'The Listening Series': increasing equity, diversity and inclusion in patient and public involvement and engagement for policy research by listening to and learning from under-represented groups.

BACKGROUND: Policy research aims to provide evidence to inform government policy decisions about health and social care. Engaging and involving the public and patients in this work is widely recognised as essential. Research funders prioritise equality, diversity and inclusion (EDI) in patient and public involvement and engagement (PPIE), but people who are most likely to experience poor outcomes are also those least likely to be involved in research. This paper describes our experience of setting out to understand how to overcome barriers to EDI in PPIE in the research carried out by the National Institute for Health and Care Research (NIHR) Policy Research Unit in Maternal and Neonatal Health and Care (PRU-MNHC), in a PPIE consultation project we called The Listening Series. METHODS: We convened five video-recorded online discussion groups involving 20 individuals advocating for groups who are under-represented in our research. Those taking part included people working with Black and Asian women and families, young parents, those from socially deprived backgrounds, and women and families with physical and learning disabilities. Discussions focussed on practical solutions to addressing challenges to people being excluded, and how to improve EDI in our research. LEARNING AND REFLECTION: Five key themes were identified: 'build trust'; 'involve us from the beginning'; 'show us impact'; 'use clear, appropriate and inclusive communication'; and 'imagine life in our shoes'. We used the learning to create a guidance document for researchers and an accompanying 15-minute film. We also took practical steps to embed the learning strategically by expanding our Task Group for PPIE in the PRU-MNHC to include four Listening Series invitees with a remit to champion EDI in our research and ensure that it is embedded in our PPIE activities. We continue to reflect on and work to address the associated challenges. CONCLUSIONS: The Listening Series helped us rethink our processes for inclusion to go beyond traditional methods of involvement and engagement. The themes identified pose challenges that require time, resource and empathic engagement from researchers to be meaningfully resolved. This has implications for policy makers and research funders who need to consider this in their processes.

WHAT WE KNOW: It is important that health care researchers involve patients and the public from a wide range of social and ethnic backgrounds in research, but we know that this often does not happen. We are a group of researchers and patient/public representatives, working in research to improve care for pregnant women and babies. We wanted to find out how to involve people from more diverse backgrounds in our research. WHAT WE DID: We organised five online discussion groups with 20 people working with Black and Asian families, young parents, those from socially deprived backgrounds and parents with physical or learning disabilities. We asked them what we should do to involve a wider range of people in our research. We called this The Listening Series. We summarised the most important things people said in a written guide for researchers and a short film. We then asked people who had been invited to take part in The Listening Series to join us to develop new ways of working together. WHAT WE LEARNED: The five themes we identified were: 'build trust'; 'involve us from the beginning'; 'show us impact'; 'use clear, appropriate and inclusive communication'; and 'imagine life in our shoes'. In summary, researchers need to take the time to build trusting relationships with patients and the public; actively listening and learning from them. This can be challenging for researchers and patient representatives. Research funders need to allow time and money for this to happen in a meaningful way.

Postpartum haemorrhage and risk of cardiovascular disease in later life: A population-based record linkage cohort study.

OBJECTIVE: To investigate the association between postpartum haemorrhage (PPH) and subsequent cardiovascular disease. DESIGN: Population-based retrospective cohort study, using record linkage between Aberdeen Maternity and Neonatal Databank (AMND) and Scottish healthcare data sets. SETTING: Grampian region, Scotland. POPULATION: A cohort of 70 904 women who gave birth after 24 weeks of gestation in the period 1986-2016. METHODS: We used extended Cox regression models to investigate the association between having had one or more occurrences of PPH in any (first or subsequent) births (exposure) and subsequent cardiovascular disease, adjusted for sociodemographic, medical, and pregnancy and birth-related factors. MAIN OUTCOME MEASURES: Cardiovascular disease identified from the prescription of selected cardiovascular medications, hospital discharge records or death from cardiovascular disease. RESULTS: In our cohort of 70 904 women (with 124 795 birth records), 25 177 women (36%) had at least one PPH. Compared with not having a PPH, having at least one PPH was associated with an increased risk of developing cardiovascular disease, as defined above, in the first year after birth (adjusted hazard ratio, aHR 1.96; 95% confidence interval, 95% CI 1.51-2.53; p < 0.001). The association was attenuated over time, but strong evidence of increased risk remained at 2-5 years (aHR 1.19, 95% CI 1.11-1.30, P < 0.001) and at 6-15 years after giving birth (aHR 1.17, 95% CI 1.05-1.30, p = 0.005). CONCLUSIONS: Compared with women who have never had a PPH, women who have had at least one episode of PPH are twice as likely to develop cardiovascular disease in the first year after birth, and some increased risk persists for up to 15 years.

Anxiety in couples undergoing IVF: evidence from E-Freeze randomised controlled trial.

STUDY QUESTION: What are the risk factors and impacts of anxiety in women and men in heterosexual couples undergoing IVF as part of a randomised trial, with a delay in embryo transfer in one arm? SUMMARY ANSWER: Duration of infertility, ethnicity, and male partner's anxiety levels were associated with women's anxiety at the start of treatment, while initial anxiety score, partner's anxiety score at embryo transfer, ethnicity, and clinic location were associated with women's anxiety levels at embryo transfer; although women undergoing IVF were more anxious than their partners for slightly different reasons, their self-reported state anxiety was not associated with achieving clinical pregnancy, nor with switching from delayed frozen embryo transfer to fresh embryo transfer in an IVF trial. WHAT IS KNOWN ALREADY: Use of IVF treatment continues to rise and patients undergoing IVF are anxious. Participating in a randomised controlled trial (RCT) with uncertainty of arm randomisation might increase their anxiety, while a delay in treatment may add further to anxiety. STUDY DESIGN SIZE DURATION: A mixed methods study was conducted using data from the multi-centre E-Freeze RCT cohort conducted across 13 clinics in the UK from 2016 to 2019. A regression analysis on anxiety scores of couples undergoing the IVF trial and a qualitative analysis of participant questionnaires were performed. PARTICIPANTS/MATERIALS SETTING METHODS: Six hundred and four couples participating in the E-Freeze trial, who had at least one useable State-Trait Anxiety Inventory (STAI) State Anxiety subscale (STAI-S) standardised self-report questionnaire for at least one of the partners, were included in the study. STAI-S scores were measured at consent for trial (T1) and again at embryo transfer (T2). Linear and log-binomial regression were used to explore the association between characteristics and STAI-S scores, and the associations between STAI-S scores and non-compliance and clinical pregnancy, respectively. Responses to the open text question were qualitatively analysed inductively using content analysis. MAIN RESULTS AND THE ROLE OF CHANCE: Women's STAI-S scores at T1 (consent) were associated with their ethnicity, duration of infertility, and their male partner's STAI-S score at T1. Women's STAI-S scores at T2 (embryo transfer) were associated with their ethnicity, location of fertility clinic, their STAI-S score at consent, and their male partner's STAI-S score at embryo transfer. The adjusted coefficient (95% CI) for women's STAI-S scores at T2 was -4.75 (-7.29, -2.20, P < 0.001) for ethnic minority versus White, -2.87 (-4.85, -0.89, P = 0.005) for Scotland versus England, 0.47 (0.37, 0.56, P < 0.001) for each point increase in their own score at T1, and 0.30 (0.21, 0.40, P < 0.001) for each point increase in their male partner's score at T2. On average, women had higher STAI-S scores than men at both time points, and a larger increase of scores between the two time points. However, women's STAI-S scores were not associated with either non-compliance with trial allocation in the 'freeze-all' trial arm, or with chances of pregnancy. Both partners, but particularly women, described feeling anxious about the outcome of IVF, with women carrying the added worry of believing that feeling stressed might itself affect the outcome. Participants highlighted the important role of support from staff in helping them to manage their anxiety. LIMITATIONS REASONS FOR CAUTION: Data were not available on education level or social support, which might influence anxiety scores. Men's baseline characteristics were not collected. WIDER IMPLICATIONS OF THE FINDINGS: Identifying couples at increased risk of emotional distress may be improved by using standardised anxiety measures at the start of the fertility treatment. Women can be reassured that their self-reported state anxiety does not affect their chances of achieving clinical pregnancy through IVF, and this may help to reduce anxiety levels. The psychological wellbeing and experiences of couples undergoing IVF could be supported by patient-centred care: making information about the whole process of treatment and choices available to both partners in accessible formats; ensuring interactions with staff are kind and supportive; and acknowledging and addressing the different concerns of women undergoing IVF and their partners. STUDY FUNDING/COMPETING INTERESTS: This study was an NIHR HTA (National Institute for Health and Care Research Health Technology Assessment) funded study. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: ISRCTN registry: ISRCTN61225414.

Women's experiences and views of routine assessment for anxiety in pregnancy and after birth: A qualitative study.

BACKGROUND: Anxiety in pregnancy and postnatally is highly prevalent but under-recognized. To identify perinatal anxiety, assessment tools must be acceptable to women who are pregnant or postnatal. METHODS: A qualitative study of women's experiences of anxiety and mental health assessment during pregnancy and after birth and views on the acceptability of perinatal anxiety assessment. Semi-structured interviews were conducted with 41 pregnant or postnatal women. Results were analysed using Sekhon et al.'s acceptability framework, as well as inductive coding of new or emergent themes. RESULTS: Women's perceptions of routine assessment for perinatal anxiety were generally favourable. Most participants thought assessment was needed and that the benefits outweighed potential negative impacts, such as unnecessary referrals to specialist services. Six themes were identified of: (1) Raising awareness; (2) Improving support; (3) Surveillance and stigma; (4) Gatekeeping; (5) Personalized care and (6) Trust. Assessment was seen as a tool for raising awareness about mental health during the perinatal period and a mechanism for normalizing discussions about mental health more generally. However, views on questionnaire assessments themselves were mixed, with some participants feeling they could become an administrative 'tick box' exercise that depersonalizes care and does not provide a space to discuss mental health problems. CONCLUSION: Routine assessment of perinatal anxiety was generally viewed as positive and acceptable; however, this was qualified by the extent to which it was informed and personalized as a process. Approaches to assessment should ideally be flexible, tailored across the perinatal period and embedded in continuity of care.

Factors associated with posttraumatic stress and anxiety among the parents of babies admitted to neonatal care: a systematic review.

BACKGROUND: Posttraumatic stress (PTS) and anxiety are common mental health problems among parents of babies admitted to a neonatal unit (NNU). This review aimed to identify sociodemographic, pregnancy and birth, and psychological factors associated with PTS and anxiety in this population. METHOD: Studies published up to December 2022 were retrieved by searching Medline, Embase, PsychoINFO, Cumulative Index to Nursing and Allied Health electronic databases. The modified Newcastle-Ottawa Scale for cohort and cross-sectional studies was used to assess the methodological quality of included studies. This review was pre-registered in PROSPERO (CRD42021270526). RESULTS: Forty-nine studies involving 8,447 parents were included; 18 studies examined factors for PTS, 24 for anxiety and 7 for both. Only one study of anxiety factors was deemed to be of good quality. Studies generally included a small sample size and were methodologically heterogeneous. Pooling of data was not feasible. Previous history of mental health problems (four studies) and parental perception of more severe infant illness (five studies) were associated with increased risk of PTS, and had the strongest evidence. Shorter gestational age (≤ 33 weeks) was associated with an increased risk of anxiety (three studies) and very low birth weight (< 1000g) was associated with an increased risk of both PTS and anxiety (one study). Stress related to the NNU environment was associated with both PTS (one study) and anxiety (two studies), and limited data suggested that early engagement in infant's care (one study), efficient parent-staff communication (one study), adequate social support (two studies) and positive coping mechanisms (one study) may be protective factors for both PTS and anxiety. Perinatal anxiety, depression and PTS were all highly comorbid conditions (as with the general population) and the existence of one mental health condition was a risk factor for others. CONCLUSION: Heterogeneity limits the interpretation of findings. Until clearer evidence is available on which parents are most at risk, good communication with parents and universal screening of PTS and anxiety for all parents whose babies are admitted to NNU is needed to identify those parents who may benefit most from mental health interventions.

Conceptual framework on barriers and facilitators to implementing perinatal mental health care and treatment for women: the MATRIx evidence synthesis.

Background: 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. Objectives: 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. 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. Data sources: Pre-planned searches were conducted on MEDLINE, EMBASE, PsychInfo and CINAHL. Review 2 also included Scopus and the Cochrane Database of Systematic Reviews. Review methods: 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. Results: 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. Limitations: 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. 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 perinatal mental health care and effective implementation of perinatal mental health services. Recommendations for health policy and practice: 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. Future work: Further research is needed to examine access to perinatal mental health care for specific groups, such as fathers, immigrants or those in lower income countries. Trial registration: This trial is registered as PROSPERO: (R1) CRD42019142854; (R2) CRD42020193107. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR 128068) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 2. See the NIHR Funding and Awards website for further award information.

Mental health problems affect one in five women during pregnancy and the first year after birth (the perinatal period). These include anxiety, depression and stress-related conditions. Mental health problems can have a negative effect on women, their partners and their children. They are also a leading cause of maternal death. It is therefore important that women who experience mental health problems get the care and treatment they need. However, only about half of women with perinatal mental health problems are identified by health services and even fewer receive treatment. This research aimed to understand what factors help or prevent women getting care or treatment for perinatal mental health problems. We did this by pulling together the findings from existing research in three phases. In phase 1 we reviewed the evidence from research studies to understand why it has been difficult for health services to assess, care for and treat women with perinatal mental health problems. In phase 2 we reviewed evidence from women's perspectives on all of the factors that prevent women from being able to get the care and treatment they need. In phase 3 we worked with a panel of women, health professionals (such as general practitioners and midwives) and health service managers to look at the findings from phases 1 and 2. We then developed frameworks that give a clear overview of factors that help or prevent women getting care and treatment. These frameworks show 39 factors that help women access services, and 66 factors that prevent access. Based on these results we have developed guidance for government, NHS service managers and health professionals, such as general practitioners, midwives, health visitors, nurses and wider teams such as receptionists. This will be shared widely with health services and professionals who support women during pregnancy and after birth to improve perinatal mental health services so that care meets women's needs.

When is the best time to screen for perinatal anxiety? A longitudinal cohort study.

BACKGROUND: For screening for anxiety during pregnancy and after birth to be efficient and effective it is important to know the optimal time to screen in order to identify women who might benefit from treatment. AIMS: To determine the optimal time to screen for perinatal anxiety to identify women with anxiety disorders and those who want treatment. A secondary aim was to examine the stability and course of perinatal anxiety over time. METHODS: Prospective longitudinal cohort study of 2243 women who completed five screening questionnaires of anxiety and mental health symptoms in early pregnancy (11 weeks), mid-pregnancy (23 weeks), late pregnancy (32 weeks) and postnatally (8 weeks). Anxiety and mental health questionnaires were the GAD7, GAD2, SAAS, CORE-10 and Whooley questions. To establish presence of anxiety disorders diagnostic interviews were conducted with a subsample of 403 participants. RESULTS: Early pregnancy was the optimal time to screen for anxiety to identify women with anxiety disorders and women wanting treatment at any time during pregnancy or postnatally. These findings were consistent across all five questionnaires of anxiety and mental health. Receiving treatment for perinatal mental health problems was most strongly associated with late pregnancy and/or postnatal assessments. Anxiety symptoms were highest in early pregnancy and decreased over time. CONCLUSION: Findings show that screening in early pregnancy is optimal for identifying women who have, or develop, anxiety disorders and who want treatment. This has clear implications for practice and policy for anxiety screening during the perinatal period.

Assessment of perinatal anxiety: diagnostic accuracy of five measures.

BACKGROUND: Anxiety in pregnancy and after giving birth (the perinatal period) is highly prevalent but under-recognised. Robust methods of assessing perinatal anxiety are essential for services to identify and treat women appropriately. AIMS: To determine which assessment measures are most psychometrically robust and effective at identifying women with perinatal anxiety (primary objective) and depression (secondary objective). METHOD: We conducted a prospective longitudinal cohort study of 2243 women who completed five measures of anxiety and depression (Generalized Anxiety Disorder scale (GAD) two- and seven-item versions; Whooley questions; Clinical Outcomes in Routine Evaluation (CORE-10); and Stirling Antenatal Anxiety Scale (SAAS)) during pregnancy (15 weeks, 22 weeks and 31 weeks) and after birth (6 weeks). To assess diagnostic accuracy a sample of 403 participants completed modules of the Mini-International Neuropsychiatric Interview (MINI). RESULTS: The best diagnostic accuracy for anxiety was shown by the CORE-10 and SAAS. The best diagnostic accuracy for depression was shown by the CORE-10, SAAS and Whooley questions, although the SAAS had lower specificity. The same cut-off scores for each measure were optimal for identifying anxiety or depression (SAAS ≥9; CORE-10 ≥9; Whooley ≥1). All measures were psychometrically robust, with good internal consistency, convergent validity and unidimensional factor structure. CONCLUSIONS: This study identified robust and effective methods of assessing perinatal anxiety and depression. We recommend using the CORE-10 or SAAS to assess perinatal anxiety and the CORE-10 or Whooley questions to assess depression. The GAD-2 and GAD-7 did not perform as well as other measures and optimal cut-offs were lower than currently recommended.

Women's awareness of perinatal mental health conditions and the acceptability of being asked about mental health in two regions in India: a qualitative study.

BACKGROUND: Mental health conditions are common during pregnancy and the first year after childbirth. Early detection allows timely support and treatment to be offered, but identifying perinatal mental health conditions may be challenging due to stigma and under-recognition of symptoms. Asking about symptoms of mental health conditions during routine antenatal and postnatal appointments can help to identify women at risk. This study explores women's awareness of perinatal mental health conditions, their views on the acceptability of being asked about mental health and any preference for specific assessment tools in two regions in India. METHODS: Focus group discussions (FGDs) were conducted with pregnant, post-partum and non-perinatal women in Kangra, Himachal Pradesh (northern India) and Bengaluru, Karnataka (southern India). Settings included a hospital antenatal clinic and obstetric ward, Anganwadi Centres and Primary Health Centres. FGDs were facilitated, audio-recorded and transcribed. Narratives were coded for emerging themes and analysed using thematic analysis. RESULTS: Seven FGDs including 36 participants were conducted. Emerging themes were: manifestations of and contributors to mental health conditions; challenges in talking about mental health; and the acceptability of being asked about mental health. Difficult familial relationships, prioritising the needs of others and pressure to have a male infant were cited as key stressors. Being asked about mental health was generally reported to be acceptable, though some women felt uncomfortable with questions about suicidality. No preference for any specific assessment tool was reported. CONCLUSIONS: Women face many stressors during the perinatal period including difficult familial relationships and societal pressure to bear a male infant. Being asked about mental health was generally considered to be acceptable, but questions relating to suicidality may be challenging in a community setting, requiring sensitivity by the interviewer. Future studies should assess the acceptability of mental health assessments in 'real world' antenatal and postnatal clinics and explore ways of overcoming the associated challenges in resource-constrained settings.

Breastfeeding rates in England during the Covid-19 pandemic and the previous decade: Analysis of national surveys and routine data.

BACKGROUND: Few studies have compared breastfeeding rates before and during the pandemic using comparable data across time. We used data from two national maternity surveys (NMS) to compare breastfeeding rates in England before and during the pandemic. METHODS: Analysis was conducted using the NMS from 2018 (pre-pandemic; n = 4,509) and 2020 (during the pandemic; n = 4,611). The prevalence of breastfeeding initiation, and 'any' breastfeeding and exclusive breastfeeding (EBF) at 6 weeks and 6 months were compared between these surveys. Data were interpreted in the context of underlying trends in these prevalences from previous NMS (from 2010 and 2014), and annual routine data for England (from 2009-10 to 2020-21). Modified Poisson regression was used to estimate adjusted risk ratios (aRR) for the effect of birth during the pandemic (2020 versus 2018) on breastfeeding, with adjustment for sociodemographic and birth-related factors. RESULTS: Breastfeeding initiation and any breastfeeding at 6 weeks remained relatively constant in the NMS and the routine data. Birth during the pandemic was associated with a 3 percentage point decrease in EBF at 6 weeks in the NMS (aRR 0.92, 95%CI: 0.87, 0.98 for pandemic versus pre-pandemic), but a smaller decrease in the routine data. Birth during the pandemic was associated with a 3 percentage point increase in any breastfeeding at 6 months in the NMS (aRR 1.05, 95%CI: 1.00, 1.10). Breastfeeding varied across different groups of women in the NMS (i.e. marked inequalities), but the small changes observed between the pandemic and pre-pandemic NMS were broadly similar across the sociodemographic and birth-related factors examined (i.e. no change in inequalities). CONCLUSION: Breastfeeding initiation and any breastfeeding at 6 weeks in England were unaffected by the pandemic, and the persistent inequalities in breastfeeding did not widen. Services should aim to reduce these inequalities in breastfeeding which have been documented since the 1970s.

The relationship between perineal trauma and postpartum psychological outcomes: a secondary analysis of a population-based survey.

BACKGROUND: Perineal trauma, involving either naturally occurring tears or episiotomy, is common during childbirth but little is known about its psychological impact. This study aimed to determine the associations between childbirth related perineal trauma and psychological outcomes reported by women three months after giving birth and to explore factors that could mediate relationships between perineal trauma and maternal psychological outcomes. METHODS: This study was a secondary analysis of data from a cross-sectional population-based survey of maternal and infant health. A total of 4,578 women responded to the survey, of which 3,307 had a vaginal birth and were eligible for inclusion into the analysis. Symptoms of depression, anxiety, and post-traumatic stress (PTS) symptoms were assessed using validated self- report measures. Physical symptoms were derived from a checklist and combined to produce a composite physical symptoms score. Regression models were fitted to explore the associations. RESULTS: Nearly three quarters of women experienced some degree of perineal trauma. Women who experienced perineal trauma reported having more postnatal physical symptoms (adjusted proportional odds ratio 1.47, 95%CI 1.38 to 1.57, p-value < 0.001), were more likely to report PTS symptoms (adjusted OR 1.19, 95%CI 1.04 to 1.36, p-value 0.010), and there was strong evidence that each unit increase in the physical symptoms score was associated with between 38 and 90% increased adjusted odds of adverse psychological symptoms. There was no evidence of association between perineal trauma and satisfaction with postnatal care, although there was strong evidence that satisfaction with labour and birth was associated with 16% reduced adjusted odds of depression and 30% reduced adjusted odds of PTS symptoms. CONCLUSIONS: Women who experienced perineal trauma were more likely to experience physical symptoms, and the more physical symptoms a woman experienced the more likely she was to report having postnatal depression, anxiety and PTS symptoms. There was some evidence of a direct association between perineal trauma and PTS symptoms but no evidence of a direct association between perineal trauma and depression or anxiety. Assessment and management of physical symptoms in the postnatal period may play an important role in reducing both physical and psychological postnatal morbidity.

Meta-review of the barriers and facilitators to women accessing perinatal mental healthcare.

Perinatal mental health (PMH) problems are common and can have an adverse impact on women and their families. However, research suggests that a substantial proportion of women with PMH problems do not access care. OBJECTIVES: To synthesise the results from previous systematic reviews of barriers and facilitators to women to seeking help, accessing help, and engaging in PMH care, and to suggest recommendations for clinical practice and policy. DESIGN: A meta-review of systematic reviews. REVIEW METHODS: Seven databases were searched and reviewed using a Preferred Reporting Items for Systematic Reviews and Meta Analyses search strategy. Studies that focused on the views of women seeking help and accessing PMH care were included. Data were analysed using thematic synthesis. Assessing the Methodological Quality of Systematic Reviews-2 was used to assess review methodology. To improve validity of results, a qualitative sensitivity analysis was conducted to assess whether themes remained consistent across all reviews, regardless of their quality rating. RESULTS: A total of 32 reviews were included. A wide range of barriers and facilitators to women accessing PMH care were identified. These mapped across a multilevel model of influential factors (individual, healthcare professional, interpersonal, organisational, political and societal) and across the care pathway (from decision to consult to receiving care). Evidence-based recommendations to support the design and delivery of PMH care were produced based on identified barriers and facilitators. CONCLUSION: The identified barriers and facilitators point to a complex interplay of many factors, highlighting the need for an international effort to increase awareness of PMH problems, reduce mental health stigma, and provide woman-centred, flexible care, delivered by well trained and culturally sensitive primary care, maternity, and psychiatric health professionals. PROSPERO REGISTRATION NUMBER: CRD42019142854.

Primary postpartum haemorrhage and longer-term physical, psychological, and psychosocial health outcomes for women and their partners in high income countries: A mixed-methods systematic review.

OBJECTIVES: Most research about outcomes following postpartum haemorrhage (PPH) has focused on immediate outcomes. There are fewer studies investigating longer-term maternal morbidity following PPH, resulting in a significant knowledge gap. This review aimed to synthesize the evidence about the longer-term physical and psychological consequences of primary PPH for women and their partners from high income settings. METHODS: The review was registered with PROSPERO and five electronic databases were searched. Studies were independently screened against the eligibility criteria by two reviewers and data were extracted from both quantitative and qualitative studies that reported non-immediate health outcomes of primary PPH. RESULTS: Data were included from 24 studies, of which 16 were quantitative, five were qualitative and three used mixed-methods. The included studies were of mixed methodological quality. Of the nine studies reporting outcomes beyond five years after birth, only two quantitative studies and one qualitative study had a follow-up period longer than ten years. Seven studies reported outcomes or experiences for partners. The evidence indicated that women with PPH were more likely to have persistent physical and psychological health problems after birth compared with women who did not have a PPH. These problems, including PTSD symptoms and cardiovascular disease, may be severe and extend for many years after birth and were more pronounced after a severe PPH, as indicated by a blood transfusion or hysterectomy. There was limited evidence about outcomes for partners after PPH, but conflicting evidence of association between PTSD and PPH among partners who witnessed PPH. CONCLUSION: This review explored existing evidence about longer-term physical and psychological health outcomes among women who had a primary PPH in high income countries, and their partners. While the evidence about health outcomes beyond five years after PPH is limited, our findings indicate that women can experience long lasting negative impacts after primary PPH, including PTSD symptoms and cardiovascular disease, extending for many years after birth. PROSPERO REGISTRATION: PROSPERO registration number: CRD42020161144.

The impact of the Covid-19 pandemic on postnatal depression: analysis of three population-based national maternity surveys in England (2014-2020).

Background: Few studies have evaluated postnatal depression before and during the Covid-19 pandemic using comparable data across time. We used data from three national maternity surveys in England to compare prevalence and risk factors for postnatal depression before and during the pandemic. Methods: Analysis was conducted using population-based surveys carried out in 2014 (n = 4571), 2018 (n = 4509), and 2020 (n = 4611). Weighted prevalence estimates for postnatal depression (EPDS score ≥13) were compared across surveys. Modified Poisson regression was used to estimate adjusted risk ratios (aRR) for the association between sociodemographic, pregnancy- and birth-related, and biopsychosocial factors, and postnatal depression. Findings: Prevalence of postnatal depression increased from 10.3% in 2014 to 16.0% in 2018 (difference = +5.7% (95% CI: 4.0-7.4); RR = 1.55 (95% CI: 1.36-1.77)) and to 23.9% in 2020 (difference = +7.9% (95% CI: 5.9-9.9); RR = 1.49 (95% CI: 1.34-1.66)). Having a long-term mental health problem (aRR range = 1.48-2.02), antenatal anxiety (aRR range = 1.73-2.12) and antenatal depression (aRR range = 1.44-2.24) were associated with increased risk of postnatal depression, whereas satisfaction with birth (aRR range = 0.89-0.92) and social support (aRR range = 0.73-0.78) were associated with decreased risk before and during the pandemic. Interpretation: This analysis indicates that Covid-19 had an important negative impact on postnatal women's mental health and may have accelerated an existing trend of increasing prevalence of postnatal depression. Risk factors for postnatal depression were consistent before and during the pandemic. Timely identification, intervention and follow-up are key to supporting women at risk, and it is essential that mechanisms to support women are strengthened during times of heightened risk such as the pandemic. Funding: NIHR Policy Research Programme.

Preventing, Mitigating, and Treating Women's Perinatal Mental Health Problems during the COVID-19 Pandemic: A Scoping Review of Reviews with a Qualitative Narrative Synthesis.

Meeting the mental health needs of perinatal women during the COVID-19 pandemic is a serious concern. This scoping review looks at how to prevent, mitigate or treat the mental health problems faced by women during a pandemic, and lays out suggestions for further research. Interventions for women with pre-existing mental health problems or health problems that develop during the perinatal period are included. The literature in English published in 2020-2021 is explored. Hand searches were conducted in PubMed and PsychINFO using the terms COVID-19, perinatal mental health and review. A total of 13 systematic and scoping reviews and meta-analyses were included. This scoping review shows that every woman should be assessed for mental health issues at every stage of her pregnancy and postpartum, with particular attention to women with a history of mental health problems. In the COVID-19 era, efforts should be focused on reducing the magnitude of stress and a perceived sense of lack of control experienced by perinatal women. Helpful instructions for women with perinatal mental health problems include mindfulness, distress tolerance skills, relaxation exercises, and interpersonal relationship building skills. Further longitudinal multicenter cohort studies could help improve the current knowledge. Promoting perinatal resilience and fostering positive coping skills, mitigating perinatal mental health problems, screening all prenatal and postpartum women for affective disorders, and using telehealth services appear to be indispensable resources. In future, governments and research agencies will need to pay greater attention to the trade-offs of reducing the spread of the virus through lockdowns, physical distancing, and quarantine measures and developing policies to mitigate the mental health impact on perinatal women.

Prevalence and risk factors for postnatal mental health problems in mothers of infants admitted to neonatal care: analysis of two population-based surveys in England.

BACKGROUND: Previous research suggests that mothers whose infants are admitted to neonatal units (NNU) experience higher rates of mental health problems compared to the general perinatal population. This study examined the prevalence and factors associated with postnatal depression, anxiety, post-traumatic stress (PTS), and comorbidity of these mental health problems for mothers of infants admitted to NNU, six months after childbirth. METHODS: This was a secondary analysis of two cross-sectional, population-based National Maternity Surveys in England in 2018 and 2020. Postnatal depression, anxiety, and PTS were assessed using standardised measures. Associations between sociodemographic, pregnancy- and birth-related factors and postnatal depression, anxiety, PTS, and comorbidity of these mental health problems were explored using modified Poisson regression and multinomial logistic regression. RESULTS: Eight thousand five hundred thirty-nine women were included in the analysis, of whom 935 were mothers of infants admitted to NNU. Prevalence of postnatal mental health problems among mothers of infants admitted to NNU was 23.7% (95%CI: 20.6-27.2) for depression, 16.0% (95%CI: 13.4-19.0) for anxiety, 14.6% (95%CI: 12.2-17.5) for PTS, 8.2% (95%CI: 6.5-10.3) for two comorbid mental health problems, and 7.5% (95%CI: 5.7-10.0) for three comorbid mental health problems six months after giving birth. These rates were consistently higher compared to mothers whose infants were not admitted to NNU (19.3% (95%CI: 18.3-20.4) for depression, 14.0% (95%CI: 13.1-15.0) for anxiety, 10.3% (95%CI: 9.5-11.1) for PTS, 8.5% (95%CI: 7.8-9.3) for two comorbid mental health problems, and 4.2% (95%CI: 3.6-4.8) for three comorbid mental health problems six months after giving birth. Among mothers of infants admitted to NNU (N = 935), the strongest risk factors for mental health problems were having a long-term mental health problem and antenatal anxiety, while social support and satisfaction with birth were protective. CONCLUSIONS: Prevalence of postnatal mental health problems was higher in mothers of infants admitted to NNU, compared to mothers of infants not admitted to NNU six months after giving birth. Experiencing previous mental health problems increased the risk of postnatal depression, anxiety, and PTS whereas social support and satisfaction with birth were protective. The findings highlight the importance of routine and repeated mental health assessments and ongoing support for mothers of infants admitted to NNU.

Disparities in who is asked about their perinatal mental health: an analysis of cross-sectional data from consecutive national maternity surveys.

BACKGROUND: The perinatal period is a vulnerable time, with one in five women experiencing mental health problems. Antenatal and postnatal appointments are key contact points for identifying women in need of support. Since 2014, the UK National Institute for Health and Care Excellence (NICE) has recommended that all women be asked about their mental health at their antenatal booking appointment and early in the postnatal period. The aim of this study was to assess the proportions of women who reported being asked about their mental health during the perinatal period across consecutive national maternity surveys (NMS) in England and to evaluate sociodemographic disparities in who was asked. METHODS: Secondary analysis was performed on cross-sectional data from the NMS in 2014-2020. In each survey, women reported whether they had been asked about their mental health antenatally (during their booking appointment) and postnatally (up to six months after giving birth). The proportions of women in each survey who reported being asked about their mental health were calculated and compared according to key sociodemographic characteristics and across survey years. Logistic regression was conducted to identify disparities in who was asked. RESULTS: The proportion of women who reported being asked about their mental health antenatally increased from 80.3% (95%CI:79.0-81.5) in 2014 to 83.4% (95%CI:82.1-84.7) in 2020, yet the proportion of women who reported being asked postnatally fell from 88.2% (95%CI:87.1-89.3) in 2014 to 73.7% (95%CI:72.2-75.2) in 2020. Ethnic minority women (aOR range:0.20 ~ 0.67) were less likely to report being asked about their mental health antenatally and postnatally across all surveys compared to White women. Women living in less socioeconomically advantaged areas (aOR range:0.65 ~ 0.75) and women living without or separately from a partner (aOR range:0.61 ~ 0.73) were also less likely to report being asked about their mental health, although there was less consistency in these disparities across the antenatal and postnatal periods and across surveys. CONCLUSIONS: Despite NICE recommendations, many women are still not asked about their mental health during the perinatal period, particularly after giving birth. Women from ethnic minority backgrounds are less likely to be asked and these disparities have persisted over time.