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INDIVIDUAL Fear of Judgement Fear of judgement from others is another barrier to women deciding to seek help or disclosing symptoms, and to implementing and delivering care successfully. Fear of being seen as a bad mum. Fear of social services. Fear of being seen as a bad mum The fear of being seen as a bad mum can act as a barrier to perinatal mental health care. "With my health visitor, I try not to let too much out, because then she won’t think I am a bad mum". Evidence level: Moderate Parts of the care pathway affected : Deciding to consult, Deciding to disclose. Key literature: Button S, et al. 2017 Fear of social services Fear of social services involvement can act as a barrier to perinatal mental health care. "I didn’t want anyone’s help to be honest after I had [my previous child]. I was so frightened that people would think I couldn’t cope and take her off me." Evidence level: High Parts of the care pathway affected: Deciding to consult, Deciding to disclose. Key literature: Megnin-Viggars O, et al. 2015 Recommendations We recommend the development an NHS Mental Health Campaign focused on stigma reduction of perinatal mental illness. We recommend the development of information aimed at increasing awareness of perinatal mental 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 PMI. How they are common, and when to seek help. Causes. How to access professional support. Services available. Maternity professionals and their role in PMH care. Myth busters on social services: For example, an analysis of reasons child protection plans were put in place in England in 2019 shows the most common reason was abuse or neglect (54.4%). Parent’s disability or illness only counted for 2.5% of referrals. Back to Individual

HEALTH PROFESSIONALS Getting it right first time It is important that health professionals take responsibility for each woman they see to help facilitate women’s journey along the care pathway. Dismissing or normalising women’s symptoms. Focussing only on infant. Not recognising help seeking. Appearing too busy. Tick box delivery. Dismissing or normalising women’s symptoms Health professionals being dismissive or normalising women’s symptoms is a barrier. "I did ask for support, but I didn’t really get any. And the health visitor’s response — ‘Well you seem like you’re doing all right’”. Evidence level: High Parts of the care pathway affected: Contact with health professionals, Decision to disclose, Referral, Access to treatment, Women’s experience of treatment. Key literature: Button S, et al 2017 Not recognising help seeking Health professionals not recognising help seeking or symptoms of perinatal mental illness can be a barrier. "I purposely circled the things ’cos I’m struggling, the health visitor didn’t get back to me, which I’m really disappointed about.” Evidence level: Moderate Parts of the care pathway affected: Contact with health professionals, Assessment. Referral. Key literature: Button S, et al 2017 Focussing only on infant Health professionals only focussing on the infant may be a barrier. "… somebody [is] not just checking on the baby but actually sitting down with you asking, ‘how are you doing?’ ‘What can I do to help you?’ ". Evidence level: Low Parts of the care pathway affected: Contact with health professionals, Decision to disclose, Provision of optimal treatment. Key literature: Megnin-Viggars O, et al. 2015 Appearing too busy Appearing to busy can be a barrier, whereas making time to address perinatal mental health symptoms is a facilitator. "The health visitor said something like: ‘You know, in this community we have to look after a thousand and something babies.’ And that instilled in me the feeling, like: ‘Oh, they are very busy these people, and I don’t have to be bothering them all the time’”. Evidence level: Moderate Parts of the care pathway affected: Contact with health professionals, Assessment, Decision to disclose, Access to treatment, Provision of optimal treatment, Women’s experience of treatment Key literature: Button S, et al 2017 Delivery of assessment Behaviours shown by health professionals during assessment can either be a barrier (i.e. carrying out assessment in a tick-box way) or a facilitator (i.e. taking a personalised approach). "I sometimes feel that they're [assessment tools] a little bit silly so I usually sort of introduce the questions, ‘we're interested in sort of how they're feeling emotionally or how they feel about the pregnancy …’ and we just go through them. But I try to sometimes re-phrase them a little bit because, depending on who I'm talking to basically, if I'm seeing a 16 year old girl who's scared out of her wits, I've got to be careful how I ask that sort of question because it's important to find out". Evidence level: Moderate Parts of the care pathway affected: Assessment, Decision to disclose. Key literature: Williams CJ, et al. 2016 Recommendations We recommend service managers employ an adequate number of workers to ensure health professionals have enough time to address women’s needs. We recommend service managers implement perinatal mental health good practice guides. This guide provides information on symptoms of perinatal mental illness, communication skills when discussing perinatal mental illness, what to do if a woman discloses perinatal mental illness and case studies of good practice. We recommend health professionals participate in continuing professional development activities related to perinatal mental health including taking part in high quality training. Back to Health Professionals

POLICY MAKERS Immigration Status Whether women were born in the country they are currently living in and how this may impact their perinatal mental health care journey. Not being born in the country currently living in. NHS Charging regulations. Not being born in the country currently living in Not being born in the country women are currently living in. "…as Hispanics we do not have insurance and money is what really counts." "Because when you’re legal you can take the child to the daycare and look for a job. . . If you don’t work, it’s like you’re dead, being alive. We want our papers so we can progress; not so we can leave or be a load to anyone, but just to work—to buy a home and give our kids a good life. . . I get depressed because I can’t live like normal people because I’m always thinking if I leave or if I stay. . . " Evidence level: High Parts of the care pathway affected : Decision to consult, Assessment, Referral, Access to treatment, Provision of optimal treatment. Key literature: Hansotte E, et al. 2017 Schmied V, et al. 2017 NHS Charging regulations Despite the NHS being free for UK residents, there are NHS charging regulations in place for those who are not residents of the United Kingdom. NHS charging regulations have a large negative impact on pregnant and postnatal women, in terms of their mental health - increasing stress and anxiety, their vulnerability to domestic violence and maternal deaths that may have been prevented through access to antenatal care. Furthermore, Public Health England has identified NHS charging for maternity care as one of the key issues that exacerbates poorer health outcomes for women and babies of colour. Recommendations We recommend support for refugee or immigrant women to be able to access care without being penalised (e.g., through deportation, through charging systems). We recommend the suspension of NHS charging regulations until a full independent review of their impact on individual and public health, simplification of charging criteria and exemptions and safeguards to protect vulnerable patients and ensure they are not denied the care they are entitled to, is carried out. This recommendation is in line with: (a) a joint statement set out by the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of Obstetricians and Gynaecologists and the Faculty of Public Health in 2018, calling for a suspension of NHS Charging; (b) a statement from the Academy of Medical Royal Colleges in 2019 released a statement calling for the suspension of the NHS charging regulations until a full independent review on individual and public health is carried out; (c) a statement from the Royal College of Paediatrics and Child Health calling for an end to NHS charging due to its adverse effects on child health and wider public health; (d) a report from Maternity Action calling for the immediate suspension of charging for NHS maternity care given the deterrent effect on women’s access to maternity care. Back to Policy Makers

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

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

SOCIETY Stigma Negative attitudes or discrimination against someone based on a distinguishing characteristic such as a mental illness, health condition, or disability. 1 Barrier to perinatal mental health care. Stigma reduction. Barrier to perinatal mental health care Stigma is a barrier to perinatal mental health care. "Oh well, I think there’s plenty, I mean I think there’s a huge stigma about feeling depressed particularly postnatal depression." 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: Shakespeare J, et al. 2003 Stigma reduction Research suggests public mental health campaigns can increase knowledge about mental illness and improve attitudes about people with mental illness. 2 A UK based example was Time to Change: Video Recommendation NHS Mental Health Campaign focused on raising awareness of perinatal mental illness and reducing stigma for perinatal mental illness. Back to Society

COMMISSIONERS Appropriate and timely services There needs to be an adequate amount of services that women can be referred on to. These services need to meet women’s needs and be offered in a timely manner. A lack of appropriate and timely services. Guidance for providing services. A lack of appropriate and timely services A lack of appropriate and timely services is a barrier to care. "I could see that [the EPDS score] was high and you make your referrals, and it was months out before she could go . . . she had to almost take her life to get seen right away. And that’s terrible that it has to come to that. I think that’s the biggest struggle." Evidence level: High 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 Guidance for providing services According to Moreton et al. 2021 to provide services that meet the needs of the population, commissioners must: Have a good knowledge of population and the healthcare need in question. Therefore, training on perinatal mental health should be mandatory for at least one commissioner in each Primary Care Network, Integrated Care System or Health Board (see recommended training [add link]) Engage with people with lived experience - services should be co-produced with those who have lived experience Have access to high quality evidence e.g. the development of perinatal mental health information guide : Symptoms of PNMI Impact on women and their families Barriers to women getting care they need and how to overcome these Effective care and treatment Examples of good practice Recommendations Provision of adequate financial resources to ensure service managers can: Recruit a multi-disciplinary team with enough staff to meet service users’ needs. Provide high-quality, time protected staff training to all staff. Provide continuity of carer. Provide resources that break down language barriers such as translators or Language Line. Provide an adequate number of appropriate services that women can be referred to in a timely manner. Provide individualised, woman-centred care. Back to Commissioners

HEALTH PROFESSIONALS Health Professional’s Attributes Characteristics that some health professionals have, may have a positive impact on whether services are implemented and delivered successfully and whether women disclose their difficulties and access care. Similar demographic characteristics . Cultural insensitivity . Valued characteristics Similar demographic characteristics Health professionals having similar demographic characteristics to women is a facilitator. "Because she understood what we go through, how our culture is, and how our belief systems are. She could understand us better than anyone else." Evidence level: High Parts of the care pathway affected: Deciding to consult, Decision to disclose, Provision of optimal treatment, Women’s experience of treatment Key literature: Masood Y, et al. 2015 Cultural insensitivity Health professionals lacking in cultural sensitivity can be a barrier. "I got answers from professionals like, there is nothing wrong with you, go back home stop disturbing us, basically you are wasting our time, and they were horrible . . .I don’t know if they would have said that if I was white." Pakistani mother. Evidence level: Moderate Parts of the care pathway affected: Decision to disclose, Access to treatment, Provision of optimal treatment. Key literature: Watson H, et al. 2019 Valued characteristics Health professionals possessing valued characteristics (e.g. being trustworthy, empathetic, kind, caring with a genuine interest) is a facilitator. "She doesn’t make little snippy comments about if your house is a mess or something…She was always there if I have a question or something and she always gets back to me no matter what.." 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: Doering JJ, et al. 2017 Recommendations We recommend service managers ensure recruitment of a diverse workforce, and staff positive interest and attitude towards providing high quality care to women. Consider HPs receiving accreditation for providing high quality care, team working, and clear communication. We recommend service managers implement perinatal mental health good practice guides . This guide provides information on symptoms of perinatal mental illness, communication skills when discussing perinatal mental illness, what to do if a woman discloses perinatal mental illness and case studies of good practice. We recommend health professionals participate in continuing professional development activities related to perinatal mental health including taking part in high quality training. Back to Health Professionals

Policy Makers Immigration status Economic status and healthcare costs Back to Conceptual Framework

Further Resources Infographics Infographic for women Recommendations for health professionals Recommendations for service managers Recommendations for commissioners Recommendations for policy makers Animations Animation for women and families Animation for health professionals Animation for service managers Conceptual frameworks MATRIx Facilitators Framework MATRIx Barriers Framework Summary report Publications Review 1 publication Review 2 publication Conceptual frameworks publication NIHR Publication Other Perinatal Mental Health Partnership - Matrix videos Recommendations Twitter (X) References

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