Authors' objectives: Perinatal mental health difficulties can occur during pregnancy or after birth and mental illness is a leading cause of maternal death. It is therefore important to identify the barriers and facilitators to implementing and accessing perinatal mental health care. Our research objective was to develop a conceptual framework of barriers and facilitators to perinatal mental health care (defined as identification, assessment, care and treatment) to inform perinatal mental health services. Perinatal mental health (PMH) difficulties can occur during pregnancy or after birth. They commonly consist of anxiety disorders, depression, post-traumatic stress disorder (PTSD) and stress-related conditions such as adjustment disorder. PMH difficulties are particularly important because of the potential negative impact on women, their partners and children. For example, they are associated with an increased risk of maternal suicide, a decline in relationship satisfaction and long-term impacts on children’s development. It is therefore important that women with PMH difficulties can access care and treatment. However, research suggests only half of women with PMH problems are identified by health services and even fewer receive treatment. This research therefore aimed to identify potential barriers and facilitators to PMH care across the care pathway, both in terms of women accessing care, and in terms of health services implementing new PMH assessment and treatment initiatives. Our primary research objective was to develop a conceptual framework of barriers and facilitators to PMH care (defined as identification, assessment, care and treatment) to inform PMH services, and highlight where further research is needed. This was done through two systematic reviews which synthesised the evidence on: Review 1 (R1) barriers and facilitators to implementing PMH care; and Review 2 (R2) barriers to women accessing PMH care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders (e.g. women, general practitioners, midwives, health visitors, psychiatrists, commissioners, third-sector organisations, etc.). Results were used to inform recommendations for policy, practice and future research in PMH care. Secondary research objectives were to: (1) determine the barriers and facilitators to implementing PMH care in health and social care services; (2) identify differences in barriers and facilitators across different health and social care settings; (3) evaluate the quality of this evidence; (4) extract recommendations for implementation, practice and research based on the barriers and facilitators identified; (5) determine the barriers and facilitators to women accessing PMH care; (6) evaluate the quality of these reviews; and (7) map the geographical distribution of the research to establish generalisability and gaps in the evidence.

Authors' results and conclusions: Review 1 included 46 studies. Most were carried out in higher income countries and evaluated as good quality with low risk of bias. Review 2 included 32 systematic reviews. Most were carried out in higher income countries and evaluated as having low confidence in the results. Barriers and facilitators to perinatal mental health care were identified at seven levels: Individual (e.g. beliefs about mental illness); Health professional (e.g. confidence addressing perinatal mental illness); Interpersonal (e.g. relationship between women and health professionals); Organisational (e.g. continuity of carer); Commissioner (e.g. referral pathways); Political (e.g. women’s economic status); and Societal (e.g. stigma). These factors impacted on perinatal mental health care at different stages of the care pathway. Results from reviews were synthesised to develop two MATRIx conceptual frameworks of the (1) barriers and (2) facilitators to perinatal mental health care. These provide pictorial representations of 66 barriers and 39 facilitators that intersect across the care pathway and at different levels. The MATRIx frameworks highlight the complex interplay of individual and system level factors across different stages of the care pathway that influence women accessing perinatal mental health care and effective implementation of perinatal mental health services. The MATRIx conceptual frameworks on barriers and facilitators highlight the need for women-centred, flexible care, delivered by well-trained, knowledgeable, and empathetic HPs working within an organisational and political structure that enables them to deliver quality care. Results also suggest a need for international efforts to reduce stigma associated with mental health difficulties. Recommendations for practice and policy were made. While recommendations are based on the evidence, they may be more or less achievable, depending on the local and national context and pressures on services. Based on the evidence, it is suggested that policy makers: (1) review the conceptual frameworks and take comprehensive, strategic and evidence-based steps to ensure there is an effective system of PMH care; (2) ensure services are adequately funded and there are enough trained staff in order to ensure every woman with PMH difficulties is able to access appropriate treatment in a timely fashion; and (3) improve access to health care for all through free health care and a fair and easy-to-access welfare system. The evidence suggests that recommendations for healthcare practice include: (1) designing care with women to ensure it meets their needs; (2) providing culturally sensitive care and increasing the accessibility of care through pictorial aids and translators; (3) ensuring chosen technology is fit for purpose, and co-designed with HPs; (4) services working together; (5) employment of enough staff from a variety of health disciplines; and (6) HPs receiving high-quality training, with protected time to complete it.

Authors' recommendations: These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to perinatal mental health care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services; and quality training for health professionals with protected time to do it.

Authors' methods: Two systematic reviews were conducted to synthesise the evidence on: Review 1 barriers and facilitators to implementing perinatal mental health care; and Review 2 barriers to women accessing perinatal mental health care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders. Pre-planned searches were conducted on MEDLINE, EMBASE, PsychInfo and CINAHL. Review 2 also included Scopus and the Cochrane Database of Systematic Reviews. In Review 1, studies were included if they examined barriers or facilitators to implementing perinatal mental health care. In Review 2, systematic reviews were included if they examined barriers and facilitators to women seeking help, accessing help and engaging in perinatal mental health care; and they used systematic search strategies. Only qualitative papers were identified from the searches. Results were analysed using thematic synthesis and themes were mapped on to a theoretically informed multi-level model then grouped to reflect different stages of the care pathway. In Review 1 only 10% of abstracts were double screened and 10% of included papers methodologically appraised by two reviewers. The majority of reviews included in Review 2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Both reviews only included papers published in academic journals and written in English. For both reviews pre-planned searches were carried out in MEDLINE (1946–present), EMBASE (1974–present), PsychInfo (1806–present) and CINAHL (1982–present). R2 also used Scopus and Cochrane Database of Systematic Reviews (Issue 8 of 12, August 2021). MeSH terms (i.e. prenatal care/anxiety/diagnosis) and Boolean operators ‘OR’ and ‘AND’ were used. Eligibility criteria for R1 were empirical studies that examined factors that either facilitated or impeded implementation of PMH care in health or social care services. These could be qualitative interviews with health professionals (HPs) or women about services; or studies describing the implementation of PMH care services. Eligibility criteria for R2 were reviews of literature on barriers and facilitators for women in the perinatal period (defined as conception to one year postpartum) to access assessment, care or treatment. Information on barriers and facilitators had to be directly drawn from perinatal women’s experiences. Only systematic reviews with a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) search strategy were included. Search results were imported into Endnote and duplicates were removed. Remaining studies were then imported into Eppi-Reviewer. In R1 10% of the results were double screened. In R2 all studies were double screened. For both reviews, 10% of included studies had their data extracted in duplicate. Methodological quality appraisal was conducted using the Joanna Briggs Critical Appraisal Tools for R1, and dual appraisal was conducted for 35% of included papers. Most studies (n = 44) had a quality rating above 70% suggesting that studies were well-conducted with low risk of bias. For R2, methodological quality of reviews was appraised using A measurement tool to assess systematic reviews-2 (AMSTAR) tool, and dual appraisal was carried out for all included reviews. The majority of reviews were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Therefore, a qualitative sensitivity analysis was carried out to assess whether themes remained consistent across all reviews regardless of their quality rating. Only qualitative papers were identified. Results were analysed using a thematic synthesis and mapping themes on to a systems level model adapted from Ferlie and Shortell’s Levels of Change framework (e.g. individual level factors, HP factors, organisational factors and larger system factors) (Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Q 2001;79(2):281–315. https://doi.org/10.1111/1468-0009.00206) and then grouped to reflect different stages of the care pathway adapted from Goldberg and Huxley’s Pathways to Care model (e.g. deciding to disclose, assessment, access to care, treatment) (Goldberg D, Huxley P. Common Mental Disorders: A Bio-Social Model. New York, NY: Tavistock/Routledge; 1992.). In R1 only 10% of abstracts were double screened and, given the large number of citations to screen, some papers may have been missed. Similarly, in R1 only 10% of included papers were methodologically appraised by two reviewers. Both reviews only included papers published in academic journals and written in English. Relevant reviews from health services, charities, third-sector organisations and other grey literature may have been missed. Furthermore, the majority of reviews in R2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. However, this was mitigated through the use of a qualitative sensitivity analysis.

Project Status: Completed

URL for project: https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR128068

Year Published: 2024

URL for published report: https://www.journalslibrary.nihr.ac.uk/hsdr/KQFE0107

URL for additional information: English

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: England, United Kingdom

DOI: 10.3310/KQFE0107

Organisation Name: NIHR Health Services and Delivery Research programme

Contact Address: NIHR Journals Library, National Institute for Health and Care Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK

Contact Name: journals.library@nihr.ac.uk

Contact Email: journals.library@nihr.ac.uk