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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.

SERVICE MANAGERS Characteristics of services across care pathway The way a service is set up and run can impact implementation of, and women’s access to perinatal mental health care. Continuity of carer. Information provision. Delivered at home. Culturally sensitive care. Delivered in medical setting. Privacy and confidentiality. Dedicated perinatal mental health champion. Technology. Logistical support. Continuity of carer Care that provides the same health professional along the care pathway is a facilitator to care. Lack of continuity of care is a barrier. "Every time I went to see the midwife, or…, I always had somebody different, and I don’t want to tell 10 people my story." Evidence level: High Parts of the care pathway affected: Assessment, Decision to disclose, Access to treatment, Provision of optimal treatment, Women’s experience of treatment. Key literature: Megnin-Viggars O, et al. 2015 Delivered at home Care that is delivered at home can be a facilitator to care. "I was more relaxed in my own home." Evidence level: Moderate Parts of the care pathway affected: Decision to consult, Assessment, Decision to disclose, Provision of optimal treatment, Women’s experience of treatment. Key literature: Myors et al. 2015 Delivered in medical setting Some women and health professionals find that care delivered in a medical setting may be a facilitator to care. Other women find it to be a barrier. "Bangladeshi women living in the UK indicated that they talked freely in the hospital about emotional problems; however, few discussed their difficulties at home apart from practical terms because of censorship by family members". "Thirteen of the women found the baby clinic an inappropriate place to complete the EPDS . The lack of time and privacy, the reluctance to make a fuss and the stress of the clinic were cited as reasons. Most women would have preferred to be screened in their own homes. ‘That first Edinburgh test, to have it filled in and then talked about in front of everybody else was just terrible.’ " Evidence level: Low Parts of the care pathway affected : Assessment, Provision of optimal treatment, Women’s experience of treatment. Key literature: Dennis & Chung-Lee, L 2006 Shakespeare, J et al. 2003 Dedicated perinatal mental health champion Care that has a dedicated person or perinatal mental health champion may be a facilitator to care. "I’ve felt the Liaison Nurse . . . her being a point of contact . . . made a big difference to my follow-up and action planning around the clients." Evidence level: Low Parts of the care pathway affected: Assessment, Referral, Access to treatment, Provision of optimal treatment. Key literature: Willey S, et al. 2018 Information provision Care that provides information about services and perinatal mental health can be a facilitator to care. A lack of information provision can be a barrier. "Some women believed that their physician did not provide sufficient information about pharmacological treatment". Evidence level: Moderate Parts of the care pathway affected: Decision to consult, Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment. Key literature: Dennis, CL & Chung-Lee, L. 2006 Culturally sensitive care Culturally sensitive care is a facilitator to care. Care that is not sensitive to women’s cultural needs is a barrier. "You need someone who’s on the same wavelength as you, who shares the same cultural experiences as you, which sometimes isn’t available." Evidence level: High Parts of the care pathway affected: Decision to consult, Contact with health professionals, Assessment, Decision to disclose, Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment. Key literature: Button S, et al. 2017 Privacy and confidentiality Care that is private and maintains women's confidentiality may be a facilitator to care. Lack of privacy may be a barrier. "The interruptions took me longer to really get relaxed." Evidence level: Low Parts of the care pathway affected: Decision to disclose, Access to treatment, Provision of optimal treatment. Key literature: Jallo N, et al. 2015 Technology Technology that is fit for purpose and that works well is a facilitator to care. Technology that does not work is a barrier. "We would be quite good in fact in asking [women to complete the EPDS ] and it’s probably because of that little reminder on the screen." Evidence level: High Parts of the care pathway affected: Assessment, Referral, Women’s experience of treatment. Key literature: Noonan M, et al. 2018 Logistical support Services that provide logistical support, such as easily accessible locations, childcare, travel costs can be facilitators to care. No logistical support can be a barrier. "And we were offered a crèche facility; I used to take him there; otherwise it would have been really difficult for me." Evidence level: Moderate Parts of the care pathway affected: Decision to consult, Access to care, Provision of optimal treatment, Women’s experience of treatment. Key literature: Masood Y, et al. 2015 Recommendations It is important services have easy-to-use technology that is compatible with other technology systems used in other services. We recommend service managers encourage co-production or user experience testing of technology to ensure ease of usability and integration into the workflow. Where compatibility between IT systems is not possible, we recommend the employment of a liaison person who has access to all systems to bridge the gap between different services. Reduction of the changeover of technology when new commissioners join, and encouragement of technology use that is compatible with other systems. Service managers need to ensure the provision of culturally sensitive care. We recommend service users collaborate with organisations such as The Motherhood Group to ensure care is culturally appropriate The Motherhood Group. Provision of care should ideally be delivered face-to-face, provide logistical support or be carried out in a home setting. If home delivery is not possible, ensure practical support is available such as childcare. We recommend co-production of care. One example of a successful co-produced service is the co-production of perinatal mental health services in Ealing, Hammersmith, Fulham & Hounslow. Back to Service Manager