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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

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

SERVICE MANAGERS Characteristics of assessment Certain aspects of assessment/screening can impact implementation of assessment, as well as whether women find assessment acceptable.​ Wording of assessment tools. Acceptability of assessment ​ Wording of assessment tools The wording of some screening tools can be a barrier to implementation ​ "I have some moms [who] ask questions about it, like, ‘What does it mean where things are getting on top of me? What do you mean?’ You know, so they, they don’t always understand the questions" (Home visitor, about the EPDS )​​. ​ Evidence level: ​Moderate ​ ​Parts of the care pathway affected : Assessment​. ​ Key literature: ​ Doering JJ, et al. 2017 Acceptability of assessment ​ Women and health professionals finding assessment acceptable can be a facilitator to implementation. Poor acceptability of assessment is a barrier.​ ​ "I remember being frustrated and ticking at the end, fine, fine, fine, or whatever it was, good, good, good, no I’m not depressed. I mean they are not going to give a job to my husband".​ ​ "I thought it [screening] was a good idea from the beginning . . . It doesn’t take a lot of time. I think sometimes it can be challenging just to get people to complete it". ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Assessment. ​ ​Key literature: ​ Segre LS, et al. 2014 ​Shakespeare J, et al. 2003 Recommendations Use easy to understand assessment tools. Collaborate with organisations such as The Motherhood Group to ensure cultural appropriateness. ​ Design or update assessment tools that use pictures alongside words for use with women whose English speaking and understanding is limited, e.g. “How are you feeling?” screening tools by Abi Sobowale (Sheffield South West NHS Trust). ​ ​ 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. ​ ​ Service managers should ensure health professionals have enough time to do this by creating an adequate workforce​. Back to Service Manager

Individual Beliefs About Health Services Beliefs About Health Professionals Beliefs About Mental Illness Deciding to Seek Help Fear of Judgement Practical Difficulties Social and Family Life Demographic & Mental Health Factors Back to Conceptual Framework

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 Social and Family Life​ A woman’s social and family life can impact help seeking, access to care, and delivery and implementation of care. ​ Social isolation​ Family and friends​ Additional personal difficulties​ Social isolation​ Social isolation can act as a barrier to perinatal mental health care, whereas social support can be a facilitator​​. ​ "Those without social relationships felt an additional burden when dealing with PPD​​ [postpartum depression]" ​ Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Decision to consult, Women’s experience of treatment​. ​ Key literature: ​ Hansotte E, et al. 2017 Family and friends​ Supportive family and friends can be a facilitator to perinatal mental health care, whereas having little support from family and friends is a barrier​. ​ "It was sort of my partner saying to me: “Right, if you don’t go, I’m basically making nyou an appointment … You can’t just keep feeling like this".​ ​ ​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: ​ Button S, et al. 2017 Additional personal difficulties​ Personal difficulties outside of perinatal mental illness such as unemployment can act as barriers to perinatal mental health care​. ​ "I have this one client. . .(who) has so many issues going on, abusive relationship which she got out of and then custody battle with the children that are going to be a year in June and she is also pregnant. . .She had so much going on that she rejected the (mental health) referral​​". ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Decision to disclose, Access to treatment​. ​ ​Key literature: ​ Boyd RC, et al. 2011 Recommendations Social isolation can be a barrier to care for some women. We therefore recommend service managers considering offering peer support to women where appropriate. Not being financially stable, and other personal difficulties can be a barrier to care. We therefore recommend the government provide a fair welfare and economic system that ensures that no one is living in poverty or in financial hardship. Back to Individual

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

Society Stigma Culture Maternal norms​ Back to Conceptual Framework

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

Animation for women Animation for health professionals Animation for service managers Conceptual Framework Resources MATRIx 2 MATRIx Informing Perinatal Mental Health Services​ Perinatal M ental Health A ssessment and TR eatment: An Evidence Synthesis and Conceptual Framework of Barriers and Facilitators to I mplementation This project is funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research Programme (NIHR 128068) and NIHR ARC North Thames. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care

INDIVIDUAL 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

INTERPERSONAL Language barriers​ A barrier to communication between people who do not speak the same language. Language barriers. Resources. Language barriers Health professionals and women not being able to understand each other, and therefore have difficulties with communicating due to language barriers is a barrier to care "When the midwife visits, I can only speak the sentences about requesting a translator … They said that this kind of service is limited … that is what is difficult being Chinese—language barrier."​ ​ Evidence level: ​High ​ ​Parts of the care pathway affected: Deciding to consult, First Contact with Health Professional, Assessment, Decision to disclose, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Sambrook Smith M, et al. 2019 Resources Resources that can be used to reduce difficulties with language barriers within services​ ​ ACACIA Family support provide pre and postnatal depression support services. They have translated patient information into multiple languages (Arabic, Bengali, Chinese, French, Hindu, Polish, Punjabi, Romanian, Samoan & Urdu). “How are you feeling?” screening tools by Abi Sobowale (Sheffield South West NHS Trust)​. Guidance from Public Health England about language interpreting and translation: Recommendations We recommend service managers ensure recruitment of a diverse workforce​. ​ We recommend service managers recruit translators or form partnerships with other agencies that can provide additional support (e.g. translation services, interpreters) to translate infographics/leaflets into local languages and to act as an interpreter at appointments if women feel comfortable. ​ We recommend service managers consider investment in live translation tools or telephone interpreting such as Language Line.​ Back to Interpersonal