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SERVICE MANAGERS Characteristics of services across care pathway​ The way a service is set up and run can impact implementation of, and women’s access to perinatal mental health care. ​ Continuity of carer​. Information provision​. Delivered at home​. Culturally sensitive care​. Delivered in medical setting​. Privacy and confidentiality​. Dedicated perinatal mental health champion​. Technology​. Logistical support. Continuity of carer​ Care that provides the same health professional along the care pathway is a facilitator to care. Lack of continuity of care is a barrier.​ "Every time I went to see the midwife, or…, I always had somebody different, and I don’t want to tell 10 people my story​."​ ​ Evidence level: ​High ​ ​Parts of the care pathway affected: Assessment, Decision to disclose, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Megnin-Viggars O, et al. 2015 Delivered at home​ Care that is delivered at home can be a facilitator to care. ​ "I was more relaxed in my own home."​ ​ Evidence level: ​Moderate ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Decision to disclose, Provision of optimal treatment, Women’s experience of treatment​. ​ Key literature: ​ Myors et al. 2015 Delivered in medical setting​ Some women and health professionals find that care delivered in a medical setting may be a facilitator to care. Other women find it to be a barrier​. ​ "Bangladeshi women living in the UK indicated that they talked freely in the hospital about emotional problems; however, few discussed their difficulties at home apart from practical terms because of censorship by family members"​. ​ "Thirteen of the women found the baby clinic an inappropriate place to complete the EPDS . The lack of time and privacy, the reluctance to make a fuss and the stress of the clinic were cited as reasons. Most women would have preferred to be screened in their own homes. ‘That first Edinburgh test, to have it filled in and then talked about in front of everybody else was just terrible.’ ​" ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected : Assessment, Provision of optimal treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Dennis & Chung-Lee, L 2006 ​Shakespeare, J et al. 2003 Dedicated perinatal mental health champion​ Care that has a dedicated person or perinatal mental health champion may be a facilitator to care. ​ ​ "I’ve felt the Liaison Nurse . . . her being a point of contact . . . made a big difference to my follow-up and action planning around the clients​."​ ​ Evidence level: ​Low ​ ​Parts of the care pathway affected: Assessment, Referral, Access to treatment, Provision of optimal treatment​. ​ Key literature: ​ Willey S, et al. 2018 Information provision​ Care that provides information about services and perinatal mental health can be a facilitator to care. A lack of information provision can be a barrier​. ​ "Some women believed that their physician did not provide sufficient information about pharmacological treatment​".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Decision to consult, Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Dennis, CL & Chung-Lee, L. 2006 Culturally sensitive care​ Culturally sensitive care is a facilitator to care. Care that is not sensitive to women’s cultural needs is a barrier​. ​ "You need someone who’s on the same wavelength as you, who shares the same cultural experiences as you, which sometimes isn’t available."​ ​ ​Evidence level: High​ ​ ​Parts of the care pathway affected: Decision to consult, Contact with health professionals, Assessment, Decision to disclose, Referral, Access to treatment, Provision of optimal treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Button S, et al. 2017 Privacy and confidentiality​ Care that is private and maintains women's confidentiality may be a facilitator to care. Lack of privacy may be a barrier​​. ​ "The interruptions took me longer to really get relaxed."​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Decision to disclose, Access to treatment, Provision of optimal treatment. ​ ​Key literature: ​ Jallo N, et al. 2015 Technology​ Technology that is fit for purpose and that works well is a facilitator to care. Technology that does not work is a barrier​. ​ "We would be quite good in fact in asking [women to complete the EPDS ] and it’s probably because of that little reminder on the screen."​ ​ ​Evidence level: High​ ​ ​Parts of the care pathway affected: Assessment, Referral, Women’s experience of treatment​. ​ ​Key literature: ​ Noonan M, et al. 2018 Logistical support ​ Services that provide logistical support, such as easily accessible locations, childcare, travel costs can be facilitators to care. No logistical support can be a barrier​. ​ "And we were offered a crèche facility; I used to take him there; otherwise it would have been really difficult for me." ​ ​Evidence level: Moderate ​ ​Parts of the care pathway affected: Decision to consult, Access to care, Provision of optimal treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Masood Y, et al. 2015 Recommendations It is important services have easy-to-use technology that is compatible with other technology systems used in other services. We recommend service managers encourage co-production or user experience testing of technology to ensure ease of usability and integration into the workflow. ​ Where compatibility between IT systems is not possible, we recommend the employment of a liaison person who has access to all systems to bridge the gap between different services. ​ Reduction of the changeover of technology when new commissioners join, and encouragement of technology use that is compatible with other systems​. Service managers need to ensure the provision of culturally sensitive care. We recommend service users collaborate with organisations such as The Motherhood Group to ensure care is culturally appropriate The Motherhood Group. ​ Provision of care should ideally be delivered face-to-face, provide logistical support or be carried out in a home setting. If home delivery is not possible, ensure practical support is available such as childcare. We recommend co-production of care. 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

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

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

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.

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

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 ​

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

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

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 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

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