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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. Plain language summary 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. Scientific summary Background and objectives Perinatal mental health (PMH) difficulties can occur during pregnancy or after birth. They commonly consist of anxiety disorders, depression, post-traumatic stress disorder (PTSD) and stress-related conditions such as adjustment disorder. PMH difficulties are particularly important because of the potential negative impact on women, their partners and children. For example, they are associated with an increased risk of maternal suicide, a decline in relationship satisfaction and long-term impacts on children’s development. It is therefore important that women with PMH difficulties can access care and treatment. However, research suggests only half of women with PMH problems are identified by health services and even fewer receive treatment. This research therefore aimed to identify potential barriers and facilitators to PMH care across the care pathway, both in terms of women accessing care, and in terms of health services implementing new PMH assessment and treatment initiatives. Our primary research objective was to develop a conceptual framework of barriers and facilitators to PMH care (defined as identification, assessment, care and treatment) to inform PMH services, and highlight where further research is needed. This was done through two systematic reviews which synthesised the evidence on: Review 1 (R1) barriers and facilitators to implementing PMH care; and Review 2 (R2) barriers to women accessing PMH care. Results were used to develop a conceptual framework which was then refined through consultations with stakeholders (e.g. women, general practitioners, midwives, health visitors, psychiatrists, commissioners, third-sector organisations, etc.). Results were used to inform recommendations for policy, practice and future research in PMH care. Secondary research objectives were to: (1) determine the barriers and facilitators to implementing PMH care in health and social care services; (2) identify differences in barriers and facilitators across different health and social care settings; (3) evaluate the quality of this evidence; (4) extract recommendations for implementation, practice and research based on the barriers and facilitators identified; (5) determine the barriers and facilitators to women accessing PMH care; (6) evaluate the quality of these reviews; and (7) map the geographical distribution of the research to establish generalisability and gaps in the evidence. Review methods For both reviews pre-planned searches were carried out in MEDLINE (1946–present), EMBASE (1974–present), PsychInfo (1806–present) and CINAHL (1982–present). R2 also used Scopus and Cochrane Database of Systematic Reviews (Issue 8 of 12, August 2021). MeSH terms (i.e. prenatal care/anxiety/diagnosis) and Boolean operators ‘OR’ and ‘AND’ were used. Eligibility criteria for R1 were empirical studies that examined factors that either facilitated or impeded implementation of PMH care in health or social care services. These could be qualitative interviews with health professionals (HPs) or women about services; or studies describing the implementation of PMH care services. Eligibility criteria for R2 were reviews of literature on barriers and facilitators for women in the perinatal period (defined as conception to one year postpartum) to access assessment, care or treatment. Information on barriers and facilitators had to be directly drawn from perinatal women’s experiences. Only systematic reviews with a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) search strategy were included. Search results were imported into Endnote and duplicates were removed. Remaining studies were then imported into Eppi-Reviewer. In R1 10% of the results were double screened. In R2 all studies were double screened. For both reviews, 10% of included studies had their data extracted in duplicate. Methodological quality appraisal was conducted using the Joanna Briggs Critical Appraisal Tools for R1, and dual appraisal was conducted for 35% of included papers. Most studies (n = 44) had a quality rating above 70% suggesting that studies were well-conducted with low risk of bias. For R2, methodological quality of reviews was appraised using A measurement tool to assess systematic reviews-2 (AMSTAR) tool, and dual appraisal was carried out for all included reviews. The majority of reviews were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. Therefore, a qualitative sensitivity analysis was carried out to assess whether themes remained consistent across all reviews regardless of their quality rating. Only qualitative papers were identified. Results were analysed using a thematic synthesis and mapping themes on to a systems level model adapted from Ferlie and Shortell’s Levels of Change framework (e.g. individual level factors, HP factors, organisational factors and larger system factors) (Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Q 2001;79(2):281–315. https://doi.org/10.1111/1468-0009.00206) and then grouped to reflect different stages of the care pathway adapted from Goldberg and Huxley’s Pathways to Care model (e.g. deciding to disclose, assessment, access to care, treatment) (Goldberg D, Huxley P. Common Mental Disorders: A Bio-Social Model. New York, NY: Tavistock/Routledge; 1992.). Review results Review 1 searches identified a total of 21,535 citations. After screening by title and abstract 10,130 records were excluded, leaving 931 papers to be screened by full text. Screening of full texts identified 43 studies to be included in the review. Forward and backward searches identified a further three papers. Therefore, 46 qualitative studies were included in the qualitative synthesis. Studies were mainly carried out in higher income countries (HICs). Implementation occurred in a wide range of settings including hospitals (n = 14); primary care (n = 12); and community-based care (n = 12). Most studies (n = 22) looked at the implementation of comprehensive care services (including screening, referral and treatment). Review 2 searches identified a total of 4086 citations. After removing duplicates and studies not meeting inclusion criteria, 2028 articles were left to be screened. Screening by title and abstract led to 1962 records being excluded, leaving 66 papers to be screened by full text. Screening of full texts identified 32 reviews of qualitative studies to be included in the meta-review. Reviews were conducted between 2006 and 2021. The number of studies included in each review varied from 4 to 40 with a total of 344 studies included across all the reviews. The reviews included studies carried out in 24 different countries. Most reviews focused on perinatal depression. Qualitative sensitivity analysis found that most themes were supported in both the higher quality and lower quality reviews. Including all reviews meant the data was richer and included marginalised women, such as refugees, migrants and women living in sub-Saharan Africa. This suggests results from R2 can be interpreted with reasonable confidence. Overall, in terms of geographical distribution and type of mental illness most studies were carried out in HICs (R1: n = 38; R2: n = 28), and the majority focused on perinatal depression (R1: n = 32; R2: n = 23). Barriers and facilitators to PMH care were identified from R1 and R2. Results from both reviews were merged together and mapped on to seven levels informed by Ferlie and Shortell’s (2001)40 framework (Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Q 2001;79(2):281–315. https://doi.org/10.1111/1468-0009.00206). These were: (1) Individual factors; (2) HP factors; (3) Interpersonal factors; (4) Organisational factors; (5) Commissioner factors; (6) Political factors; and (7) Societal factors. Factors at these levels impacted on PMH care at different stages of the care pathway. Individual level factors were the most influential in women’s decision to consult. Women not understanding HPs roles (n = 12) or not understanding what perinatal mental illness (PMI) was (n = 14) were the most cited barriers. The largest individual level facilitator to deciding to consult was recognising something was wrong (n = 8). In terms of first contact with HPs, the most commonly cited reason for women dropping out of the care pathway was if HPs were dismissive about mental illness or normalised women’s symptoms (n = 8). Assessment of PMH was influenced by multiple factors. At the individual level, the most cited barrier was the presence of family and friends with negative beliefs about mental illness (n = 7). At the HP level, assessment specific behaviours such as carrying it out in a tick box way (n = 12) was the most cited barrier. At the interpersonal level, women and HPs being able to speak openly and honestly about assessment was the most cited facilitator (n = 5). At the organisational level, the most common facilitator was the acceptability of assessment or screening for both HPs and women (n = 17). Women deciding to disclose their symptoms was also affected by multiple factors. At the individual level, fear of being judged as a bad mother (n = 7) was the most cited barrier. HPs appearing too busy was the most cited barrier (n = 5) at the HP level. A lack of a trusting relationship between women and HPs (n = 10) was the most cited interpersonal barrier. Linked to this, at the organisational level, a lack of continuity of carer (n = 8) was the most cited barrier. Stigma (n = 18), culture (n = 13) and maternal norms (n = 15) were all societal level barriers preventing the disclosure of PMH symptoms. The most commonly cited factors affecting referral were collaborative working across services (n = 7) and organisational referral procedures (n = 7). Multiple factors influenced access to treatment. At the individual level, the most cited barriers to accessing care were logistical issues such as not having childcare (n = 14), the location of the care and difficulties travelling there (n = 13). Language barriers were the biggest interpersonal barrier to women accessing care (n = 4) and related to this, a lack of culturally sensitive care was the most cited organisational barrier to access (n = 7). At the commissioner level, the most cited barrier to access was a lack of appropriate or timely services for women (n = 11). At the political level a lack of financial resources to pay for health care (n = 14) was a barrier to access. In terms of provision of optimal care, at the HP level, HPs possessing valued characteristics (n = 9), such as being trustworthy and caring, were facilitators to the provision of optimal care. At the interpersonal level, a lack of trusting relationship was a barrier to optimal care provision (n = 5). At the organisational level, the provision of individualised care (n = 11) that was appropriate to women’s needs (n = 12) was a facilitator. A lack of training related to PMI and treatment was the most cited organisational barrier (n = 15). At the wider levels, immigration status (n = 5), stigma (n = 8) and culture (n = 6) were barriers to optimal care. Multiple factors impacted women’s experience of treatment or care. At the individual level, social isolation (n = 7) was a barrier to women’s experience of care as it exacerbated their mental health difficulties further. HPs who provided hope to mothers, were caring, supportive, empathetic and went above and beyond meant women had a positive care experience (n = 9). Individualised and person-centred (n = 11) care was also associated with a positive care experience. In terms of barriers and facilitators within different health and social care settings, within hospitals the most cited factors influencing implementation were lack of time or a heavy workload (n = 8), and whether HPs were positive about the care being implemented (n = 8). In primary care, the most commonly cited factors that influenced implementation were stigma (n = 8) and family presence (n = 8). In community settings the most important factors were training (n = 8) and the characteristics of the person providing the care (n = 6). Across low-income countries, stigma (n = 4) and lack of training (n = 4) were the most cited barriers to implementation. Similarly, when health services were located in higher income countries, but women from a refugee or different cultural background accessed them, stigma (n = 6) and lack of HP training (n = 6), along with HP’s heavy workload (n = 6) and lack of collaborative working (n = 6) were the most cited barriers. The MATRIx conceptual frameworks Results from both reviews were synthesised to develop two conceptual frameworks. Eight stages outlined by Jabareen were followed to develop the frameworks: (1) mapping the selected data sources; (2) extensive reading and categorising of the selected data; (3) identifying and naming concepts; (4) deconstructing and categorising the concepts; (5) integrating concepts; (6) synthesis, resynthesis and making it all make sense; (7) validating the conceptual framework using stakeholder meetings and the Confidence in the Evidence from the Reviews of Qualitative research (CERQual) approach; and (8) rethinking the conceptual framework. Two MATRIx conceptual frameworks were developed that highlight the importance of 66 barriers and 39 facilitators to PMH care at multiple levels and that intersect across the care pathway. These conceptual frameworks informed the development of evidence-based recommendations on how to address barriers to ensure that all women are able to access the care and support they need. Recommendations were made for health policy, practice and research. Conclusions The MATRIx conceptual frameworks on barriers and facilitators highlight the need for women-centred, flexible care, delivered by well-trained, knowledgeable, and empathetic HPs working within an organisational and political structure that enables them to deliver quality care. Results also suggest a need for international efforts to reduce stigma associated with mental health difficulties. Recommendations for practice and policy were made. While recommendations are based on the evidence, they may be more or less achievable, depending on the local and national context and pressures on services. Based on the evidence, it is suggested that policy makers: (1) review the conceptual frameworks and take comprehensive, strategic and evidence-based steps to ensure there is an effective system of PMH care; (2) ensure services are adequately funded and there are enough trained staff in order to ensure every woman with PMH difficulties is able to access appropriate treatment in a timely fashion; and (3) improve access to health care for all through free health care and a fair and easy-to-access welfare system. The evidence suggests that recommendations for healthcare practice include: (1) designing care with women to ensure it meets their needs; (2) providing culturally sensitive care and increasing the accessibility of care through pictorial aids and translators; (3) ensuring chosen technology is fit for purpose, and co-designed with HPs; (4) services working together; (5) employment of enough staff from a variety of health disciplines; and (6) HPs receiving high-quality training, with protected time to complete it. Limitations In R1 only 10% of abstracts were double screened and, given the large number of citations to screen, some papers may have been missed. Similarly, in R1 only 10% of included papers were methodologically appraised by two reviewers. Both reviews only included papers published in academic journals and written in English. Relevant reviews from health services, charities, third-sector organisations and other grey literature may have been missed. Furthermore, the majority of reviews in R2 were evaluated as having low (n = 14) or critically low (n = 5) confidence in their results. However, this was mitigated through the use of a qualitative sensitivity analysis. Future work Further research is needed to examine access to PMH care for specific groups, such as fathers, immigrants or those in lower income countries. More research is needed on facilitators to implementing and accessing PMH care, as well as appropriate measures to help service managers assess whether a service is working effectively. 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.

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.

Background Perinatal mental health (PMH) problems are a leading cause of maternal death and increase the risk of poor outcomes for women and their families. It is therefore important to identify the barriers and facilitators to implementing and accessing PMH care. Aims To develop a conceptual framework of barriers and facilitators to PMH care to inform PMH services. Method Relevant literature was systematically identified, categorised and mapped onto the framework. The framework was then validated through evaluating confidence with the evidence base and feedback from stakeholders (women and families, health professionals, commissioners and policy makers). Results Barriers and facilitators to PMH care were identified at seven levels: individual (e.g. beliefs about mental illness), health professional (e.g. confidence addressing perinatal mental illness), interpersonal (e.g. relationship between women and health professionals), organisational (e.g. continuity of carer), commissioner (e.g. referral pathways), political (e.g. women's economic status) and societal (e.g. stigma). The MATRIx conceptual frameworks provide pictorial representations of 66 barriers and 39 facilitators to PMH care. Conclusions The MATRIx frameworks highlight the complex interplay of individual and system-level factors across different stages of the care pathway that influence women accessing PMH care and effective implementation of PMH services. Recommendations are made for health policy and practice. These include using the conceptual frameworks to inform comprehensive, strategic and evidence-based approaches to PMH care; ensuring care is easy to access and flexible; providing culturally sensitive care; adequate funding of services and quality training for health professionals, with protected time to complete it.

Abstract Background Pregnancy and childbirth are significant events in women’s lives and most women have expectations or plans for how they hope their labour and birth will go. It is possible that strong expectations about labour and birth lead to dissatisfaction or other negative outcomes if these expectations are not met, but it is not clear if this is the case. The aim was therefore to synthesise prospective studies in order to understand whether unmet birth expectations are associated with adverse outcomes for women, their partners and their infants. Method Searches were carried out in Academic Search Complete; CINAHL; Medline; PsycINFO, PsychArticles, PubMed, SCOPUS and Web of Science. Forward and backward searches were also completed. Studies were included if they reported prospective empirical research that examined the association between a mismatch in birth expectations/experience and postnatal outcomes in women, their children and/or their partners. Data were synthesised qualitatively using a narrative approach where study characteristics, context and methodological quality were extracted and summarised and then the differences and similarities among studies were used to draw conclusions. Results Eleven quantitative studies were identified for inclusion from nine countries. A mismatch between birth expectations and experiences was associated with reduced birth satisfaction. Three studies found a link between a mismatch and the development of postnatal post-traumatic stress disorder (PTSD). The evidence was inconsistent for postnatal depression, and fear of childbirth. Only one study looked at physical outcomes in the form of health-related quality of life. Conclusions A mismatch between birth expectations and experiences is associated with birth satisfaction and it may increase the risk of developing postnatal PTSD. However, it is not clear whether a mismatch is associated with other postnatal mental health conditions. Further prospective research is needed to examine gaps in knowledge and provide standardised methods of measuring childbirth expectations-experiences mismatch. To ensure women’s expectations are met, and therefore experience a satisfying birth experience, maternity providers should provide sensitive care, which acknowledges women’s needs and preferences, is based on open and clear communication, is delivered as early in pregnancy as possible, and enables women to make their own decisions about care. Trial registration Protocol registration: PROSPERO CRD42020191081 .

Abstract Background Early Intervention in Psychosis (EIP) services improve health outcomes for young people with psychosis in the medium–long term, but 25% of young people disengage in the first 12 months with costs to their mental health, families, society and the NHS. This study will evaluate the effectiveness, cost-effectiveness and implementation of a team-based motivational Early Youth Engagement (EYE-2) intervention. Method The study design is a cluster randomised controlled trial (RCT) with economic evaluation, comparing the EYE-2 intervention + standardised EIP service to standardised EIP service alone, with randomisation at the team level. A process evaluation will evaluate the delivery of the intervention qualitatively and quantitatively across contexts. The setting is 20 EIP teams in 5 sites: Manchester, South London, East Anglia, Thames Valley and Hampshire. Participants are young people (14–35 years) with first episode psychosis, and EIP staff. The intervention is the team-based motivational engagement (EYE-2) intervention, delivered alongside standardised EIP services, and supported by additional training, website, booklets and social groups. The comparator is the standardised EIP service. Both interventions are delivered by EIP clinicians. The primary outcome is time to disengagement (time in days from date of allocation to care coordinator to date of last contact following refusal to engage with EIP service, or lack of response to EIP contact for a consecutive 3-month period). Secondary outcomes include mental and physical health, deaths, social and occupational function, recovery, satisfaction and service use at 6, 12, 18 and 24 months. A 12-month within-trial economic evaluation will investigate cost-effectiveness from a societal perspective and from an NHS perspective. Discussion The trial will provide the first test of an engagement intervention in standardised care, with the potential for significant impact on the mental health and wellbeing of young people and their families, and economic benefits for services. The intervention will be highly scalable, supported by the toolkit including manuals, commissioning guide, training and resources, adapted to meet the needs of the diverse EIP population, and based on an in-depth process evaluation. Trial registration ISRCTN 51629746 prospectively registered 7th May 2019. Date assigned 10th May 2019.

The City Infant Faces Database (CIFD; Webb et al., 2018) is a database of 154 infant emotional expressions for use in experimental studies of infant facial communication, facial expression recognition, and parental sensitivity. The CIFD was validated only in a small sample from the general public and student midwives and nurses in the UK. This study, therefore, aimed to validate it in a larger sample of Croatian students and parents of 1-12 months old infants. Three-hundred and fifty students (Study 1), 422 mothers and 106 fathers (Study 2) were presented with images of Caucasian infant faces. The students rated images from the CIFD and Tromsø Infant Faces. They also completed questionnaires measuring empathy, alexithymia, and perceiving and expressing emotions. The parents rated the valence of facial expressions of images from the CIFD. The results were consistent with the initial validation in both the students and parents’ sample, except that agreement for negative images was lower for Croatian parents than in the UK study. Compared to the UK study, students rated images as more intense, clear, genuine, and reported stronger internal emotion. Furthermore, there was no difference in accuracy between mothers and fathers or between first-time parents and experienced parents. The CIFD is, therefore, a promising tool for research and should be further validated in other countries, focusing on its predictive validity.

Abstract Background Risk perception in relation to pregnancy and birth is a complex process influenced by multiple personal, psychological and societal factors. Traditionally, the risk perception of healthcare professionals has been presented as more objective and authoritative than that of pregnant women. Doctors have been presented as more concerned with biomedical risk than midwives. Such dichotomies oversimplify and obscure the complexity of the process. This study examines pregnancy-related risk perception in women and healthcare professionals, and what women and professionals believe about each other’s risk perception. Methods A cross sectional survey of set in UK maternity services. Participants were doctors working in obstetrics (N = 53), midwives (N = 59), pregnant women (N = 68). Participants were recruited in person from two hospitals. Doctors were also recruited online. Participants completed a questionnaire measuring the degree of perceived risk in various childbirth-related scenarios; and the extent to which they believed others agreed with them about the degree of risk generally involved in childbirth. Main outcome measures were the degree of risk perceived to the mother in baby in pregnancy scenarios, and beliefs about own perception of risk in comparison to their own group and other groups. Results There were significant differences in total risk scores between pregnant women, doctors and midwives in perception of risk to the mother in 68/80 scenarios. Doctors most frequently rated risks lowest. Total scores for perceived risk to the baby were not significantly different. There was substantial variation within each group. There was more agreement on the ranking of scenarios according to risk. Each group believed doctors perceived most risk whereas actually doctors most frequently rated risks lowest. Each group incorrectly believed their peers rated risk similarly to themselves. Conclusions Individuals cannot assume others share their perception of risk or that they make correct assessments regarding others’ risk perception. Further research should consider what factors are taken into account when making risk assessments,

Research suggests that some fathers and birth partners can experience post-traumatic stress disorder (PTSD) after witnessing a traumatic birth. Birth-related PTSD may impact on many aspects of fathers’ and birth partners’ life, including relationship breakdown, self-blame and reducing plans for future children. Despite the potential impact on birth partners’ lives there is currently no measure of birth-related PTSD validated for use with birth partners. The current study therefore adapted the City Birth Trauma Scale for use with birth partners. The City Birth Trauma Scale (Partner version) is a 29-item questionnaire developed to measure birth-related PTSD according to DSM-5 criteria: stressor criteria (A), symptoms of re-experiencing (B), avoidance (C), negative cognitions and mood (D), and hyperarousal (E), as well as duration of symptoms (F), significant distress or impairment (G), and exclusion criteria or other causes (H). A sample of 301 fathers/birth partners was recruited online and completed measures of birth-related PTSD, bonding, and demographic details. Results showed the City Birth Trauma Scale (Partner version) had good reliability (α = 0.94) and psychometric and construct validity. The fathers/birth partners version has the same two-factor structure as the original scale: (1) general symptoms and (2) birth-related symptoms, which accounted for 51% of the variance. PTSD symptoms were associated with preterm birth and maternal and infant complications. Overall, the City Birth Trauma Scale (Partner version) provides a promising measure of PTSD following childbirth that can be used in research and clinical practice.

Background. It is unknown whether the medical home reduces the impact of adverse social determinants on low-income child health. Objective. To examine whether the medical home attenuates the association between unmet basic needs and health for low-income children. Design/Methods . Secondary data analysis of the 2011-12 NSCH restricted to

The use of deep learning is becoming increasingly important in the analysis of medical data such as pattern recognition for classification. The use of primary healthcare computational medical records (CMR) data is vital in prediction of infection prevalence across a population, and decision making at a national scale. To date, the application of machine learning algorithms to CMR data remains under-utilized despite the potential impact for use in diagnostics or prevention of epidemics such as outbreaks of influenza. A particular challenge in epidemiology is how to differentiate incident cases from those that are follow-ups for the same condition. Furthermore, the CMR data are typically heterogeneous, noisy, high dimensional and incomplete, making automated analysis difficult. We introduce a methodology for converting heterogeneous data such that it is compatible with a deep autoencoder for reduction of CMR data. This approach provides a tool for real time visualization of these high dimensional data, revealing previously unknown dependencies and clusters. Our unsupervised nonlinear reduction method can be used to identify the features driving the formation of these clusters that can aid decision making in healthcare applications. The results in this work demonstrate that our methods can cluster more than 97.84% of the data (clusters >5 points) each of which is uniquely described by three attributes in the data: Clinical System (CMR system), Read Code (as recorded) and Read Term (standardized coding). Further, we propose the use of Shannon Entropy as a means to analyse the dispersion of clusters and the contribution from the underlying attributes to gain further insight from the data. Our results demonstrate that Shannon Entropy is a useful metric for analysing both the low dimensional clusters of CMR data, and also the features in the original heterogeneous data. Finally, we find that the entropy of the low dimensional clusters are directly representative of the entropy of the input data (Pearson Correlation = 0.99, R2 = 0.98) and therefore the reduced data from the deep autoencoder is reflective of the original CMR data variability.

Purpose: This research explored the impact that the relatively new role of the Health and Wellbeing Lead upon the health and wellbeing of children and their families at this school. Design/methodology/approach: This case study took place in a primary school (children aged 4-11) in the South-West of England. Data was collected through activities with children, semi-structured interviews with senior staff and parents and a "learning walk". Findings: Our data suggested that this role provided compassion, unconditional positive regard and respect for parents, factors that are frequently absent from research into parent partnerships in education. The role presented as invaluable in tackling the many mental and physical challenges that parents faced in rearing their children, and in providing their children with the best possible chance of success. Research limitations/implications: This is a single Case Study and, as such, may or may not be representative of similar schools. We also question to what extent the findings demonstrated the strength of this role "per se," or whether the impact could simply be the result of a uniquely caring and passionate individual. Practical implications: We concluded that this was a role needed in all schools, recognising the key role that parents play in their child's wellbeing, and the indirect impact that parent mental health can have upon their child's success. Social implications: It is vital that this role is not used as an excuse by the government to further reduce the already denuded Social Services landscape within communities. It is also important that this responsibility does not become yet another burden added to already overstretched teaching staff. Originality/value: This research presents a fresh perspective on the multiple pressures that parents face and how these can impact upon their child's education.

Mounting an immune response to fight disease is costly for an organism and can reduce investment in another life-history trait, such as reproduction. The terminal investment hypothesis predicts that an organism will increase reproductive effort when threatened by disease. The reproductive fitness of amphibians infected with the deadly fungal pathogen Batrachochytrium dendrobatidis (Bd) is largely unknown. In this study, we explored gametogenesis in two endangered and susceptible frog species, Pseudophryne corroboree and Litoria verreauxii alpina. Gametogenesis, both oogenesis and spermatogenesis, increased when animals were experimentally infected with Bd. In P. corroboree, infected males have thicker germinal epithelium, and a larger proportion of spermatocytes. In L. v. alpina, infected males had more spermatic cell bundles in total, and a larger proportion of spermatozoa bundles. In female L. v. alpina, ovaries and oviducts were larger in infected animals, and there were more cells present within the ovaries. Terminal investment has consequences for the evolution of disease resistance in declining species. If infected animals are increasing reproductive efforts and producing more offspring before succumbing to disease, it is possible that population-level selection for disease resistance will be minimized.

The amphibian chytrid fungus Batrachochytrium dendrobatidis (Bd) has caused mass mortality leading to population declines and extinctions in many frog species worldwide. The lack of host resistance may be due to fungal immunosuppressive effects that have been observed when Bd is incubated with cultured lymphocytes, but whether in vivo host immunosuppression occurs is unknown. We used a broad range of hematologic and protein electrophoresis biomarkers, along with various functional tests, to assess immune competence in common green (Litoria caerulea) and white-lipped (L. infrafrenata) tree frogs experimentally infected with Bd. Compared with uninfected frogs, Bd infection in L. caerulea caused a reduction in immunoglobulin and splenic lymphocyte responses to antigenic stimulation with sheep red blood cells, along with decreased white blood cell and serum protein concentrations, indicating possible impaired immune response capability of Bd-infected frogs. This is the first in vivo study suggesting that infection with Bd causes multiple defects in systemic host immune function, and this may contribute to disease development in susceptible host species. Although L. infrafrenata failed to maintain Bd infection after exposure, white blood cell and serum globulin concentrations were lower in recovered frogs compared with unexposed frogs, but antigen-specific serum and splenic antibody, and splenic cellular, responses were similar in both recovered and unexposed frogs. This may indicate potential systemic costs associated with infection clearance and/or redirection of host resources towards more effective mechanisms to overcome infection. No clear mechanism for resistance was identified in L. infrafrenata, suggesting that localized and/or innate immune defense mechanisms may be important factors involved in disease resistance in this species.