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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.

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 Individual Health Professionals Interpersonal Service Managers Commissioners Policy Makers Society

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

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

Further Resources Infographics Infographic for women​ Recommendations for health professionals Recommendations for service managers Recommendations for commissioners Recommendations for policy makers Animations Animation for women and families Animation for health professionals Animation for service managers Conceptual frameworks MATRIx Facilitators Framework MATRIx Barriers Framework Summary report​ Publications Review 1 publication​ Review 2 publication​ Conceptual frameworks publication NIHR Publication Other Perinatal Mental Health Partnership - Matrix videos Recommendations Twitter (X) References