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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

INDIVIDUAL Practical Difficulties Certain practical difficulties act as barriers to women seeking help and accessing perinatal mental health care, as well as the successful implementation and delivery of perinatal mental health care. These include:​ Lack of childcare​ Travel to services​ Timing and flexibility of services Lack of childcare Lack of childcare may act as a barrier to perinatal mental health care​​. ​ "They cannot take their child with them to their session. . .(and) a lot of times they cannot afford day care​​". ​ Evidence level: Low​ ​ ​Parts of the care pathway affected: Access to treatment​. ​ Key literature: ​ Boyd RC, et al. 2011 Location and travel costs The location of services, and the costs of travelling to services may act as a barrier to perinatal mental health care​. ​ "Yes, there was the issue of travelling. I cannot drive and my husband was admitted to the hospital​".​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Access to treatment​. ​ ​Key literature: ​ Masood Y, et al. 2015 Inflexible timing Inflexible timing of appointments may act as a barrier to perinatal mental health care​. ​ "Mothers …expressed concerns about the logistics of attending a group meeting due to already overburdened days…Some depressed mothers refused to seek treatment due to perceived insufficient time (42) and the inconvenience of attending appointments (21)​​".​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Access to treatment​. ​ ​Key literature: ​ Dennis CL & Chung-Lee L. 2006 Recommendations More research is needed into practical barriers to accessing perinatal mental health care using rigorous methodology, before recommendations for policy and practice can be made. Back to Individual

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

SOCIETY Culture Maternal norms of being a "good mother" and a "strong woman”. ​ Maternal Norms. Gender equality​. Maternal Norms Maternal norms are a barrier to perinatal mental health care. ​ "It’s quite a matriarchal society, and therefore you’ve got to cope. You’ve got to sort your family out, and so therefore you are not allowed to be depressed." ​ "I couldn’t tell anybody, because I felt like I’d let everyone down. I wanted to do really well." ​ 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: ​ Button S, et al. 2017 Gender equality​ There may be some potential to change societal beliefs around maternal norms through increasing societal expectations about fathers’ role in the family through more equal parental leave. For example, in countries where parental leave is more equal (e.g. Finland), the uptake of paid paternity leave is higher .​ ​ Changing society’s maternal norms could also be done by increasing women’s equality. Research suggests that stereotypes of what a mother or a woman should look like is beginning to change in countries where women have gained more participation in the labour force and have the right to access contraception and abortion.​ Recommendations The continuation of international policies to promote gender equality. Back to Society

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

Individual Beliefs About Health Services Beliefs About Health Professionals Beliefs About Mental Illness Deciding to Seek Help Fear of Judgement Practical Difficulties Social and Family Life Demographic & Mental Health Factors Back to Conceptual Framework

INDIVIDUAL Fear of Judgement Fear of judgement from others is another barrier to women deciding to seek help or disclosing symptoms, and to implementing and delivering care successfully.​ Fear of being seen as a bad mum. Fear of social services. Fear of being seen as a bad mum The fear of being seen as a bad mum can act as a barrier to perinatal mental health care​. ​ "With my health visitor, I try not to let too much out, because then she won’t think I am a bad mum​​". ​ Evidence level: Moderate​ ​ ​Parts of the care pathway affected : Deciding to consult, Deciding to disclose. ​ Key literature: ​ Button S, et al. 2017 Fear of social services Fear of social services involvement can act as a barrier to perinatal mental health care​. ​ "I didn’t want anyone’s help to be honest after I had [my previous child]. I was so frightened that people would think I couldn’t cope and take her off me​."​ ​ ​Evidence level: High​ ​ ​Parts of the care pathway affected: Deciding to consult, Deciding to disclose. ​ ​Key literature: ​ Megnin-Viggars O, et al. 2015 Recommendations We recommend the development an NHS Mental Health Campaign focused on stigma reduction of perinatal mental illness. ​ ​ We recommend the development of information aimed at increasing awareness of perinatal mental 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 PMI​. How they are common, and when to seek help​. Causes​. How to access professional support. ​ Services available​. Maternity professionals and their role in PMH care​. Myth busters on social services: For example, an analysis of reasons child protection plans were put in place in England in 2019 shows the most common reason was abuse or neglect (54.4%). Parent’s disability or illness only counted for 2.5% of referrals. ​ ​ Back to Individual

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

Society Stigma Culture Maternal norms​ Back to Conceptual Framework

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