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  • Immigration Status | MATRIx

    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

  • Stigma | MATRIx

    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

  • Funding | MATRIx

    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 Professional's Knowledge | MATRIx

    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

  • Appropriate and Timely Services | MATRIx

    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 | MATRIx

    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.

  • Beliefs About Mental Illness | MATRIx

    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

  • Conceptual framework | MATRIx

    Conceptual Framework Individual Health Professionals Interpersonal Service Managers Commissioners Policy Makers Society

  • Economic Status and Healthcare Costs | MATRIx

    POLICY MAKERS Economic status and healthcare costs How the cost of healthcare, and women's economic status may impact their perinatal mental health care journey. This can be exacerbated by women’s immigration status. Low income, no health insurance, high care costs. Human rights law​. Low income, no health insurance, high care costs Having a low income, no access to health insurance and the costs of health care can be a barrier "Yeah I know help is at hand.. but look at me! This house- I don't have landline. I have a phone. I have no credit on that phone. Even if I am in trouble, who am I going to call?​" ​ Evidence level: ​Moderate ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Referral, Access to treatment, Provision of optimal treatment​. ​ Key literature: ​ Bina R. 2020 Human rights law​ The UK government, under Article 25 of international human rights law , has a legal obligation to ensure: “Everyone has the right to a standard of living adequate for the health and well-being of [them]self and of [their] family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond [their] control” and to ensure “Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.”​ Recommendations We recommend free healthcare for all at the point of access. ​ We recommend adequate financial support for those who are not eligible for free healthcare, that is easy to apply for​. ​ We recommend the government ensure a fair welfare and economic system that ensures that no one is living in poverty or in financial hardship.​ Back to Policy Makers

  • Policy Makers | MATRIx

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

  • Language Barriers | MATRIx

    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

  • Care Pathways | MATRIx

    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

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