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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

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

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 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

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 Organisational aspects How the organisation and services are designed can impact implementation of perinatal mental health services, and women’s access to care. Co-location of services. Adequate workforce provision. Collaborative working across services. Assessment and referral processes. Collaborative working within services. Training. Supervision. Co-location of services Location of the service including co-location of different services within the same building may be a facilitator to care. "Another community resource that women mentioned as an enabler for seeking help …was having a comprehensive medical care system, offered at well-baby clinics, which met their own and their baby’s physical, psychological and emotional needs." Evidence level: Low Parts of the care pathway affected: Deciding to consult, Access to treatment, Provision of optimal treatment. Key literature: Bina R, et al. 2018 Collaborative working across services Collaborative working across services can be a facilitator to care, whereas no collaborative working across services is a barrier. "I think [referrals] are dependent on the nurses … Some nurses refer more than others. It all boils down to the amount of interaction the nurse has with the social worker and how much she/he believes in the ability of the social worker." Evidence level: Moderate Parts of the care pathway affected : Assessment, Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment. Key literature: Bina R, et al. 2018 Collaborative working within services Collaborative working within services can be a facilitator to care, whereas no collaborative working within services is a barrier. "Midwives had concerns that not all women were referred appropriately, but with support from one another, this situation was rectified: ‘if someone finds that there’s something that hasn’t been enacted properly, then they would always do something about it’". Evidence level: Moderate Parts of the care pathway affected : Assessment, Referral, Provision of optimal treatment. Key literature: Willey S, et al. 2018 Adequate workforce provision Employment of an adequate workforce to meet women’s needs and to ensure health professional’s have an achievable workload is a facilitator to care, whereas insufficient workforce is a barrier. "I’d like to do a lot of things, but time dictates that there’s only so much one can do". Evidence level: High Parts of the care pathway affected: Assessment , Referral, Access to treatment, Provision of optimal treatment. Key literature: Kim JJ, et al. 2009 Assessment and referral processes Clear assessment and referral processes with an organisation can be a facilitator to care, unclear processes can be barrier. "We have to send the form; the patient has to ring to say did you get the form and I am now confirming that I am going to go and then they get an appointment, for someone who is very distressed and you are asking them to jump through hoops". Evidence level: Moderate Parts of the care pathway affected: Assessment, Referral. Key literature: Noonan M, et al. 2018 Training Provision of high quality training for all professionals who come into contact with perinatal women is a facilitator to care. No training, or poor training is a barrier. "I’ve never received any formal training in this area. I do not feel adequately trained to detect postpartum depression." Evidence level: High Parts of the care pathway affected: First contact with health professionals, Assessment, Referral, Provision of optimal treatment. Key literature: Kim JJ, et al. 2009 Supervision Supervision for health professionals may be a facilitator. "...Discussing it with the supervisor gave us the clarity and also suggestions if we need to do it differently in our next session." Evidence level: Very low Parts of the care pathway affected: Assessment, Provision of optimal treatment. Key literature: Atif N, et al. 2019 Recommendations We recommend service managers ensure an adequate workforce to meet women’s needs by utilising a workforce planning tool and considering if there are a sufficient number of people in each of the key roles (psychiatrist, pharmacist, nurse, psychologist, occupational therapist, support staff, admin, peer support). We recommend service managers develop clear & easily accessible guidelines on where to refer women to depending on their need. We encourage the development of one referral form that can be uploaded and amended, discussed at multidisciplinary team meetings (this is a process used at the Perinatal Mental Health Service at South West London and St Georges Mental Health NHS Trust). Encouragement of a workspace that involves co-location, a culture of team working, sharing knowledge, approachability. Provision of training for all people working in a health service. Consider the use of simulation training, such as the one used by Brighton and Sussex University Hospitals NHS Trust provide Perinatal Mental Health Simulation Training on the identification and management of common perinatal mental health problems using actors and ‘real-life’ settings. Training should: Be ring fenced/time protected. Provide accreditation, matched to competencies and appropriate to level of involvement. Be expected for all health services staff who have contact with perinatal women. Be interactive and provided by a knowledgeable person or network. Where relevant be face-to-face. Training should cover: Symptoms of PNMI - not just depression. How to talk about PMH, what questions to ask, language use. How and where to refer to. Diverse family structures. Vulnerable groups. Health inequalities. Lived experiences. Trauma informed care. Cross cultural presentations of mental illness. How to engage women from diverse backgrounds (see The Motherhood Group, who provide training related to engaging with Black women). Service managers and policy makers could consider health professionals receiving accreditation for participating in Perinatal Mental Health Simulation Training. Back to Service Manager

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 recommendations for perinatal mental health care that are sensitive to women's faith and culture to overcome barriers. Aims To use an evidence-based co-design approach to co-create a culturally tailored care pathway and recommendations for perinatal mental health care 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 formed a group of 7 women with lived experience of perinatal mental health difficulties, and a group of 7 health professionals who work with women in the perinatal period. Methods We carried out interviews with women and health professionals to identify which barriers identified by the MATRIx 1 study were relevant to these groups, and if any additional barriers were identified. We worked with the women and health professionals to co-produce culturally and faith-sensitive recommendations for perinatal mental health care, and an updated perinatal mental health care pathway. We are currently writing up these results to be published and shared. 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.

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

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

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 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