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Service Manager Organisational aspects Characteristics of services across care pathway Characteristics of assessment Characteristics of treatment Back to Conceptual Framework

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

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

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 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

INDIVIDUAL Demographic and Mental Health Factors Certain demographic and mental health factors may impact perinatal mental health care. Ethnicity. Previous experiences of mental health services. Age. Symptoms of mental illness​. Previous diagnoses​. Ethnicity A woman’s ethnicity may influence whether she decides to consult and whether she is able to access care. There is some evidence that suggests white women are more likely than Black, Asian and Minority ethnic women to seek help and be offered perinatal mental health care​. ​ "Asian and Black women were less likely to be offered treatment than White women and health care providers were perceived to discriminate against the women on account of their ethnicity". ​ Evidence level: ​ Low ​ ​Parts of the care pathway affected: Decision to consult, Access to treatment​. ​ Key literature: ​ Watson H, et al. 2019 Age Being older may be a facilitator to perinatal mental health care. More research is needed.​ “…older women sought treatment more often, due to maturity and a greater awareness about how to find care”​. ​ ​Evidence level: Very low​ ​ ​Parts of the care pathway affected: Deciding to consult. ​ ​​Key literature: ​ Hansotte E, et al. 2017 Previous experiences of mental health services Previous positive experiences of mental health services can be a facilitator, whereas previous negative experiences can be a barrier​. ​ "That is probably why a lot of black women don’t bother going to the system . . . the majority have had nightmares. So you’re thinking, “What’s the point in going back?”​​".​ ​ ​Evidence level: Moderate​ ​ ​Parts of the care pathway affected: Decision to consult, Assessment, Decision to disclose, Access to treatment, Women’s experience of treatment​. ​ ​Key literature: ​ Watson H, et al. 2019 Symptoms of mental illness​ Current symptoms of mental illness may act as a barrier to perinatal mental health care. ​ "When I was experiencing mental health issues, it was harder for me to get out, sort of on a schedule and be punctual."​ ​ ​Evidence level: Low​ ​ ​Parts of the care pathway affected: Deciding to consult ​ ​Key literature: ​ Sorsa MA, et al. 2021 Previous diagnoses​ Having a previous diagnosis of a mental health difficulty may be a facilitator to perinatal mental health care. ​ "Furthermore, having a history of depression or anxiety and/or treatment for it was found to be associated with service use for PPD…​[postpartum depression]". ​ ​Evidence level: Very low​​ ​ ​Parts of the care pathway affected: Deciding to consult ​ ​Key literature: ​ Bina R. 2020 Recommendations We recommend the government and policy makers provide adequate funding for all mental health services, to ensure employment of the optimal number of staff to meet individual’s needs.​ ​ We recommend high quality training to be provided to all health professionals who come into contact with people who are experiencing mental health difficulties, to ensure a high level of care is provided to all. ​ Back to Individual

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

Commissioners Care pathways Appropriate and timely services Funding Back to Conceptual Framework

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

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

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