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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

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

References Atif N, Lovell K, Husain N, Sikander S, Patel V, Rahman A. Barefoot therapists: barriers and facilitators to delivering maternal mental health care through peer volunteers in Pakistan: a qualitative study. Int J Ment Health Syst. 2016;10:24. Mar 15. doi:10.1186/s13033-016-0055-9 Atif N, Nazir H, Zafar S, Chaudhri R, Atiq M, Mullany LC, Rowther AA, Malik A, Surkan PJ and Rahman A (2020) Development of a Psychological Intervention to Address Anxiety During Pregnancy in a Low-Income Country. Front. Psychiatry 10:927. doi: 10.3389/fpsyt.2019.00927 Bina R, Barak A, Posmontier B, Glasser S, Cinamon T. Social workers' perceptions of barriers to interpersonal therapy implementation for treating postpartum depression in a primary care setting in Israel. Health Soc Care Community. 2018;26(1):e75-e84. doi:10.1111/hsc.12479 Bina R. Predictors of postpartum depression service use: A theory-informed, integrative systematic review. Women Birth. 2020;33(1):e24-e32. doi:10.1016/j.wombi.2019.01.006 Boyd RC, Mogul M, Newman D, & Coyne JC. Screening and referral for postpartum depression among low-income women: a qualitative perspective from community health workers. Depression Research and Treatment. 2011. Button S, Thornton A, Lee S, Shakespeare J, Ayers S. Seeking help for perinatal psychological distress: a meta-synthesis of women's experiences. Br J Gen Pract. 2017;67(663):e692-e699. doi:10.3399/bjgp17X692549 Byatt N, Biebel K, Debordes-Jackson G, et al. Community mental health provider reluctance to provide pharmacotherapy may be a barrier to addressing perinatal depression: a preliminary study. Psychiatr Q. 2013;84(2):169-174. doi:10.1007/s11126-012-9236-0 Chartier MJ, Attawar D, Volk JS, Cooper M, Quddus F, McCarthy JA. Postpartum Mental Health Promotion: Perspectives from Mothers and Home Visitors. Public Health Nurs. 2015;32(6):671-679. doi:10.1111/phn.12205 Dennis CL, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. Birth. 2006;33(4):323-331. doi:10.1111/j.1523-536X.2006.00130.x Doering JJ, Maletta K, Laszewski A, Wichman CL, Hammel J. Needs and challenges of home visitors conducting perinatal depression screening. Infant Ment Health J. 2017;38(4):523-535. doi:10.1002/imhj.21656 Ganann R, Sword W, Newbold KB, Thabane L, Armour L, Kint B. Provider Perspectives on Facilitators and Barriers to Accessible Service Provision for Immigrant Women With Postpartum Depression: A Qualitative Study. Can J Nurs Res. 2019;51(3):191-201. doi:10.1177/0844562119852868 Hadfield H, Wittkowski A. Women's Experiences of Seeking and Receiving Psychological and Psychosocial Interventions for Postpartum Depression: A Systematic Review and Thematic Synthesis of the Qualitative Literature. J Midwifery Womens Health. 2017;62(6):723-736. doi:10.1111/jmwh.12669 Hadfield, H., Glendenning, S., Bee, P. et al. Psychological Therapy for Postnatal Depression in UK Primary Care Mental Health Services: A Qualitative Investigation Using Framework Analysis. J Child Fam Stud 28, 3519–3532 (2019). https://doi.org/10.1007/s10826-019-01535-0 Hansotte E, Payne SI, Babich SM. Positive postpartum depression screening practices and subsequent mental health treatment for low-income women in Western countries: a systematic literature review. Public Health Rev. 2017;38:3. Published 2017 Jan 31. doi:10.1186/s40985-017-0050-y Jallo N, Salyer J, Ruiz RJ, French E. Perceptions of guided imagery for stress management in pregnant African American women. Arch Psychiatr Nurs. 2015;29(4):249-254. doi:10.1016/j.apnu.2015.04.004 Jones CC, Jomeen J, Hayter M. The impact of peer support in the context of perinatal mental illness: a meta-ethnography. Midwifery. 2014;30(5):491-498. doi:10.1016/j.midw.2013.08.003 Kim JJ, La Porte LM, Adams MG, Gordon TE, Kuendig JM, Silver RK. Obstetric care provider engagement in a perinatal depression screening program. Arch Womens Ment Health. 2009;12(3):167-172. doi:10.1007/s00737-009-0057-6 Lucas G, Olander EK, Ayers S et al. No straight lines – young women’s perceptions of their mental health and wellbeing during and after pregnancy: a systematic review and meta-ethnography. BMC Women's Health 19, 152 (2019). https://doi.org/10.1186/s12905-019-0848-5 Masood Y, Lovell K, Lunat F, et al. Group psychological intervention for postnatal depression: a nested qualitative study with British South Asian women. BMC Womens Health. 2015;15:109. Published 2015 Nov 25. doi:10.1186/s12905-015-0263-5 Megnin-Viggars O, Symington I, Howard LM, Pilling S. Experience of care for mental health problems in the antenatal or postnatal period for women in the UK: a systematic review and meta-synthesis of qualitative research. Arch Womens Ment Health. 2015;18(6):745-759. doi:10.1007/s00737-015-0548-6 Morrell CJ, Sutcliffe P, Booth A, et al. A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression. Health Technol Assess. 2016;20(37):1-414. doi:10.3310/hta20370 Myors KA, Johnson M, Cleary M, Schmied V. Engaging women at risk for poor perinatal mental health outcomes: a mixed-methods study. Int J Ment Health Nurs. 2015;24(3):241-252. doi:10.1111/inm.12109 Nithianandan, N., Gibson-Helm, M., McBride, J. et al. Factors affecting implementation of perinatal mental health screening in women of refugee background. Implementation Sci 11, 150 (2016). https://doi.org/10.1186/s13012-016-0515-2 Noonan, M., Doody, O., O’Regan, A. et al. Irish general practitioners' view of perinatal mental health in general practice: a qualitative study. BMC Fam Pract 19, 196 (2018). https://doi.org/10.1186/s12875-018-0884-5 Pugh NE, Hadjistavropoulos HD, Hampton AJD, Bowen A, Williams J. Client experiences of guided internet cognitive behavior therapy for postpartum depression: a qualitative study. Arch Womens Ment Health. 2015;18(2):209-219. doi:10.1007/s00737-014-0449-0 Rowan C, McCourt C, & Bick D. (2010). Provision of perinatal mental health services in two English strategic health authorities: views and perspectives of the multi-professional team. Evidence Based Midwifery, 8(3), 98-106. Smith, M. S., Lawrence, V., Sadler, E., & Easter, A. (2019). Barriers to accessing mental health services for women with perinatal mental illness: systematic review and meta-synthesis of qualitative studies in the UK. BMJ open, 9(1), e024803. Schmied V, Black E, Naidoo N, Dahlen HG, Liamputtong P (2017) Migrant women’s experiences, meanings and ways of dealing with postnatal depression: A meta-ethnographic study. PLoS ONE 12(3): e0172385. https://doi.org/10.1371/journal.pone.0172385 Shakespeare J, Blake F, & Garcia J. A qualitative study of the acceptability of routine screening of postnatal women using the Edinburgh Postnatal Depression Scale. British Journal of General Practice. 2003; 53(493), 614-619. Sorsa MA, Kylmä J, Bondas TE. Contemplating Help-Seeking in Perinatal Psychological Distress-A Meta-Ethnography. Int J Environ Res Public Health. 2021;18(10):5226. doi:10.3390/ijerph18105226 Staneva AA, Bogossian F, & Wittkowski A. The experience of psychological distress, depression, and anxiety during pregnancy: A meta-synthesis of qualitative research. Midwifery. 2015; 31(6), 563-573. Watson H, Harrop D, Walton E, Young A, Soltani H. A systematic review of ethnic minority women's experiences of perinatal mental health conditions and services in Europe. PLoS One. 2019;14(1):e0210587. Published 2019 Jan 29. doi:10.1371/journal.pone.0210587 Willey S, Gibson-Helm M, Finch T, East C, Khan N, Boyd L, & Boyle J. Implementing innovative evidence-based perinatal mental health screening for refugee women. Women and Birth. 2018; 31, S8. Williams CJ, Turner KM, Burns A, Evans J, Bennert K. Midwives and women's views on using UK recommended depression case finding questions in antenatal care. Midwifery. 2016;35:39-46. doi:10.1016/j.midw.2016.01.015 Young CA, Burnett H, Ballinger A, et al. Embedded Maternal Mental Health Care in a Pediatric Primary Care Clinic: A Qualitative Exploration of Mothers' Experiences. Acad Pediatr. 2019;19(8):934-941. doi:10.1016/j.acap.2019.08.004

COMMISSIONERS Funding This refers to how services are paid for. A lack of funding. Funding complexities. A lack of funding A lack of funding or complexities in accessing funding can be a barrier to care. "We are unable to serve every woman in need of ongoing care. We are therefore working on additional funds, both internally and externally, to secure long-term physical and behavioural health care for our patients." Evidence level: Moderate 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 Funding complexities The government’s spending plans can be changed within the financial year. This can make it hard for services to plan their spending at the beginning of the year. See How Funding Flows by The King’s Fund for more information. Recommendations A clear and easy to access funding structure for commissioners and service managers. Continued policy support from NHS England, and the NHS related to perinatal mental health care, such as the publication of the Five Year Forward View and Long Term Plan for NHS England, and Delivering Effective Services report for NHS Scotland. We recommend the provision of a comprehensively researched and adequate budget provided to the Department of Health and Social Care, Health and Social Care Directorates so all healthcare needs for that financial year can be met. Where possible, a reduction of in-year funding changes is needed to allow for more thorough and comprehensive service planning. Back to Commissioners

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.

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