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HEALTH PROFESSIONALS Health Professional’s Attributes Characteristics that some health professionals have, may have a positive impact on whether services are implemented and delivered successfully and whether women disclose their difficulties and access care.​ Similar demographic characteristics . Cultural insensitivity . Valued characteristics​ Similar demographic characteristics ​ Health professionals having similar demographic characteristics to women is a facilitator. ​ "Because she understood what we go through, how our culture is, and how our belief systems are. She could understand us better than anyone else.​"​ ​ Evidence level: ​High ​ ​Parts of the care pathway affected: Deciding to consult, Decision to disclose, Provision of optimal treatment, Women’s experience of treatment​ ​ Key literature: ​ Masood Y, et al. 2015 Cultural insensitivity ​ Health professionals lacking in cultural sensitivity can be a barrier.​ ​ "I got answers from professionals like, there is nothing wrong with you, go back home stop disturbing us, basically you are wasting our time, and they were horrible . . .I don’t know if they would have said that if I was white." Pakistani mother​. ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Decision to disclose, Access to treatment, Provision of optimal treatment​. ​ ​Key literature: ​ Watson H, et al. 2019 Valued characteristics​ Health professionals possessing valued characteristics (e.g. being trustworthy, empathetic, kind, caring with a genuine interest) is a facilitator.​ ​ "She doesn’t make little snippy comments about if your house is a mess or something…​She was always there if I have a question or something and she always gets back to me no matter what.​." ​ ​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: ​ Doering JJ, et al. 2017 Recommendations We recommend service managers ensure recruitment of a diverse workforce, and staff positive interest and attitude towards providing high quality care to women. Consider HPs receiving accreditation for providing high quality care, team working, and clear communication​. ​ We recommend service managers implement perinatal mental health good practice guides . This guide provides information on symptoms of perinatal mental illness, communication skills when discussing perinatal mental illness, what to do if a woman discloses perinatal mental illness and case studies of good practice. ​ ​ We recommend health professionals participate in continuing professional development activities related to perinatal mental health including taking part in high quality training. Back to Health Professionals

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

HEALTH PROFESSIONALS Getting it right first time It is important that health professionals take responsibility for each woman they see to help facilitate women’s journey along the care pathway. Dismissing or normalising women’s symptoms​. Focussing only on infant. Not recognising help seeking. Appearing too busy​. Tick box delivery. Dismissing or normalising women’s symptoms​ Health professionals being dismissive or normalising women’s symptoms is a barrier. "I did ask for support, but I didn’t really get any. And the health visitor’s response — ‘Well you seem like you’re doing all right’”. ​ Evidence level: ​ High ​ ​Parts of the care pathway affected: Contact with health professionals, Decision to disclose, Referral, Access to treatment, Women’s experience of treatment​. ​ Key literature: ​ Button S, et al 2017 Not recognising help seeking Health professionals not recognising help seeking or symptoms of perinatal mental illness can be a barrier. "I purposely circled the things ’cos I’m struggling, the health visitor didn’t get back to me, which I’m really disappointed about.” ​ Evidence level: ​ Moderate ​ ​Parts of the care pathway affected: Contact with health professionals, Assessment. Referral. ​ Key literature: ​ Button S, et al 2017 Focussing only on infant ​ Health professionals only focussing on the infant may be a barrier.​ ​ "… somebody [is] not just checking on the baby but actually sitting down with you asking, ‘how are you doing?’ ‘What can I do to help you?’ ​​".​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Contact with health professionals, Decision to disclose, Provision of optimal treatment​. ​ ​Key literature: ​ Megnin-Viggars O, et al. 2015 Appearing too busy​ Appearing to busy can be a barrier, whereas making time to address perinatal mental health symptoms is a facilitator​. ​ "The health visitor said something like: ‘You know, in this community we have to look after a thousand and something babies.’ And that instilled in me the feeling, like: ‘Oh, they are very busy these people, and I don’t have to be bothering them all the time’”. ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Contact with health professionals, Assessment, Decision to disclose, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​ ​ ​Key literature: ​ Button S, et al 2017 Delivery of assessment Behaviours shown by health professionals during assessment can either be a barrier (i.e. carrying out assessment in a tick-box way) or a facilitator (i.e. taking a personalised approach)​. ​ "I sometimes feel that they're [assessment tools] a little bit silly so I usually sort of introduce the questions, ‘we're interested in sort of how they're feeling emotionally or how they feel about the pregnancy …’ and we just go through them. But I try to sometimes re-phrase them a little bit because, depending on who I'm talking to basically, if I'm seeing a 16 year old girl who's scared out of her wits, I've got to be careful how I ask that sort of question because it's important to find out​". ​ ​Evidence level: Moderate ​ ​Parts of the care pathway affected: Assessment, Decision to disclose​. ​ ​Key literature: ​ Williams CJ, et al. 2016 Recommendations We recommend service managers employ an adequate number of workers to ensure health professionals have enough time to address women’s needs​. ​ We recommend service managers implement perinatal mental health good practice guides. This guide provides information on symptoms of perinatal mental illness, communication skills when discussing perinatal mental illness, what to do if a woman discloses perinatal mental illness and case studies of good practice. ​ ​ We recommend health professionals participate in continuing professional development activities related to perinatal mental health including taking part in high quality training​. Back to Health Professionals

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

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

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

Animation Conceptual Framework MATRIx Informing Perinatal Mental Health Services​ Perinatal M ental Health A ssessment and TR eatment: An Evidence Synthesis and Conceptual Framework of Barriers and Facilitators to I mplementation 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 author(s) and not necessarily those of the NIHR or the Department of Health and Social Care

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

SOCIETY Stigma​ Negative attitudes or discrimination against someone based on a distinguishing characteristic such as a mental illness, health condition, or disability. 1 ​ Barrier to perinatal mental health care. Stigma reduction​. Barrier to perinatal mental health care Stigma is a barrier to perinatal mental health care. "Oh well, I think there’s plenty, I mean I think there’s a huge stigma about feeling depressed particularly postnatal depression​."​ ​ 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: ​ Shakespeare J, et al. 2003 Stigma reduction​ Research suggests public mental health campaigns can increase knowledge about mental illness and improve attitudes about people with mental illness. 2 ​ A UK based example was Time to Change: Video Recommendation NHS Mental Health Campaign focused on raising awareness of perinatal mental illness and reducing stigma for perinatal mental illness. Back to Society

Policy Makers Immigration status​ Economic status and healthcare costs​ Back to Conceptual Framework

Commissioners Care pathways Appropriate and timely services Funding Back to Conceptual Framework

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