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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

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

Further Resources Infographics Infographic for women Recommendations for health professionals Recommendations for service managers Recommendations for commissioners Recommendations for policy makers Animations Animation for women and families Animation for health professionals Animation for service managers Conceptual frameworks MATRIx Facilitators Framework MATRIx Barriers Framework Summary report Publications Review 1 publication Review 2 publication Conceptual frameworks publication NIHR Publication Other Perinatal Mental Health Partnership - Matrix videos Recommendations Twitter (X) References

INTERPERSONAL Trusting relationship and rapport The development of a trusting relationship and rapport between health professionals and women. Trusting relationship and rapport. Difficulties developing a trusting relationship. Trusting relationship and rapport The development of a trusting relationship is a facilitator to perinatal mental health care. "It’s like family, almost. You know what I mean? It’ s somewhere where you already feel comfortable.." Evidence level: High Parts of the care pathway affected: Deciding to consult, Assessment, Decision to disclose, Access to treatment, Provision of optimal treatment, Women’s experience of treatment. Key literature: Young CA, et al. 2019 Difficulties developing a trusting relationship Difficulties developing a trusting relationship and rapport between health professionals and women is a barrier to perinatal mental health care. "I didn’t trust them I suppose so I didn’t tell the health visitors how I was feeling". Evidence level: High Parts of the care pathway affected: Deciding to consult, Assessment, Decision to disclose, Access to treatment, Provision of optimal treatment, Women’s experience of treatment Key literature: Shakespeare J, et al. 2003 Recommendations To ensure there are opportunities for health professionals and women to form trusting relationships, we recommend continuity of carer across the care pathway. A good example of this is The Tower Team based in the Tower Hamlets, London is a high-risk caseload midwifery team that works closely with the perinatal mental health team and the consultant obstetrician for mental health at St. Thomas’ hospital. The Tower Team offers continuity of care for women with severe mental illness from their maternity booking appointment, throughout pregnancy, intrapartum and for up to 28 days postpartum. Back to Interpersonal

INDIVIDUAL Beliefs About Health Services Certain beliefs about health services can impact whether services are implemented and delivered successfully, and whether women seek help and access services. These beliefs include: Services only offer medication Services are stretched Services are too complicated No trust in health services Services only offer medication Believing health services will only offer medication for perinatal mental illness may act as a barrier to perinatal mental health care. "I knew she would just write me a prescription and send me away…that wasn’t what I wanted." Evidence level: Low Parts of the care pathway affected: Deciding to consult, Assessment, Deciding to disclose, Access to treatment, Provision of optimal treatment. Key literature: Button S, et al. 2017 Services Are Too Complicated Believing health services are too complicated may act as a barrier to perinatal mental health care "Consistently identified barriers to care for immigrant women were: ‘not understanding the health-care system’” Evidence level: Low Parts of the care pathway affected: Deciding to consult, Access to treatment. Key literature: Ganann R, et al. 2019 Services Are Stretched Believing perinatal mental health services are too stretched and therefore will be unable to help, may act as a barrier to perinatal mental health care. "I think it was just that they were really busy and just didn’t really have enough time for everybody with their kids". Evidence level: Low Parts of the care pathway affected: Deciding to consult, Deciding to disclose. Key literature: Hadfield H, et al. 2017 No trust in health services Having little trust in health services may act as a barrier to perinatal mental health care "The personal barriers described were mistrust, [and] fear of mental health service systems". Evidence level: Low Parts of the care pathway affected: Access to treatment Key literature: Boyd RC, et al. 2011 Recommendations More research is needed into beliefs about health systems using rigorous methodology, before recommendations for policy and practice can be made. Back to Individual

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

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

INDIVIDUAL Beliefs about mental illness Certain beliefs or understanding about mental illness can impact whether women seek help and access services. Not knowing what perinatal mental illness is. Not having the language. Spiritual factors. External factors. Physical factors. A normal response to motherhood. Ignoring symptoms Not knowing what perinatal mental illness is Not knowing what perinatal mental illness is can act as a barrier to perinatal mental health care. "Nobody has ever told me what it is really [postpartum depression] … I just sit here sometimes and I am crying for no reason, but I could have detected it earlier if someone had explained to me what your first symptoms were, but nobody told me" Evidence level: Moderate Parts of the care pathway affected: Deciding to consult, Deciding to disclose. Key literature: Lucas G, et al. 2019 Spiritual factors Believing that symptoms are caused by spiritual factors and therefore seeking spiritual guidance first may be a barrier to perinatal mental health care. While spiritual guidance can be helpful for some women, other women find it less helpful. “They say that she (mother) is being possessed, so instead of medicines they go for talisman (spiritual treatment)”. Evidence level: Moderate Parts of the care pathway affected: Deciding to consult. Key literature: Atif N, et al. 2016 Physical factors Believing symptoms are caused by physical factors may be a barrier to perinatal mental health care. “I thought it was just lack of sleep and this heavy cold. I thought that after a good night’s sleep it would get better, and I would be able to manage”. Evidence level: Low Parts of the care pathway affected: Deciding to consult. Key literature: Button S, et al. 2017 Not having the language Not having the language to describe perinatal mental illness may act as a barrier to perinatal mental health care. "It's hard to explain this anxiety. Because it's like something horrible is wrong, like something horrible happened to you. But nothing horrible happened to me. I don't know how to explain it". Evidence level: Low Parts of the care pathway affected: Deciding to consult, Provision of optimal treatment. Key literature: Staneva AA, et al. 2015 External factors Believing that symptoms are caused by external factors such as jobs may be a barrier to perinatal mental health care. "I think it is about the stress. . . and the (lack of) community". Evidence level: Low Parts of the care pathway affected: Deciding to consult Key literature: Schmied V, et al. 2017 A normal response to motherhood Believing symptoms are a normal response to motherhood can act as a barrier to perinatal mental health care. "These feelings were considered a part of motherhood and the postpartum period; everyone experiences it". Evidence level: Low Parts of the care pathway affected: Deciding to consult Key literature: Schmied V, et al. 2017 Ignoring symptoms Responding to symptoms by ignoring or minimising them can act as a barrier to perinatal mental health care. "And as an African-American woman, we, in order to survive, historically, have learned how to wear the mask. And I was able to, especially the second go around – you know, I could get through the day, you know, smiling. But I had deep circles up under my eyes". Evidence level: Moderate Parts of the care pathway affected: Deciding to consult Key literature: Jones CCG, et al. 2014 Recommendations We recommend the development of information aimed at increasing awareness of perinatal mental health illness such as (1) infographics/leaflets disseminated through maternity services, primary care, third sector organisations (e.g. NCT), and antenatal classes (2) short animations & videos disseminated via social media on: Symptoms of different perinatal mental illnesses. Prevalence. Causes. Best way to cope with symptoms and when to seek help. We recommend this information is developed by individual trusts, or third-party organisations (e.g., the NCT) in collaboration with the NIHR Applied Research Collaboration (ARC) Perinatal Mental Health Themes, The Perinatal Mental Health Network Scotland, the National Managed Clinical Network, and the Royal Colleges. We have provided some guidance for women navigating an imperfect system here. Back to Individual

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

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