care​. ​ "I never thought I had a right to talk about emotional problems as I was never told what the role of the nurse covers​". ​ Evidence level: Moderate confidence​​ ​ ​Parts of the care pathway affected: Deciding to consult, Deciding to disclose, Access to treatment​ ​ Key literature: ​ Morrell J, et al. 2016 Believing health professionals won’t be interested Believing health professionals won’t be interested in perinatal mental health may act as a barrier to perinatal mental health care​. ​ "Many women believed they would not be taken seriously when discussing their PPD [postpartum depression] with professionals and reported they had experienced this in previous health encounters​".​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult, Deciding to disclose​. ​ ​Key literature: ​ Hadfield H, et al. 2017 Recommendations We recommend the development of information aimed at increasing awareness of perinatal mental health services. This should include information about:​ Services available​. How to access support​. Maternity professionals and their roles in perinatal mental health care​. ​ We recommend this information is developed by individual trusts, or third-party organisations (e.g., the NCT) in collaboration with the NIHR Applied Research Collaboration (ARC) Perinatal Mental Health Themes, The Perinatal Mental Health Network Scotland, the National Managed Clinical Network, and the Royal Colleges. We have provided some guidance for women navigating an imperfect system here. Back to Individual

INDIVIDUAL Practical Difficulties Certain practical difficulties act as barriers to women seeking help and accessing perinatal mental health care, as well as the successful implementation and delivery of perinatal mental health care. These include:​ Lack of childcare​ Travel to services​ Timing and flexibility of services Lack of childcare Lack of childcare may act as a barrier to perinatal mental health care​​. ​ "They cannot take their child with them to their session. . .(and) a lot of times they cannot afford day care​​". ​ Evidence level: Low​ ​ ​Parts of the care pathway affected: Access to treatment​. ​ Key literature: ​ Boyd RC, et al. 2011 Location and travel costs The location of services, and the costs of travelling to services may act as a barrier to perinatal mental health care​. ​ "Yes, there was the issue of travelling. I cannot drive and my husband was admitted to the hospital​".​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Access to treatment​. ​ ​Key literature: ​ Masood Y, et al. 2015 Inflexible timing Inflexible timing of appointments may act as a barrier to perinatal mental health care​. ​ "Mothers …expressed concerns about the logistics of attending a group meeting due to already overburdened days…Some depressed mothers refused to seek treatment due to perceived insufficient time (42) and the inconvenience of attending appointments (21)​​".​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Access to treatment​. ​ ​Key literature: ​ Dennis CL & Chung-Lee L. 2006 Recommendations More research is needed into practical barriers to accessing perinatal mental health care using rigorous methodology, before recommendations for policy and practice can be made. Back to Individual

POLICY MAKERS Economic status and healthcare costs How the cost of healthcare, and women's economic status may impact their perinatal mental health care journey. This can be exacerbated by women’s immigration status. Low income, no health insurance, high care costs. Human rights law​. Low income, no health insurance, high care costs Having a low income, no access to health insurance and the costs of health care can be a barrier "Yeah I know help is at hand.. but look at me! This house- I don't have landline. I have a phone. I have no credit on that phone. Even if I am in trouble, who am I going to call?​" ​ Evidence level: ​Moderate ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Referral, Access to treatment, Provision of optimal treatment​. ​ Key literature: ​ Bina R. 2020 Human rights law​ The UK government, under Article 25 of international human rights law , has a legal obligation to ensure: “Everyone has the right to a standard of living adequate for the health and well-being of [them]self and of [their] family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond [their] control” and to ensure “Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.”​ Recommendations We recommend free healthcare for all at the point of access. ​ We recommend adequate financial support for those who are not eligible for free healthcare, that is easy to apply for​. ​ We recommend the government ensure a fair welfare and economic system that ensures that no one is living in poverty or in financial hardship.​ Back to Policy Makers

COMMISSIONERS Funding This refers to how services are paid for. A lack of funding. Funding complexities. A lack of funding A lack of funding or complexities in accessing funding can be a barrier​ to care. "We are unable to serve every woman in need of ongoing care. We are therefore working on additional funds, both internally and externally, to secure long-term physical and behavioural health care for our patients.​"​ ​ Evidence level: ​ Moderate ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Referral, Access to treatment, Provision of optimal treatment​. ​ Key literature: ​ Doering JJ, et al. 2017 Funding complexities The government’s spending plans can be changed within the financial year. This can make it hard for services to plan their spending at the beginning of the year. See How Funding Flows by The King’s Fund for more information. Recommendations A clear and easy to access funding structure for commissioners and service managers​. ​ Continued policy support from NHS England, and the NHS related to perinatal mental health care, such as the publication of the Five Year Forward View and Long Term Plan for NHS England, and Delivering Effective Services report for NHS Scotland.​ ​ We recommend the provision of a comprehensively researched and adequate budget provided to the Department of Health and Social Care, Health and Social Care Directorates so all healthcare needs for that financial year can be met. Where possible, a reduction of in-year funding changes is needed to allow for more thorough and comprehensive service planning. Back to Commissioners

SOCIETY Culture Maternal norms of being a "good mother" and a "strong woman”. ​ Maternal Norms. Gender equality​. Maternal Norms Maternal norms are a barrier to perinatal mental health care. ​ "It’s quite a matriarchal society, and therefore you’ve got to cope. You’ve got to sort your family out, and so therefore you are not allowed to be depressed." ​ "I couldn’t tell anybody, because I felt like I’d let everyone down. I wanted to do really well." ​ Evidence level: ​ High ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Decision to disclose, Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Button S, et al. 2017 Gender equality​ There may be some potential to change societal beliefs around maternal norms through increasing societal expectations about fathers’ role in the family through more equal parental leave. For example, in countries where parental leave is more equal (e.g. Finland), the uptake of paid paternity leave is higher .​ ​ Changing society’s maternal norms could also be done by increasing women’s equality. Research suggests that stereotypes of what a mother or a woman should look like is beginning to change in countries where women have gained more participation in the labour force and have the right to access contraception and abortion.​ Recommendations The continuation of international policies to promote gender equality. Back to Society

SERVICE MANAGERS Characteristics of services across care pathway​ The way a service is set up and run can impact implementation of, and women’s access to perinatal mental health care. ​ Continuity of carer​. Information provision​. Delivered at home​. Culturally sensitive care​. Delivered in medical setting​. Privacy and confidentiality​. Dedicated perinatal mental health champion​. Technology​. Logistical support. Continuity of carer​ Care that provides the same health professional along the care pathway is a facilitator to care. Lack of continuity of care is a barrier.​ "Every time I went to see the midwife, or…, I always had somebody different, and I don’t want to tell 10 people my story​."​ ​ Evidence level: ​High ​ ​Parts of the care pathway affected: Assessment, Decision to disclose, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Megnin-Viggars O, et al. 2015 Delivered at home​ Care that is delivered at home can be a facilitator to care. ​ "I was more relaxed in my own home."​ ​ Evidence level: ​Moderate ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Decision to disclose, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Myors et al. 2015 Delivered in medical setting​ Some women and health professionals find that care delivered in a medical setting may be a facilitator to care. Other women find it to be a barrier​. ​ "Bangladeshi women living in the UK indicated that they talked freely in the hospital about emotional problems; however, few discussed their difficulties at home apart from practical terms because of censorship by family members"​. ​ "Thirteen of the women found the baby clinic an inappropriate place to complete the EPDS . The lack of time and privacy, the reluctance to make a fuss and the stress of the clinic were cited as reasons. Most women would have preferred to be screened in their own homes. ‘That first Edinburgh test, to have it filled in and then talked about in front of everybody else was just terrible.’ ​" ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected : Assessment, Provision of optimal treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Dennis & Chung-Lee, L 2006 ​Shakespeare, J et al. 2003 Dedicated perinatal mental health champion​ Care that has a dedicated person or perinatal mental health champion may be a facilitator to care. ​ ​ "I’ve felt the Liaison Nurse . . . her being a point of contact . . . made a big difference to my follow-up and action planning around the clients​."​ ​ Evidence level: ​Low ​ ​Parts of the care pathway affected: Assessment, Referral, Access to treatment, Provision of optimal treatment​. ​ Key literature: ​ Willey S, et al. 2018 Information provision​ Care that provides information about services and perinatal mental health can be a facilitator to care. A lack of information provision can be a barrier​. ​ "Some women believed that their physician did not provide sufficient information about pharmacological treatment​".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Decision to consult, Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Dennis, CL & Chung-Lee, L. 2006 Culturally sensitive care​ Culturally sensitive care is a facilitator to care. Care that is not sensitive to women’s cultural needs is a barrier​. ​ "You need someone who’s on the same wavelength as you, who shares the same cultural experiences as you, which sometimes isn’t available."​ ​ ​Evidence level: High​ ​ ​Parts of the care pathway affected: Decision to consult, Contact with health professionals, Assessment, Decision to disclose, Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Button S, et al. 2017 Privacy and confidentiality​ Care that is private and maintains women's confidentiality may be a facilitator to care. Lack of privacy may be a barrier​​. ​ "The interruptions took me longer to really get relaxed."​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Decision to disclose, Access to treatment, Provision of optimal treatment. ​ ​Key literature: ​ Jallo N, et al. 2015 Technology​ Technology that is fit for purpose and that works well is a facilitator to care. Technology that does not work is a barrier​. ​ "We would be quite good in fact in asking [women to complete the EPDS ] and it’s probably because of that little reminder on the screen."​ ​ ​Evidence level: High​ ​ ​Parts of the care pathway affected: Assessment, Referral, Women’s experience of treatment​. ​ ​Key literature: ​ Noonan M, et al. 2018 Logistical support ​ Services that provide logistical support, such as easily accessible locations, childcare, travel costs can be facilitators to care. No logistical support can be a barrier​. ​ "And we were offered a crèche facility; I used to take him there; otherwise it would have been really difficult for me." ​ ​Evidence level: Moderate ​ ​Parts of the care pathway affected: Decision to consult, Access to care, Provision of optimal treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Masood Y, et al. 2015 Recommendations It is important services have easy-to-use technology that is compatible with other technology systems used in other services. We recommend service managers encourage co-production or user experience testing of technology to ensure ease of usability and integration into the workflow. ​ Where compatibility between IT systems is not possible, we recommend the employment of a liaison person who has access to all systems to bridge the gap between different services. ​ Reduction of the changeover of technology when new commissioners join, and encouragement of technology use that is compatible with other systems​. Service managers need to ensure the provision of culturally sensitive care. We recommend service users collaborate with organisations such as The Motherhood Group to ensure care is culturally appropriate The Motherhood Group. ​ Provision of care should ideally be delivered face-to-face, provide logistical support or be carried out in a home setting. If home delivery is not possible, ensure practical support is available such as childcare. We recommend co-production of care. One example of a successful co-produced service is the co-production of perinatal mental health services in Ealing, Hammersmith, Fulham & Hounslow. Back to Service Manager

SERVICE MANAGERS Characteristics of assessment Certain aspects of assessment/screening can impact implementation of assessment, as well as whether women find assessment acceptable.​ Wording of assessment tools. Acceptability of assessment ​ Wording of assessment tools The wording of some screening tools can be a barrier to implementation ​ "I have some moms [who] ask questions about it, like, ‘What does it mean where things are getting on top of me? What do you mean?’ You know, so they, they don’t always understand the questions" (Home visitor, about the EPDS )​​. ​ Evidence level: ​Moderate ​ ​Parts of the care pathway affected : Assessment​. ​ Key literature: ​ Doering JJ, et al. 2017 Acceptability of assessment ​ Women and health professionals finding assessment acceptable can be a facilitator to implementation. Poor acceptability of assessment is a barrier.​ ​ "I remember being frustrated and ticking at the end, fine, fine, fine, or whatever it was, good, good, good, no I’m not depressed. I mean they are not going to give a job to my husband".​ ​ "I thought it [screening] was a good idea from the beginning . . . It doesn’t take a lot of time. I think sometimes it can be challenging just to get people to complete it". ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Assessment. ​ ​Key literature: ​ Segre LS, et al. 2014 ​Shakespeare J, et al. 2003 Recommendations Use easy to understand assessment tools. Collaborate with organisations such as The Motherhood Group to ensure cultural appropriateness. ​ Design or update assessment tools that use pictures alongside words for use with women whose English speaking and understanding is limited, e.g. “How are you feeling?” screening tools by Abi Sobowale (Sheffield South West NHS Trust). ​ ​ Provide assessment in a woman-centred way. Explain questions or wording that women are not clear about. Clearly discuss results with women and explain next steps. ​ ​ Service managers should ensure health professionals have enough time to do this by creating an adequate workforce​. Back to Service Manager

Individual Beliefs About Health Services Beliefs About Health Professionals Beliefs About Mental Illness Deciding to Seek Help Fear of Judgement Practical Difficulties Social and Family Life Demographic & Mental Health Factors Back to Conceptual Framework