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

The Team. We are a team of researchers, clinicians and people with lived experience from City University London. We have collaborated with researchers at the universities of Sussex, Kings College, Stirling, Oxford, York, Hull, the NCT and Maternal Mental Health Change Agents. We are now collaborating with health professionals and researchers from Homerton University Hospital NHS Foundation trust, East London NHS Foundation trust and NIHR ARC North Thames. Members of the core project team and research group are given below. Susan Ayers Professor of Maternal and Child Health, City, University of London I lead MATRIx and specialise in perinatal mental health, particularly anxiety and birth trauma. I have worked in this area for 25 years and before being a researcher I was a mum and single parent which showed me first hand the need for research evidence to drive change in this area. Women’s voices are at the heart of what we do and everyone who takes part in our research has the potential to make a difference. We are very grateful to our MATRIx team and all our participants for helping make this happen. Becca Webb MATRIx Research Fellow, Centre for Maternal and Child Health Research, City University of London I am the research fellow for MATRIx so am conducting the reviews and working with expert stakeholders. I have led the evidence reviews and am currently working on disseminating the findings and recommendations from the MATRIx project. I am a mum and when I was pregnant saw for myself how important the work we do is. I was able to experience the newly commissioned perinatal mental health services myself, and while they were amazing, there is still lots of work to be done. Nazihah Uddin MATRIx Research Assistant, Centre for Maternal & Child Health Research, City University of London I was the research assistant for MATRIx. I am a radiographer and completed my Masters in Clinical Research in 2019. I also work part-time as the administrator for the Centre for Maternal and Child Health Research at City, University of London. I am pleased to work on MATRIx to make a difference to the care women get in pregnancy. Liz Ford Senior Lecturer in Primary Care Research, Brighton & Sussex Medical School I am a Senior Lecturer in Primary Care Research at Brighton & Sussex Medical School. I have worked in various postdoctoral positions at the University of Sussex, Barts and the London Medical School, and Brighton & Sussex Medical School. My research focuses on mental health in primary care and community settings, with a particular focus on methods for using electronic health data such as patient records. My interest in perinatal mental health started with my doctoral research on Childbirth-related post-traumatic stress disorder. Judy Shakespeare General Practitioner (GP), Oxford I am a retired GP with a longstanding interest in perinatal mental health. I previously worked as the GP champion for perinatal mental health at the Royal College of General Practitioners and published the report Falling through the Gaps: Perinatal mental health and General Practice. I also previously worked at the University of Oxford National Perinatal Epidemiology Unit. Abigail Easter Senior Lecturer in Maternal and Newborn Health, Kings College London I am Senior Lecturer in Maternal and Newborn Health in the Department of Women and Children's Health at King's College London, and Deputy Lead for the Maternity and Perinatal Mental Health Theme of the NIHR Applied Research Collaboration (ARC) South London. I completed my PhD in the impact of Eating Disorders for pregnancy, birth and motherhood. My current research focuses on maternal and perinatal mental health, and using implementation science to bridge the gap between maternity and mental healthcare services to help optimise care for women and families. Agnes Hann Research and Evaluation Manager, NCT I work for the NCT as a Research & Evaluation manager and work with researchers in perinatal mental health and vulnerable groups (including young parents, single parents). I have worked in social research for over ten years. I worked in mental health research at the McPin Foundation and completed my PhD in Anthropology, with a focus on gender and economy. Jennifer Holly Research and Evaluation Manager, NCT I am a health services researcher with a background in improving services for women affected by abuse, mental health problems and problematic substance use. As NCT’s Research and Evaluation Manager, I lead the organisation’s academic and clinical partnerships including several studies about perinatal mental health. Georgie Constaninou Research Fellow, City University of London I am a research fellow in the Centre for Maternal and Child Health Research at City, University of London. My background is in health psychology, with an interest in parents’ experiences of care including: high risk pregnancies and care for infants and children with serious health complications. I have experience in qualitative research and am the lead research fellow on this project. Aaliyah Shaikh Consultant researcher, City University of London I am the PPIE Lead on this project. I have taught on the perinatal mental health module on cultural awareness needing to be embedded in every aspect of PMH care. My PhD thesis explored British Muslims’ experiences of the perinatal period. I am passionate about trauma informed awareness and education becoming a core part of healthcare and the need for cultural safety and faith-based needs in PMH services being better provided. I was born through a traumatic birth to a young migrant mother and experienced firsthand the difficulties that arise through development thus would like to contribute to making a difference in this field. I am committed to a community-based approach to involvement in healthcare as an element of creating change that addresses deeply rooted complex health inequalities with a holistic approach. Danni Lamb Senior Research Fellow, NIHR ARC North Thames I am a senior research fellow for the NIHR ARC North Thames. My work focuses on using mixed methods to evaluate the implementation of complex health services and interventions. My previous work focussed on mental health services and interventions, particularly acute mental health services such as Crisis Resolution Teams and Acute Day Units. Emma Finlayson Perinatal and Maternal Mental Health Specialist Midwife, Homerton Hospital I am an experienced midwife with a demonstrated history of working in the hospital & health care industry. I have extensive perinatal mental health and infant mental health experience and knowledge. I am also a trainee Psychodynamic Therapist. Justine Cawley Trustwide Lead for Perinatal Mental Health at East London NHS Foundation Trust I am an experienced Clinical Nurse with a demonstrated history of working in the hospital & health care industry. I am highly skilled in Quality Improvement, Nursing, Inpatient Care, Psychiatry, and Nursing Education. I am the lead for perinatal mental health at ELFT, and I will provide guidance and expertise throughout the project. Tamsin Bicknell Consultant Midwife, Public Health and Safeguarding at Homerton Hospital I have experience in direct care for vulnerable women, safeguarding, and service development focused on reducing health inequalities, improving experiences and outcomes for those with complex psycho-social lives. I have a particular interest in those experiencing removal of a baby at birth, substance and alcohol use in pregnancy, and trauma-informed care. I will provide guidance and expertise throughout the project.

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

COMMISSIONERS Care Pathways A tool used to guide health professionals and women on what their care should look like. Clear care pathways. Incomplete, confusing carer pathways​. Clear care pathways Care pathways that are comprehensive and clearly defined can be a facilitator. ​ "…those referral pathways are pretty simple if they’re clearly articulated​."​ ​ Evidence level: ​Moderate ​ ​Parts of the care pathway affected: Assessment, Referral. ​ Key literature: ​ Nithianandan N, et al. 2016 Incomplete, confusing care pathways​ Incomplete, unclear or confusing care pathways can be a barrier.​ ​ "Numerous phone calls and a large amount of paperwork are required to complete the screening and referral process​".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Assessment, Referral. ​ ​Key literature: ​ Boyd RC, et al. 2011 Recommendations We recommend commissioners designing clear and comprehensive referral and care pathways. Examples of care pathways for NHS perinatal mental health services can be found on The Future NHS Platform for National Perinatal Mental Health: Maternal mental health services-> MMHS Resources-> 3. Pathways & system delivery models​. ​ We recommend commissioners design integrated care ensuring collaboration within and between services. Back to Commissioners

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

Conceptual Framework Individual Health Professionals Interpersonal Service Managers Commissioners Policy Makers Society

SERVICE MANAGERS Characteristics of treatment Certain aspects of treatment can impact implementation, as well as whether women find the treatment acceptable and therefore engage with it.​ Opportunity to talk. Flexibility​. Individualised care. Group support​. Appropriateness of treatment​. Face to face. Opportunity to talk Interventions that provide women with an opportunity to talk about how they are feeling may be a facilitator. ​ ​ "…the opportunity to talk and have someone ​‘really listen’ was considered therapeutic, giving the women the opportunity to ‘get things off [my] chest.’” ​ Evidence level: ​Low ​ ​Parts of the care pathway affected: Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Hadfield H, et al. 2017 Individualised care Individualised and person-centred care can be a facilitator. A lack of individualised care can be a barrier. ​ [Discussing therapy ending before she was ready] One woman stated, “Just me thinking about it [ending the visits] now makes me feel quite panicky. . . . What would have been the point of ripping off the plaster and starting to abrade the wound only to just then say, oh well.”​ ​ Evidence level: ​Moderate ​ ​Parts of the care pathway affected: Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Hadfield H, et al. 2017 Appropriateness of treatment​ Treatment that is appropriate to women’s needs can be a facilitator. Treatment that does not suit women’s needs can be a barrier. ​ "CBT [Cognitive behavioural therapy] is often indicated as first line treatment but really it’s not an option for a lot of women. They don’t have the means to access it, they don’t have the motivation to access." ​ “I don’t even have time to go to the bathroom by myself so why would I sit down and do nasal breathing?” ​Evidence level: ​ Moderate ​ ​Parts of the care pathway affected: Access to treatment, Provision of optimal treatment, Women’s experience of treatment​​. ​ Key literature: ​ Chartier MJ, et al. 2015 ​Noonan M, et al. 2018 Flexibility​ Flexible treatment can be a facilitator. Inflexible treatment can be a barrier.​ ​ "I loved that I could access the program anytime. It fit into my schedule in a way that traditional therapy could not have, as my baby is demanding and my husband works out of town."​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Provision of optimal treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Pugh NE, et al. 2015 Group support​ For some women, group support was a facilitator. Other women did not want group support and therefore found it to be a barrier.​ ​ "I was a bit intimidated – intimidated’s [sic] the wrong word I was a bit hesitant at first because I thought oh my God I’ve gotta sit in front of a bunch of other people and talk about the problems I was having, you know what are they gonna think of me, but it actually ended up being better for me being in a group​".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Provision of optimal treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Hadfield H, et al. 2019 Face-to-face ​ For some women, face to face support may be facilitator.​ ​ "...an in-person therapist would be able to personalize the learning process a little more, and spend more time on things I needed to spend more time on".​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Provision of optimal treatment, Women’s experience of treatment​. ​ ​Key literature: Pugh NE, et al. 2015 Recommendations We recommend service managers ensure the provision of culturally sensitive care, that is individualised, flexible, and appropriate to women’s needs. ​ ​ Ideally care should be be delivered face-to-face​. ​ Peer support is valued by some women too and should be considered​. ​ We recommend that care is co-produced with women. One example of a successful co-produced service is the co-production of perinatal mental health services in Ealing, Hammersmith, Fulham & Hounslow. ​ Back to Service Manager

INDIVIDUAL Beliefs About Health 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