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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

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

Society Stigma Culture Maternal norms​ Back to Conceptual Framework

MATRIx 2 The MATRIx study is led by researchers at City, University of London in collaboration with experts in London. Despite significant improvements in perinatal mental health services, there are still gaps in access for women from ethnic minority groups. MATRIx 2 wants to understand why this is, and develop a culturally sensitive care pathway to overcome barriers. Aims To use an evidence-based co-design approach to co-create a culturally tailored care pathway aimed at overcoming some of the barriers identified by the MATRIx 1 project. Objectives: (1) Identify barriers to accessing/implementing PMH care from women, health professionals and service manager’s perspectives. (2) Develop care that is appropriate to women's needs, including being culturally and religiously sensitive (3) Create outputs for services and women We will form two lived experience groups: one with women and the other with HPs and service managers at Homerton hospital or East London Foundation Trust. We will recruit from a range of sources using multiple recruitment strategies Methods We will carry out qualitative research with women and health professionals to determine which barriers identified by the MATRIx 1 study are most relevant to the service managers and women. The women and health professionals from the lived experience groups will take part. We will analyse data using thematic analysis. ​ With the lived-experience groups we will co-produce an updated perinatal mental health care pathway focusing on more culturally sensitive care, including reducing the barriers identified by the MATRIx project and results from Phase 2. ​ Take Part Would you like to share how your culture, faith or religion play a role during pregnancy and birth? ​ If you are pregnant or have given birth within the last 2 years, experienced mental health difficulties, and received your maternity care from Homerton Hospital, we would love to hear from you. ​ Fill in your contact details below and we will get back to you. First name Last name Email Your message Submit Supporting Organisations Funding This project is funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration North Thames. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Animation for women Animation for health professionals Animation for service managers Conceptual Framework Resources MATRIx 2 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) and NIHR ARC North Thames. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care

INDIVIDUAL Deciding to seek help There are two steps to women deciding to seek help. These are recognising that something is wrong and having the knowledge and understanding to know where to go to seek help.​ Supported to recognise something was wrong. Not knowing what services are available. ​ Supported to recognise something was wrong When women are supported to recognise something was wrong, this acts as a facilitator to women perinatal mental health care. ​ ​ "That’s when I thought, you know: “Something is really wrong here, I need to go to the doctors if I’m thinking about killing myself.”​" ​ Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Deciding to consult. ​ Key literature: ​ Button S, et al. 2017 Not knowing what services are available Women not knowing what services are available and where to go to seek help may be a barrier to perinatal mental health care. ​ ". . .you don’t know where to go, what to do, who to trust…". ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult. ​ ​Key literature: ​ Megnin-Viggars O, et al. 2015 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​. The 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