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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.

Animation for women Animation for health professionals Animation for service managers Conceptual Framework Resources MATRIx 2 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) and NIHR ARC North Thames. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care

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 a culturally sensitive care pathway to overcome barriers. Aims To use an evidence-based co-design approach to co-create a culturally tailored care pathway 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 will form two lived experience groups: one with women and the other with HPs and service managers at Homerton hospital or East London Foundation Trust. We will recruit from a range of sources using multiple recruitment strategies Methods We will carry out qualitative research with women and health professionals to determine which barriers identified by the MATRIx 1 study are most relevant to the service managers and women. The women and health professionals from the lived experience groups will take part. We will analyse data using thematic analysis. ​ With the lived-experience groups we will co-produce an updated perinatal mental health care pathway focusing on more culturally sensitive care, including reducing the barriers identified by the MATRIx project and results from Phase 2. ​ 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 assessment Certain aspects of assessment/screening can impact implementation of assessment, as well as whether women find assessment acceptable.​ Wording of assessment tools. Acceptability of assessment ​ Wording of assessment tools The wording of some screening tools can be a barrier to implementation ​ "I have some moms [who] ask questions about it, like, ‘What does it mean where things are getting on top of me? What do you mean?’ You know, so they, they don’t always understand the questions" (Home visitor, about the EPDS )​​. ​ Evidence level: ​Moderate ​ ​Parts of the care pathway affected : Assessment​. ​ Key literature: ​ Doering JJ, et al. 2017 Acceptability of assessment ​ Women and health professionals finding assessment acceptable can be a facilitator to implementation. Poor acceptability of assessment is a barrier.​ ​ "I remember being frustrated and ticking at the end, fine, fine, fine, or whatever it was, good, good, good, no I’m not depressed. I mean they are not going to give a job to my husband".​ ​ "I thought it [screening] was a good idea from the beginning . . . It doesn’t take a lot of time. I think sometimes it can be challenging just to get people to complete it". ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Assessment. ​ ​Key literature: ​ Segre LS, et al. 2014 ​Shakespeare J, et al. 2003 Recommendations Use easy to understand assessment tools. Collaborate with organisations such as The Motherhood Group to ensure cultural appropriateness. ​ Design or update assessment tools that use pictures alongside words for use with women whose English speaking and understanding is limited, e.g. “How are you feeling?” screening tools by Abi Sobowale (Sheffield South West NHS Trust). ​ ​ 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. ​ ​ Service managers should ensure health professionals have enough time to do this by creating an adequate workforce​. Back to Service Manager

Service Manager Organisational aspects Characteristics of services across care pathway Characteristics of assessment Characteristics of treatment Back to Conceptual Framework

INDIVIDUAL Deciding to seek help There are two steps to women deciding to seek help. These are recognising that something is wrong and having the knowledge and understanding to know where to go to seek help.​ Supported to recognise something was wrong. Not knowing what services are available. ​ Supported to recognise something was wrong When women are supported to recognise something was wrong, this acts as a facilitator to women perinatal mental health care. ​ ​ "That’s when I thought, you know: “Something is really wrong here, I need to go to the doctors if I’m thinking about killing myself.”​" ​ Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Deciding to consult. ​ Key literature: ​ Button S, et al. 2017 Not knowing what services are available Women not knowing what services are available and where to go to seek help may be a barrier to perinatal mental health care. ​ ". . .you don’t know where to go, what to do, who to trust…". ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult. ​ ​Key literature: ​ Megnin-Viggars O, et al. 2015 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​. The 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

SOCIETY Culture Culture is a complex factor that refers to a “group’s thoughts, experiences, and patterns of behaviour and its concepts, values and assumptions about life that guide behaviour” 1. Culture varies both across countries and within countries, as it can be affected by factors such as race, religion, gender etc.​ Culture different to Western view. Culturally sensitive care​. Culture different to Western view Cultural belief systems that differ to the Western view of mental illness are a barrier to perinatal mental health care. "Because depression, like if you see the symptoms of depression, it’s a mental illness. The minute you say mental illness in my country, you are crazy​."​ ​ 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: ​ Schmied V, et al. 2017 Culturally sensitive care​ Mental illnesses are not spread evenly around the world. Culture influences what we see as a mental illness. For example, ​ Amok – mostly experienced by Indonesian men after a social insult, characterised by brooding and then rage.​ Zar – Experienced by those living in the Middle East. Is related to spirit possession, characterised by laughing, crying, shouting and singing. ​ Post-traumatic stress disorder – a western mental illness occurring after a trauma. Characterised by flashbacks to the event, and avoidance of things that remind people of the event. ​ ​ Culturally sensitive care can be defined as “the ability to be appropriately responsive to the attitudes, feelings, or circumstances of groups of people that share a common and distinctive racial, national, religious, linguistic, or cultural heritage” 2. It is care that offers services in a manner that is relevant to patients’ needs and expectations​ 3. Recommendations Provide culturally sensitive care​. ​ Collaborate with organisations such as The Motherhood Group to ensure cultural appropriateness.​ ​ Co-design care with a diverse range of people to ensure appropriateness and sensitivity. Back to Society

INDIVIDUAL Demographic and Mental Health Factors Certain demographic and mental health factors may impact perinatal mental health care. Ethnicity. Previous experiences of mental health services. Age. Symptoms of mental illness​. Previous diagnoses​. Ethnicity A woman’s ethnicity may influence whether she decides to consult and whether she is able to access care. There is some evidence that suggests white women are more likely than Black, Asian and Minority ethnic women to seek help and be offered perinatal mental health care​. ​ "Asian and Black women were less likely to be offered treatment than White women and health care providers were perceived to discriminate against the women on account of their ethnicity". ​ Evidence level: ​ Low ​ ​Parts of the care pathway affected: Decision to consult, Access to treatment​. ​ Key literature: ​ Watson H, et al. 2019 Age Being older may be a facilitator to perinatal mental health care. More research is needed.​ “…older women sought treatment more often, due to maturity and a greater awareness about how to find care”​. ​ ​Evidence level: Very low​ ​ ​Parts of the care pathway affected: Deciding to consult. ​ ​​Key literature: ​ Hansotte E, et al. 2017 Previous experiences of mental health services Previous positive experiences of mental health services can be a facilitator, whereas previous negative experiences can be a barrier​. ​ "That is probably why a lot of black women don’t bother going to the system . . . the majority have had nightmares. So you’re thinking, “What’s the point in going back?”​​".​ ​ ​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: ​ Watson H, et al. 2019 Symptoms of mental illness​ Current symptoms of mental illness may act as a barrier to perinatal mental health care. ​ "When I was experiencing mental health issues, it was harder for me to get out, sort of on a schedule and be punctual."​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult ​ ​Key literature: ​ Sorsa MA, et al. 2021 Previous diagnoses​ Having a previous diagnosis of a mental health difficulty may be a facilitator to perinatal mental health care. ​ "Furthermore, having a history of depression or anxiety and/or treatment for it was found to be associated with service use for PPD…​[postpartum depression]". ​ ​Evidence level: Very low​​ ​ ​Parts of the care pathway affected: Deciding to consult ​ ​Key literature: ​ Bina R. 2020 Recommendations We recommend the government and policy makers provide adequate funding for all mental health services, to ensure employment of the optimal number of staff to meet individual’s needs.​ ​ We recommend high quality training to be provided to all health professionals who come into contact with people who are experiencing mental health difficulties, to ensure a high level of care is provided to all. ​ Back to Individual

INTERPERSONAL Shared decision making Shared decision making between healthcare professionals and women.​ Shared decision making. Resources. Shared decision making Shared decision making between women and health professionals may be a facilitator to perinatal mental health care. "Women with postpartum psychosis discussed the need for greater consultation and negotiation in antipsychotic prescription…​ … it would have been good I think to have been listened to about the side effects…It’s just they’re managing your risk.., maybe that’s what they’ve got to do clinically, but I wanted a bit more of a human face of it really."​ ​ Evidence level: ​Low ​ ​Parts of the care pathway affected: Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Megnin-Viggars O, et al. 2015 Resources NHS England provides guidance on shared decision making.​ Recommendations We recommend health professionals participate in continuing professional development activities related to perinatal mental health including participating in high quality training. ​ To ensure there are opportunities for health professionals and women to form trusting relationships, we recommend continuity of carer across the care pathway​. Back to Interpersonal

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 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