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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

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

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

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

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

INDIVIDUAL Demographic and Mental Health Factors Certain demographic and mental health factors may impact perinatal mental health care. Ethnicity. Previous experiences of mental health services. Age. Symptoms of mental illness. Previous diagnoses. Ethnicity A woman’s ethnicity may influence whether she decides to consult and whether she is able to access care. There is some evidence that suggests white women are more likely than Black, Asian and Minority ethnic women to seek help and be offered perinatal mental health care. "Asian and Black women were less likely to be offered treatment than White women and health care providers were perceived to discriminate against the women on account of their ethnicity". Evidence level: Low Parts of the care pathway affected: Decision to consult, Access to treatment. Key literature: Watson H, et al. 2019 Age Being older may be a facilitator to perinatal mental health care. More research is needed. “…older women sought treatment more often, due to maturity and a greater awareness about how to find care”. Evidence level: Very low Parts of the care pathway affected: Deciding to consult. Key literature: Hansotte E, et al. 2017 Previous experiences of mental health services Previous positive experiences of mental health services can be a facilitator, whereas previous negative experiences can be a barrier. "That is probably why a lot of black women don’t bother going to the system . . . the majority have had nightmares. So you’re thinking, “What’s the point in going back?”". Evidence level: Moderate Parts of the care pathway affected: Decision to consult, Assessment, Decision to disclose, Access to treatment, Women’s experience of treatment. Key literature: Watson H, et al. 2019 Symptoms of mental illness Current symptoms of mental illness may act as a barrier to perinatal mental health care. "When I was experiencing mental health issues, it was harder for me to get out, sort of on a schedule and be punctual." Evidence level: Low Parts of the care pathway affected: Deciding to consult Key literature: Sorsa MA, et al. 2021 Previous diagnoses Having a previous diagnosis of a mental health difficulty may be a facilitator to perinatal mental health care. "Furthermore, having a history of depression or anxiety and/or treatment for it was found to be associated with service use for PPD…[postpartum depression]". Evidence level: Very low Parts of the care pathway affected: Deciding to consult Key literature: Bina R. 2020 Recommendations We recommend the government and policy makers provide adequate funding for all mental health services, to ensure employment of the optimal number of staff to meet individual’s needs. We recommend high quality training to be provided to all health professionals who come into contact with people who are experiencing mental health difficulties, to ensure a high level of care is provided to all. 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