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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

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

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

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

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

Society Stigma Culture Maternal norms Back to Conceptual Framework

SOCIETY Culture Culture is a complex factor that refers to a “group’s thoughts, experiences, and patterns of behaviour and its concepts, values and assumptions about life that guide behaviour” 1. Culture varies both across countries and within countries, as it can be affected by factors such as race, religion, gender etc. Culture different to Western view. Culturally sensitive care. Culture different to Western view Cultural belief systems that differ to the Western view of mental illness are a barrier to perinatal mental health care. "Because depression, like if you see the symptoms of depression, it’s a mental illness. The minute you say mental illness in my country, you are crazy." 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: Schmied V, et al. 2017 Culturally sensitive care Mental illnesses are not spread evenly around the world. Culture influences what we see as a mental illness. For example, Amok – mostly experienced by Indonesian men after a social insult, characterised by brooding and then rage. Zar – Experienced by those living in the Middle East. Is related to spirit possession, characterised by laughing, crying, shouting and singing. Post-traumatic stress disorder – a western mental illness occurring after a trauma. Characterised by flashbacks to the event, and avoidance of things that remind people of the event. Culturally sensitive care can be defined as “the ability to be appropriately responsive to the attitudes, feelings, or circumstances of groups of people that share a common and distinctive racial, national, religious, linguistic, or cultural heritage” 2. It is care that offers services in a manner that is relevant to patients’ needs and expectations 3. Recommendations Provide culturally sensitive care. Collaborate with organisations such as The Motherhood Group to ensure cultural appropriateness. Co-design care with a diverse range of people to ensure appropriateness and sensitivity. Back to Society

SERVICE MANAGERS Characteristics of treatment Certain aspects of treatment can impact implementation, as well as whether women find the treatment acceptable and therefore engage with it. Opportunity to talk. Flexibility. Individualised care. Group support. Appropriateness of treatment. Face to face. Opportunity to talk Interventions that provide women with an opportunity to talk about how they are feeling may be a facilitator. "…the opportunity to talk and have someone ‘really listen’ was considered therapeutic, giving the women the opportunity to ‘get things off [my] chest.’” Evidence level: Low Parts of the care pathway affected: Provision of optimal treatment, Women’s experience of treatment. Key literature: Hadfield H, et al. 2017 Individualised care Individualised and person-centred care can be a facilitator. A lack of individualised care can be a barrier. [Discussing therapy ending before she was ready] One woman stated, “Just me thinking about it [ending the visits] now makes me feel quite panicky. . . . What would have been the point of ripping off the plaster and starting to abrade the wound only to just then say, oh well.” Evidence level: Moderate Parts of the care pathway affected: Access to treatment, Provision of optimal treatment, Women’s experience of treatment. Key literature: Hadfield H, et al. 2017 Appropriateness of treatment Treatment that is appropriate to women’s needs can be a facilitator. Treatment that does not suit women’s needs can be a barrier. "CBT [Cognitive behavioural therapy] is often indicated as first line treatment but really it’s not an option for a lot of women. They don’t have the means to access it, they don’t have the motivation to access." “I don’t even have time to go to the bathroom by myself so why would I sit down and do nasal breathing?” Evidence level: Moderate Parts of the care pathway affected: Access to treatment, Provision of optimal treatment, Women’s experience of treatment. Key literature: Chartier MJ, et al. 2015 Noonan M, et al. 2018 Flexibility Flexible treatment can be a facilitator. Inflexible treatment can be a barrier. "I loved that I could access the program anytime. It fit into my schedule in a way that traditional therapy could not have, as my baby is demanding and my husband works out of town." Evidence level: Moderate Parts of the care pathway affected: Provision of optimal treatment, Women’s experience of treatment. Key literature: Pugh NE, et al. 2015 Group support For some women, group support was a facilitator. Other women did not want group support and therefore found it to be a barrier. "I was a bit intimidated – intimidated’s [sic] the wrong word I was a bit hesitant at first because I thought oh my God I’ve gotta sit in front of a bunch of other people and talk about the problems I was having, you know what are they gonna think of me, but it actually ended up being better for me being in a group". Evidence level: Moderate Parts of the care pathway affected: Provision of optimal treatment, Women’s experience of treatment. Key literature: Hadfield H, et al. 2019 Face-to-face For some women, face to face support may be facilitator. "...an in-person therapist would be able to personalize the learning process a little more, and spend more time on things I needed to spend more time on". Evidence level: Low Parts of the care pathway affected: Provision of optimal treatment, Women’s experience of treatment. Key literature: Pugh NE, et al. 2015 Recommendations We recommend service managers ensure the provision of culturally sensitive care, that is individualised, flexible, and appropriate to women’s needs. Ideally care should be be delivered face-to-face. Peer support is valued by some women too and should be considered. We recommend that care is co-produced with women. 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

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

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

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