Perinatal Mental Health Assessment and TReatment: An Evidence Synthesis and Conceptual Framework of Barriers and Facilitators to Implementation (MATRIx)

Perinatal Mental Health Assessment and TReatment: An Evidence Synthesis and Conceptual Framework of Barriers and Facilitators to Implementation (MATRIx) Background: Perinatal mental health (PMH) 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 PMH care. Objectives: Our 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. Methods: Two systematic reviews were conducted to synthesise 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. Data sources: Pre-planned searches were conducted on Medline; Embase; PsychInfo; and CINAHL. R2 also included Scopus and the Cochrane Database of Systematic Reviews. Review methods: In R1, studies were included if they examined barriers or facilitators to implementing PMH care. In R2, systematic reviews were included if they examined barriers and facilitators to women seeking help, accessing help and engaging in PMH 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 onto a theoretically-informed multi-level model then grouped to reflect different stages of the care pathway. Results: R1 included 46 studies. Most were carried out in higher income countries (HICs) and evaluated as good quality with low risk of bias. R2 included 32 systematic reviews. Most were carried out in HICs and evaluated as having low confidence in the results. Barriers and facilitators to PMH 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 PMH 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 PMH care. These provide pictorial representations of 39 facilitators and 66 barriers that intersect across the care pathway at different levels. Limitations: In R1 10% of abstracts were double screened and 10% of included papers methodologically appraised. R2 only included reviews published in academic journals and written in English. Conclusions: The MATRIx frameworks highlight the complex interplay of individual and system level factors across different stages of the care pathway that influence women accessing PMH care and effective implementation of PMH services. Recommendations are made for health policy and practice. These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to PMH 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. Future work: Further research is needed examining access to PMH care for specific groups, such as fathers, immigrants or those in lower income countries