Realist evaluation of community perinatal mental health teams

Parts of this chapter are reproduced with permission from Fisher et al.62 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) licence, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/. The text includes minor additions and formatting changes to the original text.

Introduction

The perinatal period is a critical time for maternal and infant mental health and the long-term well-being of family members.1 While women see many health providers through pregnancy and after birth (including midwives, health visitors, GPs), until 2015 there was a lack of integrated care across the care pathway that effectively identified and treated women with more severe and complex PMH needs and the mother–infant dyad. The 5 Year Forward plan included a £365M investment to transform PMH and provide CPMHTs equitably across England.17,22,23 In the Long Term Plan (LTP) there was further investment in CPMHTs that included increasing the numbers of women seen and offering a wider skill set in teams, with particular focus on strengthening psychological treatment and parent–infant offers and providing partners with assessment and signposting. With these changes, there were key questions about whether CPMHTs effectively improved access, particularly to women most in need of support, what factors promoted their successful engagement and ongoing adherence with mental health treatment, and if the increase in staff skill mix and treatment offers effectively improved maternal and infant outcomes.

In the midst of the PMH transformation, the COVID-19 pandemic occurred. The first lockdown coincided with the week we were due to begin recruitment in WP3, and we moved to recruit and interview online only. Research findings from the pandemic have demonstrated that it had a number of impacts on perinatal women and infants, including in England there were significant changes in maternity appointments, in that they moved primarily to remote only and were sometimes reduced in number. In the beginning of the pandemic, women laboured alone, as family were not permitted to accompany them for fear of COVID contagion. Late in the pandemic, one family member might join for the delivery, but had to leave immediately thereafter. These changes were associated with increases in reports of perceived traumatic childbirths.63 Following childbirth, women reported a decrease in access to regular universal provision, including fewer health contacts for mother or baby, and a lack of ability to attend parent and baby groups, affecting socialisation.64 These changes resulted in increases in parental perceived isolation and loneliness. New families were also isolated from their wider family supports, with mixed consequences. This benefitted some families, particularly when there was conflict with extended families.65 Other families suffered from lack of support.66 There were also reports of increases in domestic violence to women.67 Overall, the prevalence of maternal mental health worsened during the pandemic,68–70 with CPMHTs reporting that women often were referred to them later in pregnancy and had more severe symptoms and complex needs when they reached the CPMHT.

Therefore, to better understand which factors ensure CPMHT successfully deliver care, the following questions were considered in this chapter:

1. What service models are effective for mothers with PMH problems and their babies? Does this vary by mental health need, who delivers the intervention, the skill mix and competencies of the service and the settings in which the services are provided?
2. Which interventions are attractive and acceptable to women, and clinically effective within/in conjunction with mainstream secondary mental health care, maternity and primary care?

Because of the timing in which we recruited and in which women had received services allowed us to examine service provision before, during and after COVID lockdowns, we were able to include the impact of COVID-related changes on service provision, their integration with other health providers, and manner of delivery on women and infant’s outcomes. We received extension funding for this project to answer additional questions specific to the impact of COVID on services, and to examine barriers and facilitators to care in women from ethnically diverse background who have PMH problems but do not access statutory mental health services. The additional questions were:

1. What has been the impact of COVID-19 on how women experience service delivery and their overall well-being?
2. What factors make PMH services resilient to public health emergencies?
3. What barriers and facilitators do women with diverse background encounter regarding access to CPMHS?

Methods

We sampled from 10 CPMHTs across England. CPMHTs were purposefully selected for variations in different components and configurations including: level of mother–infant and/or psychological interventions, collaborative care (e.g. integrated with universal and adjunctive services), quality of integration (e.g. communication, mental health colocated with maternity care), delivering perinatally tailored care, including care co-ordination versus coworking with generic mental health teams, and meeting women’s needs (flexible, remote/in home, family-centred). Three services were in the SouthWest, four were in the London/SouthEast and three were in the Midlands/NorthWest.5 The study received ethical approval by the Southwest – Central Bristol Research Ethics Committee (Reference: 19/SW/0218). The study was also registered on Research Registry (ID number 5463).

Recruitment took place between April 2020 and June 2021 and included those who experienced CPMHT care prior to and during the COVID 19 pandemic. Recruitment methods for participants are outlined below:

• Mothers: Recruited via a purposive sampling approach (with maximum variation in characteristics) that identified women with different types of mental health problems, that is serious mental illness (SMI) (psychosis, schizoaffective disorder, bipolar I), personality disorder, trauma/PTSD, depression and anxiety. A member of the direct care team approached potential participants via phone or e-mail and gave a brief overview of the study and an opt-out option. Participants were interviewed towards the end of their treatment or up to 2 years after they had completed their treatment, to avoid Hawthorne effects.
• Significant sources of support: Women were asked during their interview to identify their significant sources of support and for permission to contact them. Once contact details were obtained, the research team contacted significant sources of support to inform and consent them into the study.
• Staff: The perinatal service champion, identified at the start of the study, was asked to disseminate study information sheets to key members of staff within each professional group. Staff either came forward to be interviewed or were contacted by the research team to take part in the study. Staff members included: PMH nurses, nursery nurses, psychologists, psychiatrists, pharmacists, occupational therapists, team leaders, managers and administrative staff.

Data collection

Semistructured interviews lasting approximately 60–90 minutes, and consistent with COVID-19 related changes, were conducted via telephone or videoconference only (no in-person interviews). Interviews followed a guide that followed domains from the programme theory and was developed in collaboration with clinicians, policy-makers and persons with lived experience. Interview topics included:

• Mothers: Experiences of care including their mental health history; access to service; which service components made a difference to their access, engagement and adherence with treatment; and the impact (if any) on their mental health/well-being, functioning and their relationship with their family, including their infant.
• Significant sources of support: Perceptions of care received; the impact (if any) on the mother’s mental health/well-being and functioning; how the care received affected the mother’s relationships with their partner/family, including their infant.
• Staff: How services operate; which service components improve outcomes for mothers and babies; and which populations/presenting problems these services work for.

Data analysis

We followed RAMESES reporting guidelines.71 Interviews were audio-recorded, transcribed verbatim and analysed using NVivo 12 software (QSR International, Warrington, UK). Analysis followed a realist logic of analysis with the goal of using the collected data to develop and refine the initial programme theory into a more refined realist programme theory. Data coding was deductive (informed by our initial programme theory; see Figure 1), inductive (from the data within transcripts) and retroductive (where inferences were made based on interpretations of the data within sources about underlying causal processes, i.e. mechanisms). Data to inform our interpretation of the relationships between contexts, mechanisms and outcomes were sought across interviews (e.g. mechanisms inferred from one interview could help explain the way contexts influenced outcomes in a different interview). Synthesising data from different interviews was often necessary to compile context–mechanism–outcome configurations (CMOCs), since not all parts of the configurations were always articulated in a single interview. During data collection and analysis, we moved iteratively between the analysis of particular examples, refinement of programme theory and further data collection to test particular theories. Mechanisms and refinement of programme theory were discussed iteratively with service users and stakeholders.

Results

Across 10 different CPMHTs, we interviewed 139 women who were nearing the end of their care with the CPMHT or had finished their care within the past 2 years. We also spoke to 55 significant sources of support and 80 health and social care practitioners (Table 8).

Most women described their experiences of CPMHTs as positive and helpful to their and their baby’s well-being. This was particularly pronounced in women who had previous negative experiences of other mental health services.

Question 1: What service models are effective for mothers with perinatal mental health problems and their babies? Does this vary by mental health need, who delivers the intervention, the skill mix and competencies of the service and the settings in which the services are provided?

Effective CPMHT service models had the following components:

• integrated, co-ordinated care between CPMHTs and health providers (e.g. maternity, GPs, health visiting)
• flexible, de-stigmatising, needs-based delivery approaches
• a family-centred, approach that is engaging and acceptable to women and their families.

Integrated, co-ordinated care

Community perinatal mental health team integration with relevant health providers varied across sites. When CPMHTs had higher levels of integration with health and mental health providers, women reported greater ease of access to the CPMHT, higher perceived quality of care, better outcomes and more acceptable discharge procedures.

Good levels of CPMHT integration with other health/mental health services were evidenced when the following were in place (see Box 1 for supporting quotes):

• clear referral and discharge pathways into and from CPMHTs
• joint, co-operative models of roles and responsibilities
• ongoing sharing of knowledge and working (i.e. multidisciplinary meetings, trainings, joint clinics/meetings, colocation of PMH staff within health settings).

Previously, the perception among the referrers was – anybody pregnant and having a mental health issue should be referred to the perinatal team, it [didn’t] matter whether, you know, they have the severe end of mental illness or mild or moderate. It took a lot of work to tailor down and us receiving appropriate referrals to make the best use of the service. So, working with the midwives and GPs has been really helpful to ensure we get the right referrals.

So, we work really closely with [midwives] … and really close with the safeguarding teams, the recovery teams, and the intensive team. We don’t really have the professional team working issues that other patches have, [Service name] seems to gel quite well.

They come along to the team meetings, the specialist midwives, so that they can flag up anyone in the day that they’ve got any concerns with or who are on their caseload and to make sure that we’re both talking to each other. Specialist midwives will be invited to birth planning, or the midwives anyway, get invited to their mental health birth planning sessions. And I’ve done a few of them, depending how – if I’ve been involved a lot antenatally, I’ll be part of that as well.

I’ve been quite poorly, and I’ve been in and out of hospital, and [the health visitor] gets notified of that each time and each time she texts me and says are you okay? What happened? Do you need me? So, yeah … [CPMHT and health visitor] obviously, they liaise between themselves, which meant I didn’t need to explain myself over again. They knew what was going on with me.

Barriers to integrated care included (see Box 2 for supporting evidence):

• local underinvestment in CPMHT and related health and mental health services (e.g. 0–5 mental health, health visiting)
• high levels of staff turnover and therefore loss of shared knowledge and working relationships (e.g. CPMHT, maternity, health visiting)
• structural/organisational factors leading to misconceptions about the roles of CPMHTs and referral cut-offs.

I think we do need more different kinds of staff … [we have] no infant mental health workers … I think that’s a gap in our service.

There have been huge [staff] turnovers, and I think it’s a very stressful job. It can be quite triggering to people, and people aren’t always aware of what perinatal is before they come in. They think sort of mums and babies and, sort of, how lovely, you know, it will be lovely working with that, but actually, it can be pretty high-end stuff … it can be quite triggering … [the work] can be quite hard.

Flexible, de-stigmatising, needs-based delivery approaches

Flexible delivery approaches that adapted to maternal and family needs and risk levels were highly valued by women and promoted service engagement. Delivery modalities ranged from in-person (clinic, maternity, hospital, children’s centre) and in-home appointments, to remote videoconferencing (particularly during the COVID pandemic). Women’s preferences for how treatments were delivered varied, both between individuals and by the contexts/situations/stigma they were in at the time (Box 3). Factors determining preferences included:

In person/clinic: preferred when:

• women wanted a private, neutral, safe location
• women wanted to be able to speak freely about difficult content (trauma work, domestic violence, family conflict) outside of home context or away from family.

In home: preferred when:

• there were difficulties with infant schedules
• multiple children and/or transportation issues (or videoconferencing)
• woman needed practical/functional support with activities of daily living (including parenting support).

Remote/videoconferencing: preferred when:

• woman was socially anxious
• woman had worries about stigma and wanted to uphold their privacy from the public eye
• woman wanted ease of access and convenience, particularly in remote areas and areas with difficult and/or expensive transportation
• home felt like safe place for woman in which to discuss difficult topics.

I was in a really low place then, I was at my worst was when I wasn’t able to talk, my mind was just so jumbled, I couldn’t form sentences or yeah, I just couldn’t, all I could do really, was nod and shake my head, which was why face-to-face was just so important really. Phone contact was just impossible by this point.

Even when I was in my pyjamas and I just didn’t want visitors … she’d be like ‘oh come on, come to the door’ because she just knew I was trying to hide away through it all.

[Remote appointments were] really great, I think that’s something that should continue after Covid to be honest because it worked so much easier around the schedule and you don’t have to like get ready, get the kids ready, get out of the house, it’s twenty, thirty minutes away it’s another drive, you know, husband’s waiting in the car or with the other kid. I think this is a great way to just be able to have the service and like I think it helps with everybody’s time.

Staff highlighted moderating factors affecting mode of delivery preferences. They stressed the importance of home, or at least in-person, visits when there were worries about:

• symptoms were severe and functioning poor such that women were unable to make in-clinic appointments and needed in-person assessment and support (e.g. detecting suicidality, supporting with significant parenting/bonding issues, psychosis)
• significant deterioration in mental health including suicidality and functioning
• ‘Getting eyes on baby’/assessing the well-being of baby and the parent–infant interaction
• assessing the context in which women lived
• assessing for domestic abuse.

Staff also worked to adapt appointments to fit with women’s needs, for example, scheduling in-person appointments around times women had a midwifery or hospital appointment, and/or baby’s schedule. In preventative cases (where women were being monitored due to a history of psychosis), staff were flexible with women, empowering them to initiate contact as needed (Box 4).

The lack of face-to-face work … it’s difficult to assess risk, you know, and just kind of seeing their mum-baby interaction is really hard, I think, to kind of assess over the video.

Some women, especially women who presented in very precarious home situations, preferred to use the phone, because it gave them more privacy. But in terms of the work, the parent–infant work, we lost sight of the baby, which meant that we were concerned about not being able to set eyes on babies who may have been in safeguarding plans or who needed to have safeguarding support.

If you’re with somebody … if they’re really depressed and hopeless, if you’re in somebody’s house, you can notice a photo or notice an object and start a conversation that would hopefully lead you and them to remember when times were more hopeful, or a trip that they’ve enjoyed or a hobby that they obviously do … it changes all the dynamics.

Family-centred, acceptable, engaging community perinatal mental health teams

We found four key pillars underpinned the effectiveness of CPMHT service models. These were:

1. perceived perinatal competence (having the appropriate skills to understand and meet the needs of the mother and the infant and wider family)
2. honest and trusting relationships
3. accurate and knowledgeable reassurance (especially around fears and worries about childbirth/parenting/bonding/safeguarding concerns/medication)
4. staff/service reliability and consistency.

The way these perinatal competencies were relayed to women were fundamental; a non-judgemental and compassionate stance was a critical interactional style that determined whether women engaged fully with services. Together with the four foundational pillars, these interactional elements created a successful CPMHT service model (see Fisher et al. 2024). The extent to which these factors affected women’s engagement and outcomes varied by their context and personal characteristics (Box 5).

• for whom?
  • Women with emotionally unstable personality disorder (EUPD) and young mothers sometimes described feeling patronised and/or judged by staff and withdrawing from interactions with the service as a result.
  • Women with SMI were able to build close, trusting relationships with staff, who were sometimes the first to identity early signs of escalating mental health issues, and then provided timely support/interventions.
  • Women experiencing mental health problems for the first time described being treated with warmth, kindness and not feeling judged, and were reassured and supported in how to navigate their symptoms.

They were reassuring … I felt like my parents would disown me; my husband would leave me … I just felt like I was going to go into a mental home, a mental asylum or something, I thought I was completely crazy, and they just brought me back down to earth and like no, this happens to a lot of people and these feelings are very normal.

I saw the same person throughout, and that was absolutely brilliant … there’s something to say about continuity of care and she didn’t drop the ball once, not at all. And that really, really helped … there were open lines of communication throughout, and it was just – you felt supported.

Before my pregnancy I really didn’t trust medical professionals at all, I’ve had some quite negative experiences with them and [perinatal nurse] has completely turned my view on medical professionals around, she was amazing … I felt like I could trust her, which in the past I didn’t feel like I could trust medical professionals … but I felt safe around [perinatal nurse], she would say how it was, she wouldn’t fill me with rubbish or false hope, and she was very realistic, but also very positive.

I’d had a psychiatrist before … who I just felt had a very different manner … [the perinatal psychiatrist], he was the first psychiatrist I’d spoken to who wasn’t talking to me like a person who has a, you know, has an illness, like a sort of ill person.

Supporting discharge and ongoing recovery

Women’s experiences in services affected their readiness for discharge and where they were discharged to.

Women’s readiness for discharge was variable and was contingent on:

• Confidence in their improvements.
• Fear of independence in recovery without CPMHT support.
• Worries about ongoing mental health problems.
• Tapering of care towards the end of time with CPMHT.

Where were women discharged to?

• Primary care (most).
  • For whom?
    • Some had been referred via primary care.
    • Some had been referred via Adult Mental Health Care.
  • Contextual factors:
    • In COVID, decrease in universal community parenting support equalled a ‘cliff edge’. Some CPMHTs held onto women longer to bridge this gap.

Activity

Positive discharge experiences were linked to receiving CPMHT resources, support and individualised planning about how to manage mental health problems, family support needs and parenting during recovery (Box 6).

Outcomes

Support and information helped women:

• build a sense of efficacy about recovery
• understand what ‘safety net’ supports were available should they experience future problems
• knowledge they could access the CPMHT again if they had a future pregnancy and mental health problems.

I didn’t realise, you know, now that he’s had his birthday that that means I’m going to be discharged and that’s – I definitely feel as though I’ve taken quite a few steps backwards. I’ve – they would have done, but I said to the lady that I’ve been dealing with – what with Christmas being quite a tough time for me, anxiety-wise, and the dialectical behaviour therapy course coming to an end pretty much at the same time as them wanting to discharge me. I just said that I was really, really frightened. And she has said that she will give me one last appointment in January, just to soften the blow and see, you know, how I’m doing post-Christmas and things.

Yeah, but it went on a little longer, not majorly, hopefully because I think the nurse, she was saying to me you know, sometimes in exceptional circumstances they could push it forward, la, la, la, la, la. But from [name of nursery nurse]’s point of view and from [name of OT]’s point of view, they knew me and knew that I had asked for help and if it had come sooner, they would have been with me sooner. So, they weren’t in any hurry to decide, yeah, sorry, your son’s one, off you go. No, they saw it as, actually, detrimental to me to do that, and I really, really appreciated it. Because I was panicking, I was like ‘He’s going to be one in six weeks, what are we going to do?’ and between the two of them, they did what they had to and I really appreciate that …

Question 2: Which interventions are attractive and acceptable to women, and clinically effective within/in conjunction with mainstream secondary mental health care, maternity and primary care?

Community perinatal mental health teams offer a range of interventions that can be categorised as:

• Psychiatric medical interventions
  • specialised medication management
  • nursing mental health support
  • preconceptual counselling
• Practical
  • occupational therapy interventions focused on implementation of practical strategies
• Relational/psychological
  • parent–infant interventions that included parenting psychoeducation
  • interventions directly targeting the parent–infant relationship
  • psychoeducational and supportive groups
  • psychological interventions
  • peer-led support

Across women’s descriptions of the interventions that were attractive, acceptable and clinically effective, elements of what staff did, and the impact of these actions coalesced into key mechanisms supporting their improved well-being (Figures 3–7). These mechanisms, which were important across specific intervention types and staffing roles, were:

FIGURE 3 Context–mechanism–outcome configurations for women’s sense of social belonging. (Figure not reproduced here; see the original article.)

• support that improves women’s sense of social belonging
• family-centred approaches
  • partner/supportive other interventions
  • parent–infant interventions
• interventions that helped women to develop/apply skills
• perinatally specific expert medication advice and support.

We refined the overall programme theory to reflect these processes. The updated programme theory is presented by the domains that were impacted in the figures below.

Support that improved women’s sense of social belonging

Figure 2 provides an overview of the relationship between context, mechanism and outcomes in relation to women’s sense of social belonging, with Box 7 presenting the CMOC statements.

• When women are helped by staff to engage with supportive others who have shared experiences (C), they feel less isolated (O) because they feel a sense of social belonging (M)
• When women are helped by staff to engage with supportive others who have shared experiences (C), they have improved trust in their ability to interact securely with other parents (O), because they learn how to do this (M)
• When staff provide practical outreach to women who do not think they are entitled to care (C), they feel valued and deserving of care (O) because they develop a better understanding of their needs and entitlement (M)

Background

Most women reported feeling dismayed about having mental health problems during the perinatal period, keenly aware that their experiences of motherhood were different from other mothers’ experiences. Some described feeling rejected or ‘othered’ when they tried to join with other mothers because their own experiences were different. Mothers’ feelings of isolation were associated with:

• experiences of poor support from others in their support network (i.e. partners, family, friends)
• sense of rejection from other mothers
• entrenched negative beliefs:
  • ‘I am unworthy of asking for help’
  • ‘Good mothers should be able to parent without support’.

Activity

Community perinatal mental health team’s practical and relational psychological interventions helped women to build their social networks and the quality of their social support. This included:

• providing women with skills to communicate with safe others
• directly linking with other perinatal parents in the community or providing opportunities for shared learning in CPMHT group-based treatment sessions, [e.g. dialectical behaviour therapy (DBT) and compassion-focused therapy (CFT)]
• connecting mothers with similar women, especially useful in overcoming stigma and feared rejection from wider community groups and building lasting sources of perceived validation and support
  • For whom?
    • mothers with longer-term mental health problems (e.g. SMI, mental health problems associated with histories of complex trauma).

Women commented on the active role staff (i.e. mental health nurse, nursery nurse, occupational therapist) took in developing their ‘mummy network’, appreciating the flexibility and extra support in helping them take the first steps in joining group interventions or building contacts with community groups of parents outside CPMHT. Many noted they would have been unlikely to have joined had they not had this additional support.

Outcomes

Practical and relational psychological interventions that helped women to build connection with supportive others and develop their social and parenting networks resulted in noticeable improvements in women’s feelings of trust in their ability to interact securely with other parents (see Box 8 for quotes). This led to:

• improved sense of efficacy
• positive transformations in feelings of isolation and social fear
• sense of parental social belonging
• positive parenting identity
• better well-being.

I think I just, I should be enjoying it all, but I wasn’t at the time, and I felt guilty because of that. I felt that I wasn’t able to be, I wasn’t good enough at being a mum.

I made a really good friend through [the CPMHT mindfulness group] … once you’ve been in that system like perinatal, you can’t go to an ordinary mums [group] who have their life together and say ‘I was under the psychiatrist for so many months’ because they look at you like you’re nuts and you don’t have that community. But a friend who has gone through perinatal I can say to her ‘I’m having a really bad day today, this happened, I know it sounds stupid’ and she’ll say ‘oh, you know, this happened to me last week’. And you don’t feel that judgement.

I had my worst time in my pregnancy and obviously [the Psychologist] come through that journey with me and she thought that this CFT group would be great but didn’t realise how much … I didn’t need the help after the CFT group because I got so much out of that, and I’d got that support network.

We were doing [CFT] groups, and it was really, really good … there wasn’t very many of us there and like we’d formed like a good friendship … we went on holiday together in a caravan and stuff like that which was really, really nice.

I just didn’t want to go [Mum and Bump group] but she [staff] said oh, I think it will be really good for you, you know and the fact that she went as well it kind of made it easier.

They had … walk and talk therapy – you go up to the park with your baby in the buggy you meet other mums you have a walk around the park you get some exercise you have a coffee and a chat as you’re going so you don’t feel so alone and the occupational therapist is the one’s that area organising all these events just so that the mums don’t feel so alone which is really nice.

Family-centred approaches

Couples/supportive others

Figure 4 provides an overview of the relationship between context, mechanism and outcomes in relation to family-centred approaches taken by staff within CPMHTs in relation to couples and supportive others, with Box 9 presenting the CMOC statements.

FIGURE 4 Context–mechanism–outcome configurations for family-centred approaches focusing on couples/supportive others. (Figure not reproduced here; see the original article.)

Background

Many women talked about how their mental health problems were interlinked with their personal relationships. They highlighted how the following were strong contributors to their mental health problems and left them feeling judged, let-down and taken advantage:

• lack of support
• conflict
• domestic violence
  • For whom?
    • EUPD. Though conflict and domestic violence could affect women across diagnostic problem, those with EUPD were especially likely to report high interpersonal conflict. Women described wanting help with managing their anger and the effects of previous complex trauma on their relationships.

Others believed their relationships were built on strong foundations but described how the struggles of having a baby and mental health problems added extra pressure on communication and family support.

Partners and close others described feeling:

• scared
  • for whom?
    • post partum psychosis
    • OCD
    • severe depression
• de-skilled
• hopeless
• lost
• pushed aside and dismissed by staff in maternity, contributing to own feelings of helplessness as a parent and partner.

Activity

Women and partners/close family described how the whole family approach taken by CPMHTs made a critical difference to their recoveries and well-being (Box 10). Staff helped them to:

• gain insight into each other’s perspectives and experiences
• speak more honest, openly and safely with each other
• be more appropriately responsive to each other’s needs.

However, they noted that this support was often informal and there was a lack of availability of couples and family interventions and often poor assessment of and support for domestic violence in many of the services.

Partners and close others commented on how staff helped them understand the impact of mental health problems on the woman and ways they could effectively support them; this involved:

• providing models of effective, boundaried communication
• guidance about when and how to turn to CPMHT staff and other healthcare providers
• couples and/or family therapy (see Figure 3).

• When a woman’s partner/family have better knowledge and understanding of what the mother is going through with her mental health problems (C), they are more likely to be more honest and responsive to each other’s needs (O) because they have the confidence to do so (M)
• When women with mental health problems and their partners/ family are more honest and responsive to each other’s needs (C), they are more likely to build stronger, more resilient interactions and communication (O) because they are less judgemental? (M)
• When staff model and provide practical communication skills to partners or family members who have challenges adjusting to parenthood/familyhood in a woman’s treatment (C), they have a better understanding of what the mother is going through with her mental health problems (O) because of their greater insight (M)
• When staff model and provide practical communication skills to partners or family members who have challenges adjusting to parenthood/familyhood in a woman’s treatment (C), they have knowledge about how to help (O) because they have the opportunity to learn (M)
• When a woman’s partner/family have better knowledge and understanding of what the mother is going through with her mental health problems (C), they have reduced fears and sense of helplessness about the mother’s mental health problem (O) because they know how they might be able to help her (M)
• When women with mental health problems who are finding their relationship with their partner/family challenging are actively supported by staff (C), they are more likely to build stronger, more resilient interactions and communication (O) because they develop the skills and the confidence to do so (M)

Outcomes

As families began to face the woman’s mental health problems together, they felt less afraid and helpless, and more confident about jointly managing future challenges.

[Both of us understanding] how he unwittingly but inevitably had been part of this thing that had happened, this wasn’t just something that happened to me in isolation this was something that happened to me in the context of our new baby and our relationship and our home environment. I found [the sessions] hugely useful because I think sometimes you know when it’s just the two of you, things can become very heated or very emotional.

I think the perinatal team are the only people that have actually really helped … every other experience I’ve had with any mental health team or anything like that, it’s always been me, it’s just me, but with the perinatal [team] … it’s me and my family and that is a big thing. Because the fact that a lot of my mental health issues are to do with my family and prior to this nothing’s been – they’ve never been included.

I didn’t know, probably, myself, what I could possibly do to support her with her issues, you know, ‘cos she wasn’t able to talk to me properly about her issues, you know.

I was given a number of the CPN and there’s a few occasions when [the mum] was … having problems that I had to call her … not just for her help but for my help as well.

[My partner] didn’t realise how to help me, which, I was shocked at I think, because … he’s always been so supportive … I felt like we were at breaking point. And [perinatal nurse] really helped us. … we kind of gained perspective on where we were going wrong and letting each other talk and finish without over-talking each other.

Parenting

Figure 5 provides an overview of the relationship between context, mechanism and outcomes in relation to parenting, while Box 11 outlines the CMOC statements.

FIGURE 5 Context–mechanism–outcome configurations for parenting. (Figure not reproduced here; see the original article.)

Background

Women described how parenting difficulties were frequently a key motivator for treatment and reason for referral into the CPMHT because they worried about the impact of their symptoms on their baby. A number of women, who had not been referred because of parenting concerns, noted they still would have benefitted from parenting-related interventions. They discussed how worries and feelings of being deskilled affected their parenting confidence, and how this fed into their mental health problems.

Parenting CPMHT referral reasons included:

• Women expressed difficulties connecting with their infant
  • For whom?
    • Traumatic delivery
    • Problems breastfeeding
    • Previous histories of childhood maltreatment

• When women with bonding problems are supported by staff to have more opportunities for positive shared moments with their baby (C), they build quality of the parent–infant relationship and parental confidence (O) because mothers feel emotionally closer to their infant (M).
• When women with bonding problems fear their mental health will negatively impact their baby are supported by staff to decouple maternal mental health experiences from perceptions of connecting with baby (C), they build quality of the parent–infant relationship and parental confidence (O) because mothers feel reassured about the safety of allowing themselves to emotionally connect with their infant (M).
• When staff provide guidance and reassurance about parenting strategies to parents with low confidence of their parenting skills (C), they build quality of the parent–infant relationship and parental confidence (O) because parents feel more secure in their parenting skills (M).
• When staff show parents who are struggling with interacting sensitively with infant examples of their responsive interactions and support them to build the frequency of these interactions, in both positive and negative emotional contexts (C), they build quality of the parent–infant relationship and parental confidence (O) because parents learn how to identify and respond in a more timely and appropriate fashion to their infant’s needs (M).

Activity

Many women reported they valued interventions that:

• helped them to recognise and build on positive moments of interaction with their infant
• learn to identify when their fears about their infant were driven by their mental health symptoms, enabling them to relax and feel closer to their babies
• provided guidance, support and reassurance on concrete parenting approaches
• directed them to skills to improve interactions with infant.

Outcomes

Women reported that this support helped them to bond with baby and feel more secure in their parenting skills. Women described how having staff on the CPMHT who could seamlessly address both their needs and those of their baby was a key factor in supporting their recovery, though staff noted that the availability of more formalised parent–infant treatments offered by clinically trained staff was often limited (see Box 12 for quotes).

The nursery nurses … came in when I was struggling to feed my baby properly, I was struggling to breastfeed, and they are the best people you will ever meet. They are so calm, unflappable, they love babies so if you have a crisis which I did once or twice, and they will just take your baby, and you can leave the room and make a cup of tea.

[The nursery nurse] came in, she spoke to me about what I can do and how to look after [baby son], basically, but she just talked to me, talked to me like a human being, she related to me, that was the biggest thing … she was just giving me confidence.

That was really good and before [name of baby] was born we just had some telephone conversations about getting ready for the baby and I’d quite often talk to her [nursery nurse] about [name of first child], my toddler as well and how she was doing, and we’d talk about preparing her for the new arrival and getting ready for baby and stuff. So, yeah, it was really good.

[The nursery nurse] did various things around [baby’s] development and good toys and things like that that would be good for her development. A real focus on bonding with her, you know, creating bonding experiences.

Support that helps women to develop/apply skills

Figure 6 provides an overview of the relationship between the context, mechanism and outcomes in relation to the support provided by CPMHT which helped women to develop and apply practical skills. Box 13 provides the CMOC statements in relation to this.

FIGURE 6 Context–mechanism–outcome configuration for support that helps women to develop/apply skills. (Figure not reproduced here; see the original article.)

Background

Women frequently described mental health difficulties during the perinatal period as detrimental to their confidence as a person, parent and partner. Having a baby often meant juggling valued work, social and family activities with pregnancy and postnatal physical complications and infant caretaking needs, and women frequently described feeling lost and overwhelmed in their daily lives with mental health problems a significant barrier to their ability to undertake tasks. For many, managing pregnancy and parenting an infant while struggling with mental health difficulties felt insurmountable, and women expressed wanting and needing specific skills to help them both with their mental health and their lives as parents.

Activity

Psychological/relational interventions included:

• Psychoeducation
  • helped women get a grasp of their situation
  • understand how their symptoms can affect:
    • their thoughts about parenthood
    • themselves as mothers
    • their ability to engage in parenting, family and self-oriented activities.
• Therapy groups
  • provided women with specific skills to:
    • manage their emotions
    • cope with challenging interpersonal situations
    • understand the ups and downs in recovery
  • For whom?
    • Women with PTSD and EUPD reported a lack of interventions that directly targeted processing their trauma(s).
    • Women with SMI reported regular, frequent contact with psychiatrists, rather than being offered specific interventions, such as CBT.
    • Women who were experiencing mental health issues for the first time described talking therapies as transformative.

Practical interventions led by CPMHT staff (i.e. occupational therapists, mental health nurses) included:

• cooking/preparing meals
• leaving the house
• identifying and liaising with community parenting groups
• supporting women to form local peer support contacts.

• When staff regularly and consistently support mothers to overcome mental health barriers to engaging in parenting and other valued activities through emotional and practical skill building (C), mothers develop resilience (O) because they feel better able to regulate their emotions and actively participate in their life (M).
• When staff support women to gain knowledge about resources for managing mental health problems to women and their partners or family who feel vulnerable about how they will continue to manage post treatment (C), they develop resilience and a better understanding of how they will continue to manage post treatment (O) because they build a sense of efficacy and empowerment (M).

Outcomes

Together, mothers described how these interventions helped them overcome struggles related to mental health symptoms that interfered with their ability to function day-to-day as a parent and family member. Many reported they were fundamental for their recovery and developing longer-term resilience. Opportunities for support were missed when there was high staff turnover, sometimes resulting in women being discharged before new staff were hired (Box 14).

[The mental health nurse] said ‘right, I want you to leave the house, you must go for a walk, and [your husband] is going to text me once you’ve achieved this’ … she was almost quite strict, but she also had a real, like, soft, kind side to her as well. I think she really invested in us as a family.

The occupational therapist started coming round and cooking with me … that really got me over a hump, because up to that point I wouldn’t really even make a cup of tea for anyone, I was that frightened.

I was referred to group therapy, DBT, that was really very helpful. I really liked how it doesn’t try and convince you that there’s no problem, it just tells you, you can deal with the problem, which I found very helpful. It’s very helpful to me to have practical solutions rather than try and mull on what the problems are.

The ECS [emotional coping skills] had really connected with me and they’d really started to take effect … one of my biggest struggles was not allowing myself a bad day, feeling like everything I had achieved had been lost just because I had a bad day, so being reassured that bad days were OK and it was OK to slip back and just know that one step back is not all the way back… I felt very secure.

Perinatally specific expert medication advice and support

Figure 7 outlines the relationship between the context, mechanism and outcomes for perinatally specific expert medication advice and support given by CPMHTs. Box 15 summarises the CMOC statements for this theme.

FIGURE 7 Context–mechanism–outcome configuration for perinatally specific medication advice and support (Figure not reproduced here; see the original article.)

Background

Almost all the women under the care of the CPMHTs had been prescribed medication while they were pregnant and/or post partum, and many had significant concerns about the possible side effects of taking medication (Box 16). Before accessing the specialised support offered by CPMHT, women struggled with:

• finding reassurance and accurate and reliable advice
• struggling to know if they should take the medication and preserve their mental health with uncertain side effects for their baby or stop medication and risk deteriorating mental health.

Activity

Perinatal psychiatrists and pharmacists:

• provided expert perinatal knowledge about medications
• helped women weigh up fears, risks and benefits
• support women with preconceptual counselling; however, we found this was rarely offered (n = 11)

• When women who have concerns about whether the medication they are taking (or may have to take) are provided with advice in an open and honest way about potential risks by specialist perinatal psychiatrists and/or pharmacists with expert knowledge about the medication (C), they are more likely to feel better about ticking the medication (O) or carry on taking it [if they are already on the medication (O), because they feel listened to (M) and better informed (M)].
• When women who are distrustful about medication advice from non-specialists are provided with advice in an open and honest way about potential risks by specialist perinatal psychiatrists and/or pharmacists with expert knowledge about the medication (C), they are more likely to feel better about ticking the medication (O) or carry on taking it [if they are already on the medication (O), because they feel the advice is more credible (M)].
• When staff take the time to openly and honestly share medication options with women who have stopped taking their medication (C), women are more likely to reconsider their decision (O) because they feel they choices about their medication (M).

Outcomes

• Relief
  • For whom?
    • Women with SMI, ‘finally found someone who truly understands my needs’
• Felt heard and felt their individual circumstances and preferences were considered
• Trust in CPMHT
• Efficacy in making medication decisions
• Improved mental health

I was pregnant, I really didn’t want to take any medication, ‘cos obviously of the effects on the baby and stuff like that, and also I wanted to breastfeed.

I just knew that I just wanted to have a specialist psychiatrist. That was the main thing for me, to be under a psychiatrist that knew about using Lithium in pregnancy.

They were very good at finding medication because also I was breastfeeding, so they were very good at finding a solution for which medications I could take and couldn’t take … every month they would check in on how was I finding the medication, what were my side effects, did I like it … they were very good in keeping me informed on what I could and couldn’t take, it wasn’t just ‘here’s your pills, bye’.

I got to speak to a [specialist perinatal] pharmacist, who was absolutely brilliant … I’ve got a big chunk of paperwork which he sent me, so I could read through it, you know, as and when I pleased, to see if actually I do want to go on something, it was very, very useful … he was just really thorough … the way he explained, it had never been explained to me in that way before, and it took the fear out of it.

They suggested [medication], but I was quite reluctant … when I said I didn’t want to take it they were very supportive of that, which was really nice. I felt that my opinions were really considered … not like ‘if you don’t take this, sod you’ sort of thing.

Additional research questions

1. What has been the impact of COVID-19 on how women experience service delivery and their overall well-being?
2. What factors make perinatal mental health services resilient to public health emergencies?
3. What barriers and facilitators do women with diverse background encounter regarding access to CPMHS?

COVID-19

Results

Factors important to women during COVID-19 and their overall well-being

Background

The COVID-19 pandemic resulted in a number of changes for perinatal families that affected their well-being, including:

• Significant alternations in maternity provision (reduction in appointments, remote-only provision, partners for some parts of the COVID pandemic not allowed to accompany women in delivery or asked to leave hospital immediately thereafter, lack of postnatal support from medical professionals and from community sector support, e.g. parent and baby groups).
• Reductions in family and social network contact and support due to social distancing, affecting women’s access to practical support.
• For those in socially deprived circumstances:
  • Report increased levels of conflict and stress associated with living in cramped spaces with little access to outdoor space.
  • Struggle with digital poverty and lack of access to information, healthcare providers and digital links with family and friends.
  • Work in poorly paid ‘essential worker’ categories (e.g. food delivery, waste removal work, and domestic services) with increased risk of being exposed to the COVID-19 virus.
• Changes in conflict and/or support
  • Families with pre-existing conflict reported increases in conflict, and, in some cases, domestic violence.
  • Families with less conflict reported increases in positive family time and mothers reported an increase in practical support from non-birthing partners.

Women we interviewed who experienced care from the CPMHT during the COVID-19 pandemic discussed the following service-related factors related to what they perceived to be ‘good’ care that impacted positively on their well-being:

• Clear lines of communication throughout their care, from accessing services through to discharge was seen as especially important during a period that otherwise had high levels of uncertainty.
• Having a clear link and supported referral to another service where available (NHS or voluntary sector) was appreciated and seen as especially helpful.

Box 17 provides quotes from women of their experience of communication from CPMHTs and links between services.

Communication from PMH team

[I]t was hard because obviously we’ve never had a pandemic before, and, but yeah, they didn’t really tell me much.

So, a few times during those seven weeks, she did say, oh, shall I call you tomorrow and I would say yes please and then I would never get a call and I’d be home waiting, and I’d arranged for someone to look after the baby so I could speak to her and I would just have nothing.

Clear links between services

[I]t meant that I was without support (after Mother and Baby Unit discharge) for a really long period of time, and it’s my kind of belief that I feel like they shouldn’t discharge you until you’ve got an appointment with another team … I was discharged before my daughter was one … So, I kind of just feel like where’s the continuity of care there? They did so much and my care during my pregnancy and during that initial period was fantastic, and I just feel like it ended on a bad note.

Continuing treatment offer versus narrowing treatment offer to serious mental illness business

I think that I’m aware now that … about how they’ve really tightened up all the criteria because of lockdown. And it almost feels, like I said earlier, like they’ve used that as an excuse … but it’s looks like they’re only seeing, it’s almost they’re just a crisis team now … you wouldn’t get in if you have OCD or depression or anxiety, no one is seen now … I think also, because I’m aware that people might not look very complex on paper, but that doesn’t mean that they’re not suicidal or really struggling.

The transition to digital forms of care was rapid in many, though not all, mental health care trusts. Some women experienced telephone-only care, while others were in CPMHTs that delivered care via videoconferencing. Box 18 provides quotes on the types of communications women experienced from CPMHTs. Although responses varied, as women grew accustomed to digital delivery, they typically reported a preference for a blended approach that combined in-person with digital forms of contact. The diagram below outlines women and staff’s accounts of how different components of digital delivery worked:

It was actually quite difficult to open up over the telephone, because you sort of put the telephone façade on.

I think in terms of the therapy it would have been lovely to have had some face-to-face, but we did videocalls every single time, doing the CBT. And I really really liked that aspect of it, because it was just really nice to talk to someone face-to-face in a sense.

I would have like to have tried that (video call) because I found it’s quite difficult to see how to describe how he (baby) feeds. It might have been better if she (staff member) could have seen it.

I got offered a nursery nurse, but because of COVID it was going to be over the phone and I just felt it was a bit pointless.

FIGURE 8 Components of successful remote delivery. HIV, health visitor; NHSTTad, NHS Talking Therapies for anxiety and depression. (Figure not reproduced here; see the original article.)

Boxes 19 and 20 provide quotes on the benefits and drawbacks of remote delivery and challenges in signposting during COVID.

Greater reach to larger groups of individuals

[T]hings feel less scary maybe because you’re not having to go to hospital and be in that environment.

For a couple of ladies, they’ve got older children, and had it been in the community, our community group, face-to-face, we would say – if you’ve got children over one, they can’t come to the group. But because it’s in their own home, you know, their children have been at home, and it’s been OK.

[P]ractically there are lots of challenges with setting up groups when you’ve got an area as big as [name of county] because it’s enormous and getting, you know, a group together on a day when people can manage … has been a challenge, but actually online it’s … provided an opportunity to do it.

Inequalities in access to digital technology/service using unfamiliar technologies

The software [AttendAnywhere] wasn’t working great, overall, I had one and a half (sessions) … By the third one it worked.

I wanted to go to a sensory group and – it’s on video but, obviously, I haven’t got a laptop.

Treatment at home

I find it [videoconference] more difficult because I’m not in a private setting … you haven’t got the privacy.

… when you’re there in the room having an appointment it’s your time it’s your space it’s and then you leave it in that room and you go for it. Whereas, at the moment … it’s in my home, I would prefer it you can walk away from.

Support

And then quite often what we’ll do is … signpost them. and link them with a local children’s centre … In pre-Covid, we would probably go along with them, for a first time, just to … introduce them to … one of the family workers at the children’s centres.

Additional research question

What factors make PMH services resilient to public health emergencies?

Additional research question 2

What factors make PMH services resilient to public health emergencies?

Background

The COVID-19 pandemic provided a natural test of health and social care, with some established practice suspended, and in other cases, new care provision rapidly adapted and implemented. PMH services experienced challenges in team working with staff feeling isolated and disjointed in their practice, with a lack of access to normal services and resources. This proved to be a difficult situation which led to either clients and services accepting the situation for what it was or not resulting in adaptations being made or keeping to rigid structures that were in place. Those services and staff who accepted the challenging situation COVID presented adapted and used alternative ways of working which meet the needs of their women. Other services which adhered to rigid structures resulted in a reduced offering in their service.

Results

Table 9 outlines the themes explaining resilience of services from the qualitative data.

Client and service acceptance of situation

There was an element of acceptance from both women and services on what type of care could be delivered. Box 21 presents quotes on how staff adapted to and accepted changes in service delivery during COVID. Women understood the difficulties services were experiencing and were appreciative of whatever care they could get. Services adapted from providing face-to-face contact to initially telephone contacts and eventually video calls. It was apparent that the types of contact used to deliver care was important for both families and the types of healthcare professionals. While telephone calls were useful for checking in with women, they were not appropriate for providing advice on mother–infant bonding or feeding. Video calls were increasingly used as the pandemic progressed, particularly when delivering a psychological intervention or conducting a medication review. However, not all healthcare trusts were adaptable to the needs of the service or the population they served in terms of the variability of the platforms that could be used. Services found that better platform choices were associated with ease of use, familiarity to both the client and staff members, security and ability to use for no cost (e.g. WhatsApp, Menlo Park, CA, USA). Services that were open to using platforms that better suited their clients adapted and used whatever was both confidential and acceptable to clients to maintain care for their clients. This provided an opportunity for services to provide a good level of care during these challenging times, resulting in positive outcomes for clients and their families (more connectedness, access to interventions).

I think, actually, we’ve been reasonably stable, everything’s remained the same, it’s just been virtual. There was some sort of jigging about in terms of how you manage duty and the duty phone, but we’ve continued to have weekly team meetings, I’ve continued to do all of my visits.

We got it all set up and then really from lockdown we’ve all been agile working from home and [name], our manager, is trying to negotiate to get us places where we can see people where we think it’s important, face to face, but that’s not organised yet.

Some of the women that we think needed face to face we still offer face to face but we had the full PPE kits so we had the PPE kits provided for us so you can see those women that needed to be seen.

[W]e’re going to find out what parents want from groups and design our group programme about, around what’s what people would like. We’ve got a few ideas continues the Walk and Play. We’re thinking maybe of a virtual cooking/weaning group. A creative group possibly that could incorporate art, writing, music, yeah, so we’re working on that.

Maybe I’ve been not discharging people as much, just aware how isolated people are, because they can’t go to children’s centre groups, less groups are running, they’re maybe not seeing their friends and family as much, so yeah, maybe, I haven’t been aware of that, but maybe I have been keeping people on and not discharging as soon.

Client and service not accepting of the situation

Services that were rigid in their approach to provision of care during the pandemic did not adapt to the needs of their client, resulting in a reduction of their offer. Box 22 presents quotes on how staff found it difficult to accept the situation they were in during the pandemic. Women reported reduced range of psychological interventions being offered and staff felt limited in the types of interventions they could offer remotely. For example, trauma-based interventions delivered over video call in a woman’s home were in some cases not acceptable, as home was a safe space for them. However, alternatives were not suggested by staff in these situations (e.g. in the car) as services at times overweighed the risks of treatment versus the risk of non-delivery to pregnant women. Some services increased their threshold for access, only accepting women of higher needs and more serious mental health issues.

Yeah, definitely. We’re not going one to one, that’s straight off, we’ve not been doing anywhere near as many home visits and one to one anything as we would usually do. I would usually use a lot of CBT, and I find that almost impossible to do any other way but face to face, and that may well be that’s my skills deficit because I know that it can be done electronically but I don’t find it easy to do it that way.

I think because obviously we’ve had to adapt our criteria, so, we’re not seeing that perhaps low level, and we are looking at mental illness, people that are, you know, in the community and high end. So, people have got – people were looked at, you know, if there’s some work that needs to be done to tidy it up or, you know, looking at discharging client load to free up caseloads and work, to work more intensively with those that are our new referral criteria, so that was a big change.

There’s obviously some things that we can’t do so much, so I used to do, when Covid started I was doing Exposure, Response, Prevention with a lady with OCD, in her home. And that became very difficult to do online, so there’s definitely some things that you can’t really do online.

Additional research question 3

What barriers and facilitators do women with diverse backgrounds encounter regarding access to CPMHT?

Aim of study:

• qualitatively explore ethnic minority women’s perceptions of barriers and facilitators to accessing specialist community PMH.

Methods

Participants

• n = 28 ethnic minority women in England
• Inclusion criteria:
  • gave birth within the past 4 years
  • experienced self-defined mental health problems during pregnancy or the 2 years following childbirth
  • did not receive statuary PMH support.

Procedures

• Semistructured interview guide developed study team and the study’s PAG.
  • Questions included:
    • women’s views of their community’s perception of PMH and motherhood
    • perceived barriers to PMH support
    • their PMH experiences and interactions with health professionals
    • their recommendations for improving access.

Data analysis

Interviews were audio-recorded and transcribed verbatim. Thematic analysis was used to analyse the data.

Results

Participant characteristics are described in Table 10. Themes of women’s views of PMH are presented in Figure 9.

FIGURE 9 Themes of women’s views of PMH and support. (Figure not reproduced here; see the original article.)

Cultural beliefs and expectations

• Beliefs and perceptions of PMH.
  • Awareness of PMH was generally high across different ethnic groups.
  • Stigma about PMH within communities was high.
    • Black women reported mental health problems were sometimes perceived as a ‘normal part of life’ that people ‘have to go through’.
    • In Black communities, physical health was emphasised over mental health.
    • Women in Asian communities reported a subtle difference, ‘mental health isn’t important. You’re a mum now. You have to get on with things’.
    • Women from other ethnicities reported that ‘mental health is not something you discuss’.
• Expectations of motherhood.
  • Balancing compound expectations: mainstream motherhood expectations, expectations of the wider ethnic (e.g. Black) community, and expectations of motherhood within their specific community.
    • For example, being a ‘strong Black woman’ and not letting community or self down with mental health problems.
    • Feeling pressure to uphold religious values and behaviours as a mother that do not seem to be valued by mainstream British culture (e.g. Muslim, South Asian women).
    • ‘Giving it all’ as a mother and giving up self in the process. In Italian culture, this being based in ideals of the Virgin Mary, in South Asian culture, ideal mother seen as the one who does and gives all.
• Naming PMH.
  • Language: Lack of labels for PMH within own culture.
    • Could not label the problem for themselves as these words were lacking in their own culture.
    • Fifty per cent of participants were first-generation immigrants who flagged language as a barrier to speaking to healthcare professionals.

Help-seeking patterns

• Ethnicity.
  • Black and ‘other’ ethnicities would first seek help informally from their own families and communities.
  • South Asian women were wary about seeking informal help because of high community stigma and lack of confidentiality within community. Lack of individuals in their community who might act as ‘cues to action’ but more willingness to accept support outside community if it is confidential.

Accessibility barriers

• Women’s perceptions of health professionals.
  • Women’s willingness to seek professional help significantly impacted by their negative previous experiences of healthcare interactions.
    • Both personal and community accounts of healthcare discrimination were high.
      • Accounts of perceived discrimination in maternity particularly prevalent.
      • When women experienced discrimination in maternity, they expressed worries about then receiving mental health care from professionals.
• Positive experiences from peers.
  • In the face of perceived discrimination and stigma, women expressed desire to be ‘understood’.
  • Peer support provided a safe place where women felt a shared and common history that provided unspoken validation.

Discussion

As expected, the comprehensive CPMHT model yielded substantial improvements in the experiences and mental health outcomes of women and infants. These improvements were facilitated by a range of processes grounded in the integrated and reciprocal relationships between the CPMHT and other mental health providers.

Benefits to a comprehensive CPMHT included:

• Improved access through streamlined referral processes, particularly within maternity care, because the CPMHT provided PMH education and improved linkage.
• Expanded capacity to deliver acceptable, evidence-based interventions for complex, serious PMH problems (e.g. PTSD, OCD, EUPD) with a strong emphasis on a family-centred approach. Noteworthy domains highlighted in our revised programme theory contributed to improved mental health: specialised medication advice, bolstering social belonging and close social relationships and enhancing mental health management skills.
• Improvement in women’s outcomes and experiences with the CPMHT increasing health provider confidence in referring to the team.

Women often described their experiences with the CPMHT as transformative, particularly among those with previous experiences of secondary mental health. The CPMHT was viewed as a nurturing service, treating them as mothers rather than as a person with a mental health problem. The pivotal role of staff ‘soft skills’ was highlighted, and included consistent, non-judgemental and compassionate care, which fostered engagement and openness in women and helped ensured they were able to get the treatments they needed. These results are consistent with a broader literature highlighting the importance of ‘soft skills’ across mental health treatment, but especially in reaching and engaging people with complex social and emotional needs,72 the target population for CPMHTs.

Community perinatal mental health teams were still undergoing rapid expansion during the evaluation. Provision within the teams we sampled varied. The COVID-19 pandemic revealed how reductions in universal maternity and voluntary sector care and a move to remote provision affected women and infants. CPMHTs struggled with an increasingly complex caseload, and at times were wary about discharging women as there was little existing support in the community. Remote provision was successful in some cases, and less acceptable in others, especially when this was marked by slow transitions, use of technology that was not familiar to women, staff who were also unfamiliar with or worried with using technology and disclosed this to women and did not help them with becoming familiar with how to use the technology. Busy pregnant women, those living in circumstances where they could find privacy, and women living in remote areas had more favourable opinions of remote provision. Socially isolated women, those with higher risk profiles and women struggling with bonding benefitted from in-person contact. While teams adapted to COVID-19 changes, care remained inconsistent across many CPMHTs. Although care pathways and support for severe mental illness were robust in most teams, disparities in referral pathways and intervention availability for other mental health problems were apparent. For example, psychological support was lacking in some CPMHTs, impacting women with PTSD, OCD, anxiety and depression. Co-ordination between CPMHTs and adult mental health care was limited for women with EUPD and complex trauma. Although some services began offering parent–infant support, direct intervention was generally lacking. Though many services have enhanced their provision since we conducted our interviews, not all CPMHTs have achieved the full flexible aims of the LTP.

Moreover, it became evident that CPMHTs were not effectively reaching women from diverse ethnic backgrounds, which is concerning given their heightened risk for adverse obstetric and neonatal outcomes. To fully understand the needs of ethnically diverse populations, additional research using different recruitment approaches is needed. Further, addressing historical discrimination and mistrust in mental healthcare engagement is essential to rectifying this gap.

Strengths and limitations

This is one of the largest and most comprehensive qualitative studies of perinatal treatment engagement and outcomes. We sampled a range of CPMHTs across England and a broad range of women with different mental health problems. By taking a realist approach, this study extended previous literature in this domain by examining causal factors underlying women’s engagement with PMH services, examining what worked for whom and when.

Although the sample here is based on women who were referred to the service and opted to attend at least an initial appointment, we did have accounts from women who initially engaged well, but then disengaged, and women who did not initially engage well with the service but returned at a later date. These women’s accounts helped us to distinguish between what worked and what did not work for women once they started with CPMHS, though this was qualified by high levels of missing quantitative data and variation in types of data collected from services, which meant a mixed-methods analysis was not possible.

In conclusion, comprehensive CPMHTs hold substantial promise for women facing complex and serious mental health challenges, benefiting both them and their families. The model’s warm, inclusive approach presents an opportunity to address disparities in PMH care delivery, but this necessitates collaborative efforts between services and communities.