Search Results

The Team. We are a team of researchers, clinicians and people with lived experience from City University London. We have collaborated with researchers at the universities of Sussex, Kings College, Stirling, Oxford, York, Hull, the NCT and Maternal Mental Health Change Agents. We are now collaborating with health professionals and researchers from Homerton University Hospital NHS Foundation trust, East London NHS Foundation trust and NIHR ARC North Thames. 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. Georgie Constaninou Research Fellow, City University of London I am a research fellow in the Centre for Maternal and Child Health Research at City, University of London. My background is in health psychology, with an interest in parents’ experiences of care including: high risk pregnancies and care for infants and children with serious health complications. I have experience in qualitative research and am the lead research fellow on this project. Aaliyah Shaikh Consultant researcher, City University of London I am the PPIE Lead on this project. I have taught on the perinatal mental health module on cultural awareness needing to be embedded in every aspect of PMH care. My PhD thesis explored British Muslims’ experiences of the perinatal period. I am passionate about trauma informed awareness and education becoming a core part of healthcare and the need for cultural safety and faith-based needs in PMH services being better provided. I was born through a traumatic birth to a young migrant mother and experienced firsthand the difficulties that arise through development thus would like to contribute to making a difference in this field. I am committed to a community-based approach to involvement in healthcare as an element of creating change that addresses deeply rooted complex health inequalities with a holistic approach. Danni Lamb Senior Research Fellow, NIHR ARC North Thames I am a senior research fellow for the NIHR ARC North Thames. My work focuses on using mixed methods to evaluate the implementation of complex health services and interventions. My previous work focussed on mental health services and interventions, particularly acute mental health services such as Crisis Resolution Teams and Acute Day Units. Emma Finlayson Perinatal and Maternal Mental Health Specialist Midwife, Homerton Hospital I am an experienced midwife with a demonstrated history of working in the hospital & health care industry. I have extensive perinatal mental health and infant mental health experience and knowledge. I am also a trainee Psychodynamic Therapist. Justine Cawley Trustwide Lead for Perinatal Mental Health at East London NHS Foundation Trust I am an experienced Clinical Nurse with a demonstrated history of working in the hospital & health care industry. I am highly skilled in Quality Improvement, Nursing, Inpatient Care, Psychiatry, and Nursing Education. I am the lead for perinatal mental health at ELFT, and I will provide guidance and expertise throughout the project. Tamsin Bicknell Consultant Midwife, Public Health and Safeguarding at Homerton Hospital I have experience in direct care for vulnerable women, safeguarding, and service development focused on reducing health inequalities, improving experiences and outcomes for those with complex psycho-social lives. I have a particular interest in those experiencing removal of a baby at birth, substance and alcohol use in pregnancy, and trauma-informed care. I will provide guidance and expertise throughout the project.

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

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. ​ 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.

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

INTERPERSONAL Open and honest communication​ Open and honest communication between women and health professionals. Open and honest communication . A lack of open and honest communication. Open and honest communication ​ Open and honest communication between women and health professionals can be a facilitator to perinatal mental health care​. "And I was so grateful, and then I just talked to her, and it was so nice to be able to talk freely with her [about the EPDS ] at the time.​"​ ​ Evidence level: ​ Moderate ​ ​Parts of the care pathway affected: Deciding to consult, Assessment, Decision to disclose, Women’s experience of treatment​. ​ Key literature: ​ Shakespeare J, et al. 2003 A lack of open and honest communication ​ A lack of open and honest communication between women and health professionals can be a barrier to perinatal mental health care​. ​ "Women reported that they were given incorrect or incomplete information because staff felt that they could not communicate with them, leaving them unsure of the appropriate places and people to talk to…​​".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Deciding to consult, Assessment, Decision to disclose, Women’s experience of treatment​. ​ ​Key literature: ​ Watson H, et al. 2019 Recommendations We recommend health professionals participate in continuing professional development activities related to perinatal mental health including participating in high quality training which focuses on communication skills​. ​ To ensure there are opportunities for health professionals and women to form trusting relationships and therefore encourage open and honest communication, we recommend continuity of carer across the care pathway​. Back to Interpersonal

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 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

HEALTH PROFESSIONALS Health professionals' knowledge​ Health professionals' knowledge about perinatal mental health symptoms and referral pathways can influence implementation and delivery of care, as well as whether women disclose their symptoms and access care. ​ Knowledge about perinatal mental illness​. Confidence of health professionals ​. Knowledge about referral pathways ​. Knowledge about perinatal mental illness​ Health professionals having good knowledge about perinatal mental health symptoms can be a facilitator to care, whereas a lack of knowledge can be a barrier. "’Oh I was seeing so and so but when they found out I was pregnant they discontinued my medication.’” That…happens frequently. Very frequently…their provider won’t [prescribe] because of their pregnancy."​ ​ Evidence level: ​ Moderate ​ ​Parts of the care pathway affected: Contact with health professionals, Assessment, Access to treatment​. ​ Key literature: ​ Byatt N, et al. 2013 Confidence of health professionals ​ Related to knowledge, a health professional with high levels of confidence in addressing perinatal mental health can be a facilitator. Low confidence can be a barrier.​ ​ "Look, I feel insecure at the moment, as I have not yet had the chance to try [this therapy with a client], and I have to practice…​".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Assessment, Referral, Provision of optimal treatment​. ​ ​Key literature: ​ Bina R, et al. 2018 Knowledge about referral pathways ​ Health professionals having good knowledge about services and referral pathways can be a facilitator to care, but lack of knowledge can be a barrier​​. ​ "The health professionals interviewed in both Trusts were not always aware of the services available in other areas of the health service and recommended the provision and circulation of named links to support more joined up working​​". ​ ​Evidence level: High ​ ​Parts of the care pathway affected: Assessment, Referral, Access to treatment​. ​ ​Key literature: ​ Rowan C, et al. 2010 Recommendations We recommend health professionals participate in continuing professional development activities related to perinatal mental health including participating in high quality training [LINK TO TRAINING RECOMMENDATION]​. ​ Service managers and policy makers could consider health professionals receiving accreditation for participating in training. Back to Health Professionals

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

Recommendations Recommendations for policy​ Many elements of the conceptual frameworks can be modified by policy makers and government activity (e.g. workforce provision, healthcare capacity, training etc). Therefore, we recommend policy makers review the frameworks and take comprehensive, strategic and evidence-based efforts to ensure there is an effective system of PMH care. ​ ​ Funding is required to ensure high quality care provision. Therefore, the provision of a comprehensively researched and adequate budget is needed so that all healthcare needs for that financial year can be met. Funding needs to be adequate for service needs and easily accessible. Funding structures may need to be revised depending on the needs of the community in which the service is delivered (e.g. affordable health insurance where free healthcare is not available). ​ ​ The reduction of health inequalities is needed. It is therefore advisable that policy is put in place: (i) improve equality between the sexes/genders by ensuring equal rights for women and men; (ii) in terms of ethnicity, for example changes at the legislative level are needed to protect those who have migrated to a different country from being penalised for accessing healthcare; and (iii) in terms of income, a fair and easily accessible welfare system is needed to prevent health inequalities based on deprivation.​ ​ To see this as in infographic click here Recommendations for practice (service managers) In terms of care, it is recommended that care is co-produced with women and is personalised and culturally appropriate. Increasing the flexibility and accessibility of services should be done through offering home visits and, where this is not possible, providing out-of-hours appointments located in an area with good transport links and an accessible building to allow for pushchairs. In addition, service managers could consider the provision of virtual consultations using web-based platforms, but women should be given the choice about whether virtual consultations are right for them.​ ​ Culturally sensitive care and increased accessibility of care is required for women who are unable to, or have difficulty speaking the country’s official language. This can be done via pictorial aids, the purchase of products such as Language Line, or through collaboration with translation agencies.​ ​ Technology can be a facilitator to PMH services in terms of assessment, referral and intervention. Thus, technology systems should be co-produced with HPs and women to ensure ease of usability and integration into the workflow.​ ​ Where not already implemented, multi-disciplinary teams should be created which facilitates choice and personalised care and ensures an adequate workforce to meet women’s needs. We need to break down silo working and encourage collaborative and joint working within and across services. Collaboration between services is needed with a focus on the identification and building of working relationships and networks with other services (e.g., Citizens Advice Bureau). Furthermore, the building of a coalition of health visitors, midwives, general practitioners, Improving Access to Psychological Therapies practitioners, psychologists and psychiatrists is needed to encourage referral and reduce the risk of women falling out of the care pathway.​ ​ HPs should be provided with high quality training that is delivered face-to-face and incorporates role play simulators where appropriate. This should include training in cultural sensitivity and cross-cultural mental health. Training time for HPs should be built into workloads and be protected.​ ​ To see this as in infographic click here​ Recommendations for practice (health professionals)​ A facilitator to perinatal mental health care was health professionals having good knowledge about perinatal mental health, services and referral pathways. Therefore, health professionals should participate in continuing professional development activities related to perinatal mental health including participating in high quality training. When in contact with women, health professional should listen to women’s concerns and take them seriously. Take the time to address their concerns and take responsibility of that woman to ensure she is referred to appropriate services. 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.​ ​ To see this as in infographic click here Recommendations for women and families We have also designed recommendations for women and families – navigating the system, click here for this infographic.

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

Conceptual Framework Individual Health Professionals Interpersonal Service Managers Commissioners Policy Makers Society