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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

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