Can we identify the prevalence of perinatal mental health using routinely collected health data?: A review of publicly available perinatal mental health data sources in England.

Introduction: Perinatal mental health (PMH) conditions affect around one in four women, and may be even higher in women from some ethnic minority groups and those living in low socioeconomic circumstances. Poor PMH causes significant distress and can have lifelong adverse impacts for some children. In England, current prevalence rates are estimated using mental health data of the general population and do not take sociodemographic variance of geographical areas into account. Services cannot plan their capacity and ensure appropriate and timely support using these estimates. Our aim was to see if PMH prevalence rates could be identified using existing publicly available sources of routine health data. Methods: A review of data sources was completed by searching NHS Digital (now NHS England), Public Health England and other national PMH resources, performing keyword searches online, and research team knowledge of the field. The sources were screened for routine data that could be used to produce prevalence of PMH conditions by sociodemographic variation. Included sources were reviewed for their utility in accessibility, data relevance and technical specification relating to PMH and sociodemographic data items. Results: We found a PMH data 'blind spot' with significant inadequacies in the utility of all identified data sources, making it impossible to provide information on the prevalence of PMH in England and understand variation by sociodemographic differences. Conclusions: To enhance the utility of publicly available routine data to provide PMH prevalence rates requires improved mandatory PMH data capture in universal services, available publicly via one platform and including assessment outcomes and sociodemographic data.

LGBTQ+ new and expectant parents' experiences of perinatal services during the UK's first COVID-19 lockdown.

BACKGROUND: COVID-19 created specific challenges for new and expectant parents and perinatal services. Services changed rapidly in the United Kingdom (UK), including the withdrawal of home birth services, birth center closures, and restrictions on the number of birth partners allowed in the birth room. The purpose of this study was to examine how these changes affected the experiences of LGBTQ+ parents in the UK. METHODS: An online survey was conducted in April 2020 to provide real-time data capture of new and expectant families' experiences. It was open to those in the third trimester, or to those who had given birth since the beginning of the first UK lockdown period, and their partners. The survey asked open-ended questions about perinatal experiences. Demographic data were also collected, including sexual orientation and gender. Responses were collected from 1754 participants, including 76 who self-identified as LGBTQ+. RESULTS: Thematic analysis identified that LGBTQ+ new and expectant parents faced similar issues to cisgendered, heterosexual expectant parents, though additional concerns were also noted relating to support and recognition. Heterocentric policies negatively affect lesbian families. Non-birthing co-mothers feared invalidation as parents. Sexual minority pregnant women were more likely than heterosexual pregnant women to consider additional birth supporters and to consider freebirthing. DISCUSSION: Service changes introduced in the pandemic were cisheteronormative, creating additional challenges for LGBTQ+ new and expectant parents and compounding existing inequalities. When planning, changing, or evaluating perinatal services, specific consideration is needed to include birthing parents who are not mothers and mothers who did not give birth. If appropriate care is not available, consequences may include impaired perinatal wellbeing and restricted birth choices. Including sexual orientation and gender in data collection enables different perspectives to be considered.

Women's experience of post-traumatic growth following a traumatic birth: an interpretive phenomenological analysis.

BACKGROUND: Approximately 3-5% of women experience post-traumatic stress disorder following birth; positive experiences that can follow traumatic birth are under-researched. AIMS AND OBJECTIVES: To explore how women experience post-traumatic growth following a traumatic birth. METHODS: Interpretative Phenomenological Analysis was used to explore experiences of women who self-identified as having found positive benefits through coping with a traumatic birth. Eight women who had birthed in the past five years in the UK were recruited online and interviewed face-to-face. RESULTS: Three superordinate themes were developed: 'The total opposite to what I'd expected' (participants' struggle to understand and integrate their birth experience in the postnatal period); 'I see it a bit differently now' (processes experienced in coming to a place of growth); and 'A much better place' (experienced growth 'outcomes'). DISCUSSION: Faced with shattered assumptions whereby their birth experiences contrasted with their expectations, participants felt their identities as women and mothers were challenged. In overcoming these challenges, participants described actively striving to cope and make sense of their experience. Multiple factors facilitated this, notably partner support, telling their birth story, acknowledging the impact and developing a compassionate narrative. Although growth was experienced in ways commonly reported by survivors of challenging life events, some aspects appeared pertinent to birth trauma. CONCLUSIONS: Widening our understanding of the range of experiences following traumatic birth and making these narratives public may offer hope for some women and families and inform health professionals' education and practice. Further research would be needed before advocating interventions to foster post-traumatic growth.

Service user and stakeholder engagement in maternal and newborn health research in low- and middle-income countries: A systematic review protocol.

BACKGROUND: Service user and stakeholder engagement have been widely considered as key aspects in translating knowledge into realistic policies and practices. However, there is a paucity of accumulative evidence about service user and stakeholder engagements in maternal and newborn health (MNH) research in low- and middle-income countries (LMICs). Therefore, we aim to systematically review the existing literature that includes service user and stakeholder engagement in maternal and newborn health research in low- and middle-income countries. MATERIALS AND METHODS: The design of this protocol is guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA-P) checklist. We will systematically run the search in PubMed/MEDLINE, PsycINFO, Scopus, Science Direct, and CINAHL to obtain relevant peer-reviewed literature published between January 1990 and March 2023. The list of extracted references will be screened by applying the study inclusion criteria, and eligible studies will be processed for further evaluation before being included in the review. The quality of the selected study will be assessed using the critical appraisal skills program (CASP) checklists and the Mixed Method Appraisal Tool (MMAT) checklist. A narrative synthesis will be used to synthesised results from all the included studies. DISCUSSION AND CONCLUSION: To the best of our knowledge, this systematic review will be the first synthesised evidence on service user and stakeholder engagement in maternal and newborn health research in low- and middle-income countries. The study highlights the importance of service user and stakeholder roles in designing, implementing, and evaluating maternal and newborn health interventions in resource-poor settings. The evidence from this review is expected to be useful for national and international researchers/stakeholders for practising meaningful and effective ways of engaging users and stakeholders in maternal and newborn health research and related activities. The PROSPERO registration number is CRD42022314613.

The COSI trial: a study protocol for a multi-centre, randomised controlled trial to explore the clinical and cost-effectiveness of the Circle of Security-Parenting Intervention in community perinatal mental health services in England.

BACKGROUND: Perinatal mental health difficulties affect up to 27% of birthing parents during pregnancy and the first postnatal year, and if untreated are associated with difficulties in bonding and long-term adverse outcomes to children. There are large evidence gaps related to psychological treatment, particularly in group therapy approaches and parent-infant interventions. One intervention showing preliminary efficacious findings and user acceptability is Circle of Security-Parenting (COS-P), which is a brief, weekly, group programme. However, these studies were underpowered and predominantly non-randomised, and there has never been a research trial in England or with birthing parents experiencing severe and complex perinatal mental health difficulties. The aim of the research is to conduct a randomised control trial to test whether COS-P will reduce perinatal mental health symptoms in birthing parents accessing NHS perinatal mental health services, compared to treatment as usual (TAU). Secondary objectives include exploring whether the intervention improves parenting sensitivity, emotion regulation skills, attachment security and infant development. Additionally, the project aims to examine whether the intervention is acceptable to parents and NHS staff, and whether it is cost-effective. METHODS: COSI is an individually randomised, single-blind parallel arm controlled trial with an embedded internal pilot aiming to recruit 369 participants in a 2:1 ratio (intervention: TAU). Participants will be recruited from ten NHS community perinatal mental health services in England and screened based on clinical levels of both mental health symptoms (average CORE-OM score ≥ 1.1) and postnatal bonding difficulties (total PBQ score ≥ 12). This trial has 90% power to detect a MCID of 5 points on the CORE-OM. Primary and secondary outcomes will be measured at baseline, 3, 7 and 12 months after baseline. Service use and quality of life measures will also be collected alongside a process evaluation of parents' and interveners' views and experiences. DISCUSSION: This will be the first large pragmatic trial to test whether COS-P is effective for birthing parents with severe and complex perinatal mental health difficulties in improving their mental health symptoms. If shown to be effective, the intervention could be delivered widely across the NHS and other similar services globally. TRIAL REGISTRATION: ISRCTN, ISRCTN18308962. Registered 18 February 2022.

Potentials and challenges of using co-design in health services research in low- and middle-income countries.

Co-design with people having poor access to health services and fragile health systems in low- and middle-income countries can be momentous in bringing service users and other stakeholders together to improve the delivery and utilisation of health services. There is ample of evidence from high-income countries regarding how co-design can translate available evidence into developing acceptable, feasible, and adaptable health solutions in different settings. However, there is limited literature on co-design in health research in the context of low- and middle-income countries. Therefore, it is crucial to understand how knowledge about collaborative working can be translated into policy and practice in the context of low- and middle-income countries. Thus, this paper discusses the concept of co-design, co-production, and co-creation in health and the potentiality and challenges of using co-design in health services research in low- and middle-income countries. Despite the challenges, the co-design research has considerable potential to encourage the meaningful engagement of service users and other stakeholders in developing, implementing, and evaluating real-world solutions in low- and middle-income countries. It is essential to balance power dynamics in a co-design process through mutual recognition and respect, participant diversity, and reciprocity and flexibility in sharing. The inclusive and collaborative approach to working is complex due to existing rigid hierarchical structures, socio-cultural beliefs, political interference and working practices. However, this could be minimised by developing transparent terms of reference that reflect the value and benefits of equal partnership in particular co-design work.

Non-birthing mothers' experiences of perinatal anxiety and depression: Understanding the perspectives of the non-birthing mothers in female same-sex parented families.

OBJECTIVE: Partners of birthing mothers can themselves experience perinatal mental health (PMH) difficulties. Despite birth rates increasing amongst LGBTQIA+ communities and the significant impact of PMH difficulties, this area is under-researched. This study aimed to examine the experiences of perinatal depression and anxiety of non-birthing mothers in female same-sex parented families. DESIGN: Interpretative Phenomenological Analysis (IPA) was used to explore the experiences of non-birthing mothers who self-identified as having experienced perinatal anxiety and/or depression. SETTING AND PARTICIPANTS: Sevenparticipants were recruited from online and local voluntary and support networks for LGBTQIA+ communities and for PMH. Interviews were in-person, online or via telephone. MEASUREMENTS AND FINDINGS: Six themes were generated. Distress was characterised by feelings of "Failure and Inadequacy in Role" (i.e., parent, partner and individual) and "Powerlessness and Intolerable Uncertainty" in their parenting journey. These feelings were reciprocally influenced by perceptions of the "Legitimacy of (Di)stress as a Non-birthing Parent", which impacted help-seeking. Stressors that contributed to these experiences were: "Parenting Without" a parental role template, social recognition and safety, and parental connectedness; and "Changed Relationship Dynamics" with their partner. Finally,participants spoke about "Moving Forward" in their lives. KEY CONCLUSIONS: Some findings are consistent with the literature on paternal mental health, including parents' emphasis on protecting their family and experiencing services as focusing on the birthing parent. Others appeared distinct or amplified for LGBTQIA+ parents, including the lack of a defined and socially recognised role; stigma concerning both mental health and homophobia; exclusion from heteronormative healthcare systems; and the importance placed on biological connectedness. IMPLICATIONS FOR PRACTICE: Culturally competent care is needed to tackle minority stress and recognise diverse family forms.

"We Should Be Working Together, and It Felt like They Disrupted That": Pregnant Women and Partners' Experiences of Maternity Care in the First UK COVID-19 Pandemic Lockdown.

Pregnant women were identified as being at elevated risk from COVID-19 early in the pandemic. Certain restrictions were placed upon birth partners accompanying their pregnant partner to in-person maternity consultations and for in-patient maternity care. In the absence of a central directive in England, the nature of restrictions varied across maternity services. Eleven participants (seven pregnant women and four partners), who were expectant parents during the first UK COVID-19 pandemic lockdown, took part in serial interviews in pregnancy and the postnatal period. Data were subject to a reflexive thematic analysis. Four main themes were identified, with sub-themes: uncertainty and anxiety (uncertainty and anxiety about COVID-19, uncertainty and anxiety about maternity services); disruption of partnering and parenting role; complexity around entering hospital spaces (hospitals offering protection while posing threat, individual health professionals in inflexible systems); and attempting to feel in control. Separating couples may result in disruption to their anticipated roles and significant distress to both partners, with potential impacts for mental health and future family relationships. Trauma-informed perspectives are relevant for understanding parents' experiences of maternity care in the pandemic and identifying ways to improve care to promote and protect the mental health of all parents.

Addressing inequalities in the identification and management of perinatal mental health difficulties: The perspectives of minoritised women, healthcare practitioners and the voluntary sector.

Background: Perinatal mental health (PMH) difficulties affect approximately one in five birthing women. If not identified and managed appropriately, these PMH difficulties can carry impacts across generations, affecting mental health and relationship outcomes. There are known inequalities in identification and management across the healthcare pathway. Whilst barriers and facilitators have been identified there is a lack of clarity about how these relate to the avoidable and unfair inequalities experienced by various groups of women. Further research is required to understand how to address inequalities in PMH. Aim: To understand the key factors that enable and hinder access to PMH care for women from minoritised groups across the PMH care pathway, and how these have been affected by the COVID-19 pandemic. Methods: A sequential mixed-methods approach gathered views and experiences from stakeholders in one region in northern England. This included an online survey with 145 NHS healthcare practitioners and semi-structured interviews with 19 women from ethnic minority and/or socio-economically deprived backgrounds who had experienced PMH difficulties, and 12 key informants from the voluntary and community sector workforce. Quantitative data were analysed using descriptive statistics and framework analysis was applied to qualitative data. Findings: Barriers and facilitators were mapped using a socio-technical framework to understand the role of (i) processes, (ii) people (organised as women, practitioners and others), (iii) technology, and (iv) the system as a whole in deepening or alleviating inequalities. Influences that were identified as pertinent to inequalities in identification and management included provision of interpreters, digital exclusion, stigma, disempowerment, distrust of services, practitioner attitudes, data capture, representation in the workforce, narrow rules of engagement and partnership working. Stakeholder groups expressed that several barriers were further compounded by the COVID-19 pandemic. Discussion: The findings highlight the need for change at the system level to tackle inequalities across the PMH care pathway. Four inter-connected recommendations were developed to enable this systems change: building emotional safety between professionals and women; making PMH a part of core healthcare business; increasing cultural competency specific to PMH; and enhanced partnership working.

Trans and non-binary pregnancy, traumatic birth, and perinatal mental health: a scoping review.

Background: Many trans and non-binary people wish to be parents. However, few countries record figures for trans and non-binary people becoming pregnant/impregnating their partners. Pregnant non-binary people and trans men may be growing populations, with heightened vulnerabilities to traumatic birth and perinatal mental health difficulties (i.e. pregnancy-one year postpartum). Aim: To conduct a scoping review on traumatic birth and perinatal mental health in trans and non-binary people to identify research evidence, summarize findings, and identify gaps. Methods: Electronic databases were searched to identify published English-language evidence. Eligibility was not restricted by type of study, country, or date. Findings: All studies were from the Global North and most participants were white. The literature focuses on structural and psychological barriers faced by non-binary people and trans men and on the lack of reliable medical information available. There is a lack of empirical research and, to date, no research into trans and non-binary parents' experiences has focused on traumatic birth or perinatal mental health. However, common themes of dysphoria, visibility, isolation, and the importance of individualized respectful care indicate potential vulnerability factors. Trans women's and non-binary people's experiences are particularly under-researched. Discussion: The themes of dysphoria, visibility, and isolation present a series of challenges to pregnant non-binary people and trans men. These coalesce with external events and internal choices, creating the potential to make the individual feel not man enough, not trans enough, not pregnant enough, and not safe enough during pregnancy, birth, and the postpartum. Further research involving trans people is needed to inform future services.

Muslim women's experiences of maternity services in the UK: qualitative systematic review and thematic synthesis.

BACKGROUND: This review aimed to identify and synthesise evidence of Muslim women's experiences of maternity services in the UK. A systematic review and thematic synthesis of qualitative evidence, unrestricted by type of publication was conducted. Muslim women who had accessed maternity services in the UK, regardless of obstetric or medical history were included. METHOD: Databases were searched from 2001 to 2019 and screened for inclusion using pre-determined criteria. The Critical Appraisal Skills Programme Qualitative Research Checklist was used to assess study quality and findings were synthesised using thematic synthesis, as described by Thomas and Harden. RESULTS: Six studies were included. The following five themes were identified: Islamic practices and Individualised care; Talk, Teach and Translate; Injustice, Inequity and Intolerance; If Allah wills; and, 'It's not all that bad'. Synthesis highlighted the significance of Islam in shaping many of the women's decision-making relating to antenatal screening and medication, which was contrasted with healthcare professionals' limited awareness of the importance of Islam for motherhood. The majority of women experienced poor maternity care which at times indicated stereotypical and discriminatory behaviour. CONCLUSIONS: Education for healthcare professionals is warranted, to enhance the quality and cultural competency in providing appropriate care that acknowledges and meets Muslim women's needs.

Assessing the Mental Health of Fathers, Other Co-parents, and Partners in the Perinatal Period: Mixed Methods Evidence Synthesis.

Introduction: Five to 10 percentage of fathers experience perinatal depression and 5-15% experience perinatal anxiety, with rates increasing when mothers are also experiencing perinatal mental health disorders. Perinatal mental illness in either parent contributes to adverse child and family outcomes. While there are increasing calls to assess the mental health of both parents, universal services (e.g., maternity) and specialist perinatal mental health services usually focus on the mother (i.e., the gestational parent). The aim of this review was to identify and synthesize evidence on the performance of mental health screening tools and the acceptability of mental health assessment, specifically in relation to fathers, other co-parents and partners in the perinatal period. Methods: A systematic search was conducted using electronic databases (MEDLINE, PsycINFO, Maternity, and Infant Care Database and CINAHL). Articles were eligible if they included expectant or new partners, regardless of the partner's gender or relationship status. Accuracy was determined by comparison of screening tool with diagnostic interview. Acceptability was predominantly assessed through parents' and health professionals' perspectives. Narrative synthesis was applied to all elements of the review, with thematic analysis applied to the acceptability studies. Results: Seven accuracy studies and 20 acceptability studies were included. The review identified that existing evidence focuses on resident fathers and assessing depression in universal settings. All accuracy studies assessed the Edinburgh Postnatal Depression Scale but with highly varied results. Evidence on acceptability in practice is limited to postnatal settings. Amongst both fathers and health professionals, views on assessment are mixed. Identified challenges were categorized at the individual-, practitioner- and service-level. These include: gendered perspectives on mental health; the potential to compromise support offered to mothers; practitioners' knowledge, skills, and confidence; service culture and remit; time pressures; opportunity for contact; and the need for tools, training, supervision and onward referral routes. Conclusion: There is a paucity of published evidence on assessing the mental health of fathers, co-mothers, step-parents and other partners in the perinatal period. Whilst practitioners need to be responsive to mental health needs, further research is needed with stakeholders in a range of practice settings, with attention to ethical and practical considerations, to inform the implementation of evidence-based assessment.

The Applicability and Performance of Tools Used to Assess the Father-Offspring Relationship in Relation to Parental Psychopathology and Offspring Outcomes.

Introduction: Father-infant interactions are important for optimal offspring outcomes. Moreover, paternal perinatal psychopathology is associated with psychological and developmental disturbances in the offspring, and this risk may increase when both parents are unwell. While, the father-offspring relationship is a plausible mechanism of risk transmission, there is presently no "gold standard" tool for assessing the father-offspring relationship. Therefore, we systematically searched and reviewed the application and performance of tools used to assess the father-offspring relationship from pregnancy to 24-months postnatal. Methods: Four electronic databases (including MEDLINE, PsycINFO, Maternity and Infant Care Database, and CINAHL) were searched. Selected articles included evidence of father-offspring relationship assessment in relation to parental perinatal psychopathology and/or offspring outcomes. Data was extracted and synthesized according to the following: (i) evidence supporting the performance of tools in terms of their psychometric properties when applied in the context of fathers, (ii) tool specific characteristics, and (iii) study specific methodological aspects in which the tool was embedded. Results: Of the 30,500 records eligible for screening, 38 unique tools used to assess the father-offspring relationship were identified, from 61 studies. Ten tools were employed in the context of paternal psychopathology, three in the context of maternal psychopathology, and seven in the context of both maternal and paternal psychopathology, while nine tools were applied in the context of offspring outcomes only. The remaining nine tools were used in the context of both parental psychopathology (i.e., paternal, and/or maternal psychopathology) and offspring outcomes. Evidence supporting the psychometric robustness of the extracted observational, self-report and interview-based tools was generally limited. Most tools were originally developed in maternal samples-with few tools demonstrating evidence of content validation specific to fathers. Furthermore, various elements influencing tool performance were recognized-including variation in tool characteristics (e.g., relationship dimensions assessed, assessment mode, and scoring formats) and study specific methodological aspects, (e.g., setting and study design, sample characteristics, timing and nature of parental psychopathology, and offspring outcomes). Conclusion: Given the strengths and limitations of each mode of assessment, future studies may benefit from a multimethod approach to assessing the father-offspring relationship, which may provide a more accurate assessment than one method alone.

Exploring the Feasibility of Use of An Online Dietary Assessment Tool (myfood24) in Women with Gestational Diabetes.

myfood24 is an online 24 hr dietary recall tool developed for nutritional epidemiological research. Its clinical application has been unexplored. This mixed methods study explores the feasibility and usability of myfood24 as a food record in a clinical population, women with gestational diabetes (GDM). Women were asked to complete five myfood24 food records, followed by a user questionnaire (including the System Usability Scale (SUS), a measure of usability), and were invited to participate in a semi-structured interview. Of the 199 participants, the mean age was 33 years, mean booking body mass index (BMI) 29.7 kg/m², 36% primiparous, 57% White, 33% Asian. Of these, 121 (61%) completed myfood24 at least once and 73 (37%) completed the user questionnaire; 15 were interviewed. The SUS was found to be good (mean 70.9, 95% CI 67.1, 74.6). Interviews identified areas for improvement, including optimisation for mobile devices, and as a clinical management tool. This study demonstrates that myfood24 can be used as an online food record in a clinical population, and has the potential to support self-management in women with GDM. However, results should be interpreted cautiously given the responders' demographic characteristics. Further research to explore the barriers and facilitators of uptake in people from ethnic minority and lower socioeconomic backgrounds is recommended.

Evaluation of trained volunteer doula services for disadvantaged women in five areas in England: women's experiences.

Disadvantaged childbearing women experience barriers to accessing health and social care services and face greater risk of adverse medical, social and emotional outcomes. Support from doulas (trained lay women) has been identified as a way to improve outcomes; however, in the UK doula support is usually paid-for privately by the individual, limiting access among disadvantaged groups. As part of an independent multi-site evaluation of a volunteer doula service, this study examined women's experiences of one-to-one support from a trained volunteer doula during pregnancy, labour and the post-natal period among women living in five low-income communities in England. A mixed methods multi-site evaluation was conducted with women (total n = 137) who received the service before December 2012, using a combination of questionnaires (n = 136), and individual or group interviews (n = 12). Topics explored with women included the timing and nature of support, its impact, the relationship with the doula and negative experiences. Most women valued volunteer support, describing positive impacts for emotional health and well-being, and their relationships with their partners. Such impacts did not depend upon the volunteer's presence during labour and birth. Indeed, only half (75/137; 54.7%) had a doula attend their birth. Many experienced volunteer support as a friendship, distinct from the relationships offered by healthcare professionals and family. This led to potential feelings of loss in these often isolated women when the relationship ended. Volunteer doula support that supplements routine maternity services is potentially beneficial for disadvantaged women in the UK even when it does not involve birth support. However, the distress experienced by some women at the conclusion of their relationship with their volunteer doula may compromise the service's impact. Greater consideration is needed for managing the ending of a one-to-one relationship with a volunteer, particularly given the likelihood of it coinciding with a period of heightened emotional vulnerability.