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.

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.

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.

Scoping review: mapping clinical guidelines and policy documents that address the needs of women who are dependent on drugs during the perinatal period.

BACKGROUND: Women who use or are in treatment for drug use during the perinatal period often have complex needs and presenting comorbidity. Women who use opioids during pregnancy, and their infants, experience poor outcomes. Drug use by women during pregnancy is a public health priority. This scoping review aimed to (1) map clinical guidelines, treatment protocols and good practice guidance across the UK for women who use or are in treatment for drug use during the perinatal period, (2) identify recommended best practice across health and social care for optimising outcomes and reducing inequalities for these women and (3) identify potential gaps within guidance. METHODS: We followed the Joanna Briggs International (JBI) guidance on scoping reviews and PRISMA Scr extension. A registered protocol, containing a clear search strategy, inclusion, and exclusion criteria was adhered to. Reviewers double screened 25%, discussing disagreements. Data were extracted using a predefined template and charted in tables. Recommendations for best practice were organised around agreed categories. RESULTS: Of 968 documents screened, 111 met the inclusion criteria. The documents included UK-wide, national, regional, and organisational policy documents. They varied in the degree they were relevant to women who use or are in treatment for drug use during the perinatal period, the settings to which they applied, and their intended users. Most were created without patient or public involvement and lacked any clear evidence base. Overall, documents recommended an integrated model of care with a lead professional, clear referral pathways and information sharing between agencies. Guidance suggested referrals should be made to specialist midwives, drug, and social care services. A holistic assessment, inclusive of fathers / partners was suggested. Recent documents advocated a trauma-informed care approach. Opioid substitution therapy (OST) was recommended throughout pregnancy where required. Potential gaps were identified around provision of support for women postnatally, especially when their baby is removed from their care. CONCLUSIONS: This synthesis of recommended practice provides key information for practitioners, service providers and policy makers. It also highlights the need for guidelines to be evidence-based, informed by the experiences of women who use or are in treatment for drug use during the perinatal period, and to address the support needs of postnatal women who have their babies removed from their care.

Mapping factors that may influence attrition and retention of midwives: a scoping review protocol.

INTRODUCTION: An appropriately staffed midwifery workforce is essential for the provision of safe and high-quality maternity care. However, there is a global and national shortage of midwives. Understaffed maternity services are frequently identified as contributing to unsafe care provision and adverse outcomes for mothers and babies. While there is a need to recruit midwives through pre-registration midwifery programmes, this has significant resource implications, and is counteracted to a large extent by the high number of midwives leaving the workforce. It is increasingly recognised that there is a critical need to attend to retention in midwifery in order to develop and maintain safe staffing levels. The objective of this review is to collate and map factors that have been found to influence attrition and retention in midwifery. METHODS AND ANALYSIS: Joanna Briggs Institute guidance for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews will be used to guide the review process and reporting of the review. CINAHL, MEDLINE, PsycINFO and Scopus databases will be searched for relevant literature from date of inception to 21 July 2023. Research from high-income countries that explores factors that influence leaving intentions for midwives will be included. Literature from low-income and middle-income countries, and studies where nursing and midwifery data cannot be disaggregated will be excluded. Two reviewers will screen 20% of retrieved citations in duplicate, the first author will screen the remaining results. Data will be extracted using a preformed data extraction tool by the first author. Findings will be presented in narrative, tabular and graphical formats. ETHICS AND DISSEMINATION: The review will collate data from existing research, therefore ethics approval is not required. Findings will be published in journals, presented at conferences and will be translated into infographics and other formats for online dissemination.

Drivers of mortality in COVID ARDS depend on patient sub-type.

The most common cause of death in people with COVID-19 is Acute Respiratory Distress Syndrome (ARDS). Prior studies have demonstrated that ARDS is a heterogeneous syndrome and have identified ARDS sub-types (phenoclusters). However, non-COVID-19 ARDS phenoclusters do not clearly apply to COVID-19 ARDS patients. In this retrospective cohort study, we implemented an iterative approach, combining supervised and unsupervised machine learning methodologies, to identify clinically relevant COVID-19 ARDS phenoclusters, as well as characteristics that are predictive of the outcome for each phenocluster. To this end, we applied a supervised model to identify risk factors for hospital mortality for each phenocluster and compared these between phenoclusters and the entire cohort. We trained the models using a comprehensive, preprocessed dataset of 2,864 hospitalized COVID-19 ARDS patients. Our research demonstrates that the risk factors predicting mortality in the overall cohort of COVID-19 ARDS may not necessarily apply to specific phenoclusters. Additionally, some risk factors increase the risk of hospital mortality in some phenoclusters but decrease mortality in others. These phenocluster-specific risk factors would not have been observed with a single predictive model. Heterogeneity in phenoclusters of COVID-19 ARDS as well as the drivers of mortality may partially explain challenges in finding effective treatments for all patients with ARDS.

Experience of induction of labour: a cross-sectional postnatal survey of women at UK maternity units.

OBJECTIVES: This study explored women's views and experiences of key elements of the induction of labour (IOL) process, including at home or in hospital cervical ripening (CR). DESIGN: A questionnaire-based postnatal survey undertaken as part of the CHOICE Study process evaluation. The questionnaire was administered online and included fixed response and free-text options. SETTING: National Health Service maternity units in the UK. PARTICIPANTS: 309 women who had an IOL. OUTCOME MEASURES: The primary outcome measure was experience of IOL. Few women returned home during CR, meaning that statistical comparison between those who experienced home-based and hospital-based CR was not possible. Findings are reported as descriptive statistics with content analysis of women's comments providing context. RESULTS: Information to support choice and understand what to expect about IOL is often inadequate or unavailable. Having IOL can create anxiety and remove options for birth that women had hoped would enhance their experience. Although it can provide a more comfortable environment, home CR is not always an acceptable solution. Women described maternity care negatively impacted by staffing shortages; delays to care sometimes led to unsafe situations. Women who had a positive experience of IOL described supportive interaction with staff as a significant contribution to that. CONCLUSIONS: Women do not experience IOL as a benign and consequence free intervention. There is urgent need for research to better target IOL and optimise safety and experience for women and their babies. Relatively few women were offered CR at home and further research is needed on this experience.

Clinicians' perspectives and experiences of providing cervical ripening at home or in-hospital in the United Kingdom.

Induction of labour, or starting labour artificially, is offered when the risks of continuing pregnancy are believed to outweigh the risks of the baby being born. In the United Kingdom, cervical ripening is recommended as the first stage of induction. Increasingly, maternity services are offering this outpatient or 'at home', despite limited evidence on its acceptability and how different approaches to cervical ripening work in practice. There is also a paucity of literature on clinicians' experiences of providing induction care in general, despite their central role in developing local guidelines and delivering this care. This paper explores induction, specifically cervical ripening and the option to return home during that process, from the perspective of midwives, obstetricians and other maternity staff. As part of a process evaluation involving five case studies undertaken in British maternity services, interviews and focus groups were conducted with clinicians who provide induction of labour care. The thematic findings were generated through in-depth analysis and are grouped to reflect key points within the process of cervical ripening care: 'Implementing home cervical ripening', 'Putting local policy into practice', 'Giving information about induction' and 'Providing cervical ripening'. A range of practices and views regarding induction were recorded, showing how the integration of home cervical ripening is not always straightforward. Findings demonstrate that providing induction of labour care is complex and represents a significant workload. Home cervical ripening was seen as a solution to managing this workload; however, findings highlighted ways in which this expectation might not be borne out in practice. More comprehensive research is needed on workload impacts and possible lateral effects within other areas of maternity services.

Qualitative evaluation of rapid implementation of remote blood pressure self-monitoring in pregnancy during Covid-19.

In March 2020, the World Health Organisation named the severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2), which causes corona virus disease 2019 (COVID -19), as a pandemic. Pregnant women were considered at increased risk of developing severe COVID-19 after viral infection. In response maternity services reduced face-to-face consultations with high-risk pregnant women by supplying blood pressure monitors for supported self-monitoring. This paper explores the experiences of patients and clinicians of the rapid roll-out of supported self-monitoring programme in Scotland during the first and second wave of the COVID-19 pandemic. We conducted semi-structured telephone interviews with high-risk women and healthcare professionals who were using supported self-monitoring of blood pressure (BP) In four case studies during the COVID-19 pandemic. 20 women, 15 midwives and 4 obstetricians took part in the interviews. Interviews with healthcare professionals showed that while implementation occurred at pace and at scale across the National Health Service (NHS) in Scotland, implementation differed locally, resulting in mixed experiences. Study Participants observed several barriers and facilitators to implementation. Women value the simplicity of use and convenience of the digital communications platforms while health professionals were more interested in their impact on reducing workload for both women and health professionals largely found self-monitoring acceptable, with only a few exceptions. These results show that rapid change can occur in the NHS at a national level when there is a shared motivation. While self-monitoring is acceptable to most women, decisions regarding self-monitoring should be made jointly and on an individual basis.

Discriminating Acute Respiratory Distress Syndrome from other forms of respiratory failure via iterative machine learning.

Acute Respiratory Distress Syndrome (ARDS) is associated with high morbidity and mortality. Identification of ARDS enables lung protective strategies, quality improvement interventions, and clinical trial enrolment, but remains challenging particularly in the first 24 hours of mechanical ventilation. To address this we built an algorithm capable of discriminating ARDS from other similarly presenting disorders immediately following mechanical ventilation. Specifically, a clinical team examined medical records from 1263 ICU-admitted, mechanically ventilated patients, retrospectively assigning each patient a diagnosis of "ARDS" or "non-ARDS" (e.g., pulmonary edema). Exploiting data readily available in the clinical setting, including patient demographics, laboratory test results from before the initiation of mechanical ventilation, and features extracted by natural language processing of radiology reports, we applied an iterative pre-processing and machine learning framework. The resulting model successfully discriminated ARDS from non-ARDS causes of respiratory failure (AUC = 0.85) among patients meeting Berlin criteria for severe hypoxia. This analysis also highlighted novel patient variables that were informative for identifying ARDS in ICU settings.

Should pregnant women know their individual risk of future pelvic floor dysfunction? A qualitative study.

BACKGROUND: The study aimed to explore: • pregnant women's and healthcare professionals' perspectives on provision of individual risk scores for future Pelvic Floor Dysfunction (PFD), • the feasibility of providing this during routine maternity care, • actions women might take as a result of knowing their PFD risk. METHODS: Qualitative study. SETTING: UK NHS Health Board. PARTICIPANTS: Pregnant women (n = 14), obstetricians (n = 6), midwives (n = 8) and physiotherapists (n = 3). A purposive sample of pregnant women and obstetric healthcare professionals were introduced to the UR-CHOICE calculator, which estimates a woman's PFD risk, and were shown examples of low, medium and high-risk women. Data were collected in 2019 by semi-structured interview and focus group and analysed using the Framework Approach. RESULTS: Women's PFD knowledge was limited, meaning they were unlikely to raise PFD risk with healthcare professionals. Women believed it was important to know their individual PFD risk and that knowledge would motivate them to undertake preventative activities. Healthcare professionals believed it was important to discuss PFD risk, however limited time and concerns over increased caesarean section rates prevented this in all but high-risk women or those that expressed concerns. CONCLUSION: Women want to know their PFD risk. As part of an intervention based within a pregnant woman/ maternity healthcare professional consultation, the UR-CHOICE calculator could support discussion to consider preventative PFD activities and to enable women to be more prepared should PFD occur. A randomised controlled trial is needed to test the effectiveness of an intervention which includes the UR-CHOICE calculator in reducing PFD.

Promoting smoking cessation during pregnancy: A feasibility and pilot trial of a digital storytelling intervention delivered via text-messaging.

OBJECTIVE: Smoking during pregnancy causes risks to mother and infant health. We investigated the feasibility and likely success of SKIP-IT, a narrative and picture-based smoking cessation intervention delivered via text messages. METHODS: A feasibility and pilot trial. We aimed to recruit 70 pregnant women who smoked, randomised to usual care alone, or usual care and the SKIP-IT intervention, between 12 weeks of pregnancy and 6 weeks post due-date. Outcomes assessed were recruitment, retention, acceptability of, and engagement with the intervention, smoking behaviour, intentions, perceived risk, and self-efficacy. RESULTS: Of 312 women initially approached by smoking cessation services only 54 (17%) agreed to be contacted by the research team. Twenty were then either ineligible or uncontactable and 28 (82%) participated. Most women reported texts to be entertaining and helpful. The proportion of women not smoking at follow-up was lower in the intervention group, but numbers were too small to draw conclusions about effectiveness. CONCLUSION: The intervention was acceptable, but difficulty in making initial and follow-up contacts meant our methods were unfeasible for a larger trial. PRACTICE IMPLICATIONS: Digital Storytelling interventions could help women quit smoking, but further research is required to identify alternative methods for studies with pregnant women who smoke.

Exploring pain characteristics in nulliparous women; A precursor to developing support for women in the latent phase of labour.

BACKGROUND: Admission to hospital in the latent phase of labour is associated with a cascade of unnecessary intervention. Women who seek early hospital admission may have heightened fear and anxiety in relation to pain routed in their pre-pregnancy experiences. OBJECTIVE: To determine the prevalence of pain catastrophising in a healthy non-pregnant population and explore previous pain experiences and fear of childbirth as characteristics that might predict pain catastrophising. DESIGN: Prospective observational study across two higher education institutions in Scotland and England using a semi-structured survey administered through Bristol Online Surveys. Four validated questionnaires were used to identify the prevalence of pain catastrophising and fear of childbirth in nulliparous women of reproductive age. RESULTS: The survey was completed by 122 women undertaking an undergraduate degree and aged between 18 and 23 years. A high prevalence of pain catastrophising was found: a cut-off score of 20 and above = 47.5% (58/122 participants), a cut-off score of 30 and above = 21.3% (26/122). Fear of pain (ß = 0.14, t = 4.21, p <0 .001) and pain-related anxiety (ß = 0.40, t = 11.39, p <0 .001) were significant predictors of pain catastrophisation. However, there was no correlation between fear of childbirth and pain catastrophisation. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: It is reasonable to hypothesise that the pain catastrophising scale may be a good tool to predict those women likely to require additional support in the latent phase of labour; however further work is needed to explore this with a group of pregnant women.

The Malaysian Women's Experience of Care and Management of Postnatal Depression.

OBJECTIVES: Early detection and intervention for Maternal Postnatal Depression (PND) are imperative to prevent devastating consequences for mothers, babies, and families. However, there are no guidelines that explicitly focus on the management of PND in Malaysia. Consequently, it is unclear whether women with PND are receiving proper care and treatment. Therefore, this study aimed to explore Malaysian Women's experience in managing PND symptoms. METHODS: A qualitative study was conducted among 33 women attending Maternal and Child Health (MCH) clinics in Kuala Lumpur. Data were obtained through a face-to-face semi-structured interview and analysed using framework analysis. RESULTS: The women considered PND as a personal and temporary issue. Therefore, professional care was deemed unnecessary for them. Additionally, all Malay women considered religious approach as their primary coping strategy for PND. However, this was not the case for most Indian and Chinese women. CONCLUSION: The findings of this study indicated that women did not acknowledge the roles of Healthcare Practitioners (HCPs) in alleviating their emotional distress.Also, they perceived PND as a personal problem and less serious emotional condition. It is due to this perception that the women adopted self-help care as their primary coping strategy for PND. However, the coping strategy varied between different cultures. These findings underscore the importance of HCPs' proactive action to detect and alleviate PND symptoms as their attitude towards PND may influence Women's help-seeking behaviour.

Cervical ripening at home or in-hospital-prospective cohort study and process evaluation (CHOICE) study: a protocol.

INTRODUCTION: The aim of the cervical ripening at home or in-hospital-prospective cohort study and process evaluation (CHOICE) study is to compare home versus in-hospital cervical ripening to determine whether home cervical ripening is safe (for the primary outcome of neonatal unit (NNU) admission), acceptable to women and cost-effective from the perspective of both women and the National Health Service (NHS). METHODS AND ANALYSIS: We will perform a prospective multicentre observational cohort study with an internal pilot phase. We will obtain data from electronic health records from at least 14 maternity units offering only in-hospital cervical ripening and 12 offering dinoprostone home cervical ripening. We will also conduct a cost-effectiveness analysis and a mixed methods study to evaluate processes and women/partner experiences. Our primary sample size is 8533 women with singleton pregnancies undergoing induction of labour (IOL) at 39+0 weeks' gestation or more. To achieve this and contextualise our findings, we will collect data relating to a cohort of approximately 41 000 women undergoing IOL after 37 weeks. We will use mixed effects logistic regression for the non-inferiority comparison of NNU admission and propensity score matched adjustment to control for treatment indication bias. The economic analysis will be undertaken from the perspective of the NHS and Personal Social Services (PSS) and the pregnant woman. It will include a within-study cost-effectiveness analysis and a lifetime cost-utility analysis to account for any long-term impacts of the cervical ripening strategies. Outcomes will be reported as incremental cost per NNU admission avoided and incremental cost per quality adjusted life year gained. RESEARCH ETHICS APPROVAL AND DISSEMINATION: CHOICE has been funded and approved by the National Institute of Healthcare Research Health Technology and Assessment, and the results will be disseminated via publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ISRCTN32652461.

Barriers and facilitators to implementing perinatal mental health care in health and social care settings: a systematic review.

The improvement of perinatal mental health formed part of WHO's Millennium Development Goals. Research suggests that the implementation of perinatal mental health care is variable. To ensure successful implementation, barriers and facilitators to implementing perinatal mental health services need to be identified. Therefore, we aimed to identify the barriers and facilitators to implementing assessment, care, referral, and treatment for perinatal mental health into health and social care services. In this systematic review, we searched CINAHL, Embase, MEDLINE, and PsycINFO with no language restrictions for primary research articles published between database inception and Dec 11, 2019. Forward and backward searches of included studies were completed by March 31, 2020. Studies were eligible if they made statements about factors that either facilitated or impeded the implementation of perinatal mental health assessment, care, referral, or treatment. Partial (10%) dual screening was done. Data were extracted with EPPI-Reviewer 4 and analysed by use of a thematic synthesis. The protocol is registered on PROSPERO, CRD42019142854. Database searching identified 21 535 citations, of which 46 studies were included. Implementation occurred in a wide range of settings and was affected by individual (eg, an inability to attend treatment), health-care professional (eg, training), interpersonal (eg, trusting relationships), organisational (eg, clear referral pathways), political (eg, funding), and societal factors (eg, stigma and culture). A complex range of barriers and facilitators affect the implementation of perinatal mental health policy and practice. Perinatal mental health services should be flexible and women-centred, and delivered by well trained health-care professionals working within a structure that facilitates continuity of carer. Strategies that can be used to improve implementation include, but are not limited to, co-production of services, implementation team meetings, funding, and coalition building. Future research should focus on implementation barriers and facilitators dependent on illness severity, the health-care setting, and inpatient care.