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Animation Conceptual Framework MATRIx Informing Perinatal Mental Health Services​ Perinatal M ental Health A ssessment and TR eatment: An Evidence Synthesis and Conceptual Framework of Barriers and Facilitators to I mplementation This project is funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research Programme (NIHR 128068). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care

Further Resources Recommendations for policy infographic Recommendations for service managers infographic Recommendations for health professionals infographic​ Infographic for women​ Summary report​ Recommendations for commissioners Review 1 publication​ References ​ Perinatal Mental Health Partnership - Matrix videos MATRIx Barriers Framework MATRIx Facilitators Framework Animation for policy makers and service managers

The Team. We are a team of researchers, clinicians and people with lived experience from City University London. We are collaborating with researchers at the universities of Sussex, Kings College, Stirling, Oxford, York, Hull, the NCT and Maternal Mental Health Change Agents. Members of the core project team and research group are given below. Susan Ayers Professor of Maternal and Child Health, City, University of London I lead MATRIx and specialise in perinatal mental health, particularly anxiety and birth trauma. I have worked in this area for 25 years and before being a researcher I was a mum and single parent which showed me first hand the need for research evidence to drive change in this area. Women’s voices are at the heart of what we do and everyone who takes part in our research has the potential to make a difference. We are very grateful to our MATRIx team and all our participants for helping make this happen. Becca Webb MATRIx Research Fellow, Centre for Maternal and Child Health Research, City University of London I am the research fellow for MATRIx so am conducting the reviews and working with expert stakeholders. I have led the evidence reviews and am currently working on disseminating the findings and recommendations from the MATRIx project. I am a mum and when I was pregnant saw for myself how important the work we do is. I was able to experience the newly commissioned perinatal mental health services myself, and while they were amazing, there is still lots of work to be done. Nazihah Uddin MATRIx Research Assistant, Centre for Maternal & Child Health Research, City University of London I was the research assistant for MATRIx. I am a radiographer and completed my Masters in Clinical Research in 2019. I also work part-time as the administrator for the Centre for Maternal and Child Health Research at City, University of London. I am pleased to work on MATRIx to make a difference to the care women get in pregnancy. Liz Ford Senior Lecturer in Primary Care Research, Brighton & Sussex Medical School I am a Senior Lecturer in Primary Care Research at Brighton & Sussex Medical School. I have worked in various postdoctoral positions at the University of Sussex, Barts and the London Medical School, and Brighton & Sussex Medical School. My research focuses on mental health in primary care and community settings, with a particular focus on methods for using electronic health data such as patient records. My interest in perinatal mental health started with my doctoral research on Childbirth-related post-traumatic stress disorder. Judy Shakespeare General Practitioner (GP), Oxford I am a retired GP with a longstanding interest in perinatal mental health. I previously worked as the GP champion for perinatal mental health at the Royal College of General Practitioners and published the report Falling through the Gaps: Perinatal mental health and General Practice. I also previously worked at the University of Oxford National Perinatal Epidemiology Unit. Abigail Easter Senior Lecturer in Maternal and Newborn Health, Kings College London I am Senior Lecturer in Maternal and Newborn Health in the Department of Women and Children's Health at King's College London, and Deputy Lead for the Maternity and Perinatal Mental Health Theme of the NIHR Applied Research Collaboration (ARC) South London. I completed my PhD in the impact of Eating Disorders for pregnancy, birth and motherhood. My current research focuses on maternal and perinatal mental health, and using implementation science to bridge the gap between maternity and mental healthcare services to help optimise care for women and families. Agnes Hann Research and Evaluation Manager, NCT I work for the NCT as a Research & Evaluation manager and work with researchers in perinatal mental health and vulnerable groups (including young parents, single parents). I have worked in social research for over ten years. I worked in mental health research at the McPin Foundation and completed my PhD in Anthropology, with a focus on gender and economy. Jennifer Holly Research and Evaluation Manager, NCT I am a health services researcher with a background in improving services for women affected by abuse, mental health problems and problematic substance use. As NCT’s Research and Evaluation Manager, I lead the organisation’s academic and clinical partnerships including several studies about perinatal mental health.

INDIVIDUAL Beliefs About Health Services ​ Certain beliefs about health services can impact whether services are implemented and delivered successfully, and whether women seek help and access services. These beliefs include:​ Services only offer medication Services are stretched​ Services are too complicated No trust in health services Services only offer medication Believing health services will only offer medication for perinatal mental illness may act as a barrier to perinatal mental health care​.​ ​ "I knew she would just write me a prescription and send me away…that wasn’t what I wanted​.​" ​ Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult, Assessment, Deciding to disclose, Access to treatment, Provision of optimal treatment.​​ ​ Key literature: ​ Button S, et al. 2017 Services Are Too Complicated Believing health services are too complicated may act as a barrier to perinatal mental health care​ ​ "Consistently identified barriers to care for immigrant women were: ‘not understanding the health-care system’” ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult, Access to treatment​. ​ ​​Key literature: ​ Ganann R, et al. 2019 Services Are Stretched Believing perinatal mental health services are too stretched and therefore will be unable to help, may act as a barrier to perinatal mental health care.​​ ​ "I think it was just that they were really busy and just didn’t really have enough time for everybody with their kids".​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult, Deciding to disclose​. ​ ​Key literature: ​ Hadfield H, et al. 2017 No trust in health services Having little trust in health services may act as a barrier to perinatal mental health care​ ​ "The personal barriers described were mistrust, [and] fear of mental health service systems". ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Access to treatment​ ​ ​Key literature: ​ Boyd RC, et al. 2011 Recommendations More research is needed into beliefs about health systems using rigorous methodology, before recommendations for policy and practice can be made. Back to Individual

INDIVIDUAL Beliefs about mental illness Certain beliefs or understanding about mental illness can impact whether women seek help and access services. ​ Not knowing what perinatal mental illness is. Not having the language. Spiritual factors. External factors. Physical factors. A normal response to motherhood. Ignoring symptoms Not knowing what perinatal mental illness is Not knowing what perinatal mental illness is can act as a barrier to perinatal mental health care​. ​ "Nobody has ever told me what it is really [postpartum depression] … I just sit here sometimes and I am crying for no reason, but I could have detected it earlier if someone had explained to me what your first symptoms were, but nobody told me​" ​ Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Deciding to consult, Deciding to disclose. ​ Key literature: ​ Lucas G, et al. 2019 Spiritual factors Believing that symptoms are caused by spiritual factors and therefore seeking spiritual guidance first may be a barrier to perinatal mental health care. While spiritual guidance can be helpful for some women, other women find it less helpful.​ “They say that she (mother) is being possessed, so instead of medicines they go for talisman (spiritual treatment)”​. ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Deciding to consult. ​ ​​Key literature: ​ Atif N, et al. 2016 Physical factors Believing symptoms are caused by physical factors may be a barrier to perinatal mental health care​. ​ “I thought it was just lack of sleep and this heavy cold. I thought that after a good night’s sleep it would get better, and I would be able to manage​”​. ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult. ​ ​​Key literature: ​ Button S, et al. 2017 Not having the language Not having the language to describe perinatal mental illness may act as a barrier to perinatal mental health care​. ​ "It's hard to explain this anxiety. Because it's like something horrible is wrong, like something horrible happened to you. But nothing horrible happened to me. I don't know how to explain it​".​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult, Provision of optimal treatment​. ​ ​Key literature: ​ Staneva AA, et al. 2015 External factors Believing that symptoms are caused by external factors such as jobs may be a barrier to perinatal mental health care. ​ "I think it is about the stress. . . and the (lack of) community​". ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult ​ ​Key literature: ​ Schmied V, et al. 2017 A normal response to motherhood Believing symptoms are a normal response to motherhood can act as a barrier to perinatal mental health care. ​ "These feelings were considered a part of motherhood and the postpartum period; everyone experiences it​​". ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult ​ ​Key literature: ​ Schmied V, et al. 2017 Ignoring symptoms Responding to symptoms by ignoring or minimising them can act as a barrier to perinatal mental health care. ​ "And as an African-American woman, we, in order to survive, historically, have learned how to wear the mask. And I was able to, especially the second go around – you know, I could get through the day, you know, smiling. But I had deep circles up under my eyes". ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Deciding to consult ​ ​Key literature: ​ Jones CCG, et al. 2014 Recommendations We recommend the development of information aimed at increasing awareness of perinatal mental health illness such as (1) infographics/leaflets disseminated through maternity services, primary care, third sector organisations (e.g. NCT), and antenatal classes (2) short animations & videos disseminated via social media on:​ Symptoms of different perinatal mental illnesses​. Prevalence​. Causes​. Best way to cope with symptoms and when to seek help.​ ​ 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

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

Interpersonal Trusting relationship and rapport​ Language barriers​ Shared decision making​ Open and honest communication​ Back to Conceptual Framework

About MATRIx The MATRIx study is led by researchers at City, University of London in collaboration with experts across the UK. MATRIx reviewed the research evidence on what prevents women who are pregnant or after birth from getting support and treatment they need if they are struggling with emotional or psychological problems. On the basis of these reviews we developed recommendations for healthcare services about how to tackle these barriers to make sure women and families get the help they need. The project involved experts and stakeholders from many different backgrounds and disciplines.​ Aims Identify potential barriers and facilitators to assessment and treatment of perinatal mental health problems across the care pathway, both in terms of women accessing care or treatment, as well as in terms of NHS services implementing new assessment and treatment initiatives. Develop a conceptual framework of barriers and facilitators to implementation that will inform healthcare services and practice, care pathways, and highlight where further research is needed. We screened all search results for relevance and critically appraised the methodology of included papers using Joanna Briggs Critical Appraisal Tools for review 1, and the AMSTAR 2 tool for review 2. Methods Results were analysed using a thematic synthesis and mapping themes onto a systems level model adapted from Ferlie and Shortell’s (2001) Levels of Change framework (e.g. individual level factors, HCP factors, organisational factors and larger system factors) and then grouped to reflect different stages of the care pathway adapted from Goldberg and Huxley’s (1992) Pathways to Care model (e.g. deciding to disclose, assessment, access to care, treatment). Two MATRIx conceptual frameworks were developed that highlight the importance of 66 barriers and 39 facilitators to perinatal mental healthcare at multiple levels that intersect across the care pathway. These conceptual frameworks informed the development of evidence-based recommendations on how to address barriers to ensure that all women are able to access the care and support they need. Recommendations were made for health policy, practice and research. Supporting Organisations Suggested Citation MATRIx study team (2021). Conceptual Framework for Perinatal Mental Health: online tool London, UK. Additional Information Acknowledgements​ We would like to acknowledge our collaborators Agnes Hann, Camilla Rosan, Andrea Sinesi and Clare Thompson for their input throughout the project. Thanks are also due to Nia Roberts who conducted the literature searches for both evidence reviews, and to Nazihah Uddin and Georgina Constantinou who assisted with screening, methodological quality appraisals and data extraction for the reviews. We are very grateful for the advice and oversight of the Study Steering Committee: Professor Jenny Billings (Chair), Dame Professor Cathy Warwick, Kathryn Grant, Dr Fiona Campbell and Dr Sarah Taha. Finally, many thanks to the health professionals, managers, commissioners, parents and other stakeholders who gave us their valuable feedback on the framework.​ Funding This project is funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research programme (NIHR 128068). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. Contact Us First Name Last Name Email Write a message Submit Thanks for submitting!

Service Manager Organisational aspects Characteristics of services across care pathway Characteristics of assessment Characteristics of treatment Back to Conceptual Framework

Conceptual Framework Individual Health Professionals Interpersonal Service Managers Commissioners Policy Makers 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