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INTERPERSONAL Open and honest communication​ Open and honest communication between women and health professionals. Open and honest communication . A lack of open and honest communication. Open and honest communication ​ Open and honest communication between women and health professionals can be a facilitator to perinatal mental health care​. "And I was so grateful, and then I just talked to her, and it was so nice to be able to talk freely with her [about the EPDS ] at the time.​"​ ​ Evidence level: ​ Moderate ​ ​Parts of the care pathway affected: Deciding to consult, Assessment, Decision to disclose, Women’s experience of treatment​. ​ Key literature: ​ Shakespeare J, et al. 2003 A lack of open and honest communication ​ A lack of open and honest communication between women and health professionals can be a barrier to perinatal mental health care​. ​ "Women reported that they were given incorrect or incomplete information because staff felt that they could not communicate with them, leaving them unsure of the appropriate places and people to talk to…​​".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Deciding to consult, Assessment, Decision to disclose, Women’s experience of treatment​. ​ ​Key literature: ​ Watson H, et al. 2019 Recommendations We recommend health professionals participate in continuing professional development activities related to perinatal mental health including participating in high quality training which focuses on communication skills​. ​ To ensure there are opportunities for health professionals and women to form trusting relationships and therefore encourage open and honest communication, we recommend continuity of carer across the care pathway​. Back to Interpersonal

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

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

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

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

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

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

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

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

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

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

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