Search Results

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

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

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

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

References Atif N, Lovell K, Husain N, Sikander S, Patel V, Rahman A. Barefoot therapists: barriers and facilitators to delivering maternal mental health care through peer volunteers in Pakistan: a qualitative study. Int J Ment Health Syst. 2016;10:24. Mar 15. doi:10.1186/s13033-016-0055-9 ​ Atif N, Nazir H, Zafar S, Chaudhri R, Atiq M, Mullany LC, Rowther AA, Malik A, Surkan PJ and Rahman A (2020) Development of a Psychological Intervention to Address Anxiety During Pregnancy in a Low-Income Country. Front. Psychiatry 10:927. doi: 10.3389/fpsyt.2019.00927 ​ Bina R, Barak A, Posmontier B, Glasser S, Cinamon T. Social workers' perceptions of barriers to interpersonal therapy implementation for treating postpartum depression in a primary care setting in Israel. Health Soc Care Community. 2018;26(1):e75-e84. doi:10.1111/hsc.12479 ​ Bina R. Predictors of postpartum depression service use: A theory-informed, integrative systematic review. Women Birth. 2020;33(1):e24-e32. doi:10.1016/j.wombi.2019.01.006 ​ Boyd RC, Mogul M, Newman D, & Coyne JC. Screening and referral for postpartum depression among low-income women: a qualitative perspective from community health workers. Depression Research and Treatment. 2011. ​ Button S, Thornton A, Lee S, Shakespeare J, Ayers S. Seeking help for perinatal psychological distress: a meta-synthesis of women's experiences. Br J Gen Pract. 2017;67(663):e692-e699. doi:10.3399/bjgp17X692549 ​ Byatt N, Biebel K, Debordes-Jackson G, et al. Community mental health provider reluctance to provide pharmacotherapy may be a barrier to addressing perinatal depression: a preliminary study. Psychiatr Q. 2013;84(2):169-174. doi:10.1007/s11126-012-9236-0 ​ Chartier MJ, Attawar D, Volk JS, Cooper M, Quddus F, McCarthy JA. Postpartum Mental Health Promotion: Perspectives from Mothers and Home Visitors. Public Health Nurs. 2015;32(6):671-679. doi:10.1111/phn.12205 ​ Dennis CL, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. Birth. 2006;33(4):323-331. doi:10.1111/j.1523-536X.2006.00130.x ​ Doering JJ, Maletta K, Laszewski A, Wichman CL, Hammel J. Needs and challenges of home visitors conducting perinatal depression screening. Infant Ment Health J. 2017;38(4):523-535. doi:10.1002/imhj.21656 ​ Ganann R, Sword W, Newbold KB, Thabane L, Armour L, Kint B. Provider Perspectives on Facilitators and Barriers to Accessible Service Provision for Immigrant Women With Postpartum Depression: A Qualitative Study. Can J Nurs Res. 2019;51(3):191-201. doi:10.1177/0844562119852868 ​ Hadfield H, Wittkowski A. Women's Experiences of Seeking and Receiving Psychological and Psychosocial Interventions for Postpartum Depression: A Systematic Review and Thematic Synthesis of the Qualitative Literature. J Midwifery Womens Health. 2017;62(6):723-736. doi:10.1111/jmwh.12669 ​ Hadfield, H., Glendenning, S., Bee, P. et al. Psychological Therapy for Postnatal Depression in UK Primary Care Mental Health Services: A Qualitative Investigation Using Framework Analysis. J Child Fam Stud 28, 3519–3532 (2019). https://doi.org/10.1007/s10826-019-01535-0 ​ Hansotte E, Payne SI, Babich SM. Positive postpartum depression screening practices and subsequent mental health treatment for low-income women in Western countries: a systematic literature review. Public Health Rev. 2017;38:3. Published 2017 Jan 31. doi:10.1186/s40985-017-0050-y ​ Jallo N, Salyer J, Ruiz RJ, French E. Perceptions of guided imagery for stress management in pregnant African American women. Arch Psychiatr Nurs. 2015;29(4):249-254. doi:10.1016/j.apnu.2015.04.004 ​ Jones CC, Jomeen J, Hayter M. The impact of peer support in the context of perinatal mental illness: a meta-ethnography. Midwifery. 2014;30(5):491-498. doi:10.1016/j.midw.2013.08.003 ​ Kim JJ, La Porte LM, Adams MG, Gordon TE, Kuendig JM, Silver RK. Obstetric care provider engagement in a perinatal depression screening program. Arch Womens Ment Health. 2009;12(3):167-172. doi:10.1007/s00737-009-0057-6 ​ Lucas G, Olander EK, Ayers S et al. No straight lines – young women’s perceptions of their mental health and wellbeing during and after pregnancy: a systematic review and meta-ethnography. BMC Women's Health 19, 152 (2019). https://doi.org/10.1186/s12905-019-0848-5 ​ Masood Y, Lovell K, Lunat F, et al. Group psychological intervention for postnatal depression: a nested qualitative study with British South Asian women. BMC Womens Health. 2015;15:109. Published 2015 Nov 25. doi:10.1186/s12905-015-0263-5 ​ Megnin-Viggars O, Symington I, Howard LM, Pilling S. Experience of care for mental health problems in the antenatal or postnatal period for women in the UK: a systematic review and meta-synthesis of qualitative research. Arch Womens Ment Health. 2015;18(6):745-759. doi:10.1007/s00737-015-0548-6 ​ Morrell CJ, Sutcliffe P, Booth A, et al. A systematic review, evidence synthesis and meta-analysis of quantitative and qualitative studies evaluating the clinical effectiveness, the cost-effectiveness, safety and acceptability of interventions to prevent postnatal depression. Health Technol Assess. 2016;20(37):1-414. doi:10.3310/hta20370 ​ Myors KA, Johnson M, Cleary M, Schmied V. Engaging women at risk for poor perinatal mental health outcomes: a mixed-methods study. Int J Ment Health Nurs. 2015;24(3):241-252. doi:10.1111/inm.12109 ​ Nithianandan, N., Gibson-Helm, M., McBride, J. et al. Factors affecting implementation of perinatal mental health screening in women of refugee background. Implementation Sci 11, 150 (2016). https://doi.org/10.1186/s13012-016-0515-2 ​ Noonan, M., Doody, O., O’Regan, A. et al. Irish general practitioners' view of perinatal mental health in general practice: a qualitative study. BMC Fam Pract 19, 196 (2018). https://doi.org/10.1186/s12875-018-0884-5 ​ Pugh NE, Hadjistavropoulos HD, Hampton AJD, Bowen A, Williams J. Client experiences of guided internet cognitive behavior therapy for postpartum depression: a qualitative study. Arch Womens Ment Health. 2015;18(2):209-219. doi:10.1007/s00737-014-0449-0 ​ Rowan C, McCourt C, & Bick D. (2010). Provision of perinatal mental health services in two English strategic health authorities: views and perspectives of the multi-professional team. Evidence Based Midwifery, 8(3), 98-106. ​ Smith, M. S., Lawrence, V., Sadler, E., & Easter, A. (2019). Barriers to accessing mental health services for women with perinatal mental illness: systematic review and meta-synthesis of qualitative studies in the UK. BMJ open, 9(1), e024803. ​ Schmied V, Black E, Naidoo N, Dahlen HG, Liamputtong P (2017) Migrant women’s experiences, meanings and ways of dealing with postnatal depression: A meta-ethnographic study. PLoS ONE 12(3): e0172385. https://doi.org/10.1371/journal.pone.0172385 ​ Shakespeare J, Blake F, & Garcia J. A qualitative study of the acceptability of routine screening of postnatal women using the Edinburgh Postnatal Depression Scale. British Journal of General Practice. 2003; 53(493), 614-619. ​ Sorsa MA, Kylmä J, Bondas TE. Contemplating Help-Seeking in Perinatal Psychological Distress-A Meta-Ethnography. Int J Environ Res Public Health. 2021;18(10):5226. doi:10.3390/ijerph18105226 ​ Staneva AA, Bogossian F, & Wittkowski A. The experience of psychological distress, depression, and anxiety during pregnancy: A meta-synthesis of qualitative research. Midwifery. 2015; 31(6), 563-573. ​ Watson H, Harrop D, Walton E, Young A, Soltani H. A systematic review of ethnic minority women's experiences of perinatal mental health conditions and services in Europe. PLoS One. 2019;14(1):e0210587. Published 2019 Jan 29. doi:10.1371/journal.pone.0210587 ​ Willey S, Gibson-Helm M, Finch T, East C, Khan N, Boyd L, & Boyle J. Implementing innovative evidence-based perinatal mental health screening for refugee women. Women and Birth. 2018; 31, S8. ​ Williams CJ, Turner KM, Burns A, Evans J, Bennert K. Midwives and women's views on using UK recommended depression case finding questions in antenatal care. Midwifery. 2016;35:39-46. doi:10.1016/j.midw.2016.01.015 ​ Young CA, Burnett H, Ballinger A, et al. Embedded Maternal Mental Health Care in a Pediatric Primary Care Clinic: A Qualitative Exploration of Mothers' Experiences. Acad Pediatr. 2019;19(8):934-941. doi:10.1016/j.acap.2019.08.004 ​

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

POLICY MAKERS Immigration Status Whether women were born in the country they are currently living in and how this may impact their perinatal mental health care journey​. Not being born in the country currently living in. NHS Charging regulations​. Not being born in the country currently living in Not being born in the country women are currently living in. "…as Hispanics we do not have insurance and money is what really counts."​ ​ "Because when you’re legal you can take the child to the daycare and look for a job. . . If you don’t work, it’s like you’re dead, being alive. We want our papers so we can progress; not so we can leave or be a load to anyone, but just to work—to buy a home and give our kids a good life. . . I get depressed because I can’t live like normal people because I’m always thinking if I leave or if I stay. . . ​"​ ​ Evidence level: ​High ​ ​Parts of the care pathway affected : Decision to consult, Assessment, Referral, Access to treatment, Provision of optimal treatment​. ​ Key literature: ​ Hansotte E, et al. 2017 ​Schmied V, et al. 2017 NHS Charging regulations​ Despite the NHS being free for UK residents, there are NHS charging regulations in place for those who are not residents of the United Kingdom. ​ NHS charging regulations have a large negative impact on pregnant and postnatal women, in terms of their mental health - increasing stress and anxiety, their vulnerability to domestic violence and maternal deaths that may have been prevented through access to antenatal care. ​ Furthermore, Public Health England has identified NHS charging for maternity care as one of the key issues that exacerbates poorer health outcomes for women and babies of colour.​ Recommendations We recommend support for refugee or immigrant women to be able to access care without being penalised (e.g., through deportation, through charging systems).​ ​ We recommend the suspension of NHS charging regulations until a full independent review of their impact on individual and public health, simplification of charging criteria and exemptions and safeguards to protect vulnerable patients and ensure they are not denied the care they are entitled to, is carried out​. This recommendation is in line with: (a) a joint statement set out by the Royal College of Physicians, the Royal College of Paediatrics and Child Health, the Royal College of Obstetricians and Gynaecologists and the Faculty of Public Health in 2018, calling for a suspension of NHS Charging; (b) a statement from the Academy of Medical Royal Colleges in 2019 released a statement calling for the suspension of the NHS charging regulations until a full independent review on individual and public health is carried out; (c) a statement from the Royal College of Paediatrics and Child Health calling for an end to NHS charging due to its adverse effects on child health and wider public health; (d) a report from Maternity Action calling for the immediate suspension of charging for NHS maternity care given the deterrent effect on women’s access to maternity care. ​ Back to Policy Makers

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

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

HEALTH PROFESSIONALS Health professionals' knowledge​ Health professionals' knowledge about perinatal mental health symptoms and referral pathways can influence implementation and delivery of care, as well as whether women disclose their symptoms and access care. ​ Knowledge about perinatal mental illness​. Confidence of health professionals ​. Knowledge about referral pathways ​. Knowledge about perinatal mental illness​ Health professionals having good knowledge about perinatal mental health symptoms can be a facilitator to care, whereas a lack of knowledge can be a barrier. "’Oh I was seeing so and so but when they found out I was pregnant they discontinued my medication.’” That…happens frequently. Very frequently…their provider won’t [prescribe] because of their pregnancy."​ ​ Evidence level: ​ Moderate ​ ​Parts of the care pathway affected: Contact with health professionals, Assessment, Access to treatment​. ​ Key literature: ​ Byatt N, et al. 2013 Confidence of health professionals ​ Related to knowledge, a health professional with high levels of confidence in addressing perinatal mental health can be a facilitator. Low confidence can be a barrier.​ ​ "Look, I feel insecure at the moment, as I have not yet had the chance to try [this therapy with a client], and I have to practice…​".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Assessment, Referral, Provision of optimal treatment​. ​ ​Key literature: ​ Bina R, et al. 2018 Knowledge about referral pathways ​ Health professionals having good knowledge about services and referral pathways can be a facilitator to care, but lack of knowledge can be a barrier​​. ​ "The health professionals interviewed in both Trusts were not always aware of the services available in other areas of the health service and recommended the provision and circulation of named links to support more joined up working​​". ​ ​Evidence level: High ​ ​Parts of the care pathway affected: Assessment, Referral, Access to treatment​. ​ ​Key literature: ​ Rowan C, et al. 2010 Recommendations We recommend health professionals participate in continuing professional development activities related to perinatal mental health including participating in high quality training [LINK TO TRAINING RECOMMENDATION]​. ​ Service managers and policy makers could consider health professionals receiving accreditation for participating in training. Back to Health Professionals

COMMISSIONERS Appropriate and timely services There needs to be an adequate amount of services that women can be referred on to. These services need to meet women’s needs and be offered in a timely manner. A lack of appropriate and timely services. Guidance for providing services. A lack of appropriate and timely services A lack of appropriate and timely services is a barrier​ to care​. ​ "I could see that [the EPDS score] was high and you make your referrals, and it was months out before she could go . . . she had to almost take her life to get seen right away. And that’s terrible that it has to come to that. I think that’s the biggest struggle.​"​ ​ Evidence level: ​High ​ ​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 Guidance for providing services According to Moreton et al. 2021 to provide services that meet the needs of the population, commissioners must:​ Have a good knowledge of population and the healthcare need in question. Therefore, training on perinatal mental health should be mandatory for at least one commissioner in each Primary Care Network, Integrated Care System or Health Board (see recommended training [add link])​ Engage with people with lived experience - services should be co-produced with those who have lived experience Have access to high quality evidence e.g. the development of perinatal mental health information guide : ​ Symptoms of PNMI​ Impact on women and their families​ Barriers to women getting care they need and how to overcome these​ Effective care and treatment​ Examples of good practice​ Recommendations Provision of adequate financial resources to ensure service managers can: ​ Recruit a multi-disciplinary team with enough staff to meet service users’ needs​. Provide high-quality, time protected staff training to all staff​. Provide continuity of carer​. Provide resources that break down language barriers such as translators or Language Line​. Provide an adequate number of appropriate services that women can be referred to in a timely manner​. Provide individualised, woman-centred care. Back to Commissioners

Recommendations Recommendations for policy​ Many elements of the conceptual frameworks can be modified by policy makers and government activity (e.g. workforce provision, healthcare capacity, training etc). Therefore, we recommend policy makers review the frameworks and take comprehensive, strategic and evidence-based efforts to ensure there is an effective system of PMH care. ​ ​ Funding is required to ensure high quality care provision. Therefore, the provision of a comprehensively researched and adequate budget is needed so that all healthcare needs for that financial year can be met. Funding needs to be adequate for service needs and easily accessible. Funding structures may need to be revised depending on the needs of the community in which the service is delivered (e.g. affordable health insurance where free healthcare is not available). ​ ​ The reduction of health inequalities is needed. It is therefore advisable that policy is put in place: (i) improve equality between the sexes/genders by ensuring equal rights for women and men; (ii) in terms of ethnicity, for example changes at the legislative level are needed to protect those who have migrated to a different country from being penalised for accessing healthcare; and (iii) in terms of income, a fair and easily accessible welfare system is needed to prevent health inequalities based on deprivation.​ ​ To see this as in infographic click here Recommendations for practice (service managers) In terms of care, it is recommended that care is co-produced with women and is personalised and culturally appropriate. Increasing the flexibility and accessibility of services should be done through offering home visits and, where this is not possible, providing out-of-hours appointments located in an area with good transport links and an accessible building to allow for pushchairs. In addition, service managers could consider the provision of virtual consultations using web-based platforms, but women should be given the choice about whether virtual consultations are right for them.​ ​ Culturally sensitive care and increased accessibility of care is required for women who are unable to, or have difficulty speaking the country’s official language. This can be done via pictorial aids, the purchase of products such as Language Line, or through collaboration with translation agencies.​ ​ Technology can be a facilitator to PMH services in terms of assessment, referral and intervention. Thus, technology systems should be co-produced with HPs and women to ensure ease of usability and integration into the workflow.​ ​ Where not already implemented, multi-disciplinary teams should be created which facilitates choice and personalised care and ensures an adequate workforce to meet women’s needs. We need to break down silo working and encourage collaborative and joint working within and across services. Collaboration between services is needed with a focus on the identification and building of working relationships and networks with other services (e.g., Citizens Advice Bureau). Furthermore, the building of a coalition of health visitors, midwives, general practitioners, Improving Access to Psychological Therapies practitioners, psychologists and psychiatrists is needed to encourage referral and reduce the risk of women falling out of the care pathway.​ ​ HPs should be provided with high quality training that is delivered face-to-face and incorporates role play simulators where appropriate. This should include training in cultural sensitivity and cross-cultural mental health. Training time for HPs should be built into workloads and be protected.​ ​ To see this as in infographic click here​ Recommendations for practice (health professionals)​ A facilitator to perinatal mental health care was health professionals having good knowledge about perinatal mental health, services and referral pathways. Therefore, health professionals should participate in continuing professional development activities related to perinatal mental health including participating in high quality training. When in contact with women, health professional should listen to women’s concerns and take them seriously. Take the time to address their concerns and take responsibility of that woman to ensure she is referred to appropriate services. 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.​ ​ To see this as in infographic click here Recommendations for women and families We have also designed recommendations for women and families – navigating the system, click here for this infographic.