Peer supporters and peer facilitators create a friendly and welcoming environment by being warm, demonstrating care and using positive language. Human relationships are crucial to peer support. Peer supporters and facilitators need to be free to share about themselves and have control over how much to share. Whilst the relationship should be nurturing, open and honest, peer supporters should guide conversations and ensure they are boundaried and safe. Therefore, peer supporters and group facilitators should be further along in their recovery. That does not mean that mums that have not been trained cannot offer peer support to each other in a group setting. However, this needs to be managed by a trained facilitator.

Group facilitators should encourage group members to think about their individual boundaries and how to maintain them in the group. This includes thinking about how much they are willing to share and hear, and whether they want to maintain contact with other group members outside of the peer support group.

A safe and welcoming environment is supported by robust safeguarding structures that ensure the safety of everyone involved including mums, babies and peer supporters.

Peer support organisations need clear child and adult safeguarding policies and procedures, a safeguarding lead and clear reporting systems. These should be understood by staff, volunteers and project members/service users. If relevant, projects or services should also have lone working and home visiting policies and procedures in place. Peer supporters need to be trained in recognising and responding to potential safeguarding concerns. They should be supported to reflect on how to balance maintaining confidentiality and trust with acting to safeguard mums and babies.

Online peer support, whether a group-based forum or one to one messaging, should be facilitated through a moderated platform. Moderators should maintain safety by removing inappropriate and triggering posts and reaching out to platform users posing safeguarding concerns. In both face to face and online peer support, safety can be supported by positive relationships with clinical services. These can be useful in addressing safeguarding concerns and signposting of women who need additional support.

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Ideally, peer support should address the financial barriers women face in accessing peer support, for example by covering transport costs and not organising activities that will cost women money. Using accessible language women can relate to can also be important. This may include avoiding mental health terminology in favour of more neutral terms like emotional wellbeing.

Maintaining control over what peer support to engage in and when can contribute to accessibility. This includes a choice of different types of peer support including whether it takes place in person or online, in a one to one or group format, and in the form of structured discussions about mental health or informal chats and activities. Choice over how often to engage in peer support (e.g. not being required to attend every session) and to what extent (e.g. not having to share at every session) is also important.

The option of phone and online peer support can increase accessibility, especially in rural areas with fewer face to face options. However, this may not be appropriate for everyone as some women might struggle with literacy or have limited internet access.

It may be that a range of peer support options cannot be achieved within one project, service or organisation, especially when it comes to small projects based in the community. Therefore it is important for different peer support projects and services to work together collaboratively as the full range of peer support choices on offer will increase accessibility of peer support to individual mums.

What each project or service can and should do is to increase accessibility for the specific group of women it is aiming to support. From this perspective, increasing accessibility might mean defining membership more narrowly.

This is important for women who might be reluctant to attend general maternal mental health peer support. This includes women with less common maternal mental health experiences such as postpartum psychosis, perinatal OCD or birth trauma. It could also include women from minority ethnic backgrounds, refugee and migrant women, women with disabilities, lesbian and bisexual women, and women who have experienced homelessness, drug and alcohol misuse, or contact with the criminal justice system.

Projects or services will need to consider if there are any specific accessibility issues relevant for women that they support and respond accordingly (e.g. running sessions in languages other than English).

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However, the two should establish relationships of interdependence and equal recognition should be afforded to both approaches. Maintaining positive relationships with local clinical teams can enable peer support projects or services to support women better, for example via mutual referral. A relationship with clinical services can be particularly useful for peer-led groups running in the community. It facilitates access to appropriate channels for any safeguarding concerns and could provide an avenue for accessing clinical supervision for peer supporters. However, peer support should be able to accommodate the needs of women who prefer to avoid clinical mental health interventions because of previous negative experiences. Therefore, good peer support remains one step removed from clinical services.

Different models and degrees of collaboration with clinical services advance or hinder different aspects of peer support. Peer support projects or services need to make their own decisions regarding what is suitable for them.

Negotiating relationships with clinical services may be more challenging in certain contexts, for example when peer support is funded by the NHS or located within the NHS. In those contexts, encouraging meaningful peer leadership and involvement of mums in making decisions about what the peer support is aiming to achieve can ensure peer support maintains its distinct nature.

While there is likely to be some overlap with clinical mental health outcomes, peer support projects or services should define their own outcomes. These may include things like feeling heard and understood or dealing better with being unwell (rather than focusing solely on becoming well).

Not all peer support projects or services will identify the same set of outcomes as relevant to their work. This can vary depending on the focus and context of the peer support and may reflect cultural variation in mental health concepts. Outcomes should be developed in consultation with mums who can identify what feels relevant to them. This can include outcomes specific to individual women (for example, reconnecting with a family member with whom they have a fraught relationship) or outcomes that could be relevant to all women in the peer support (for example, normalising the experience of having mental health difficulties or living with a particular mental health diagnosis).

When consulting women, it is important to consider what language to use – for example, asking about what they would like to get out of peer support rather than what outcomes they would like to achieve.

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What can be considered relevant lived experience may differ depending on the context of peer support. At a minimum, this includes experience of maternity and mental health difficulties or struggling with emotional wellbeing. In peer support aimed at women with a particular mental health diagnosis, from a particular demographic or with a particular experience, such as twin and multiple births, disability, migration, drug and alcohol use, or contact with the criminal justice system, relevant lived experience will be more narrowly defined. This will shape who can be considered a peer in a specific peer support context. This may change over time as the project or service develops and should be reflected upon periodically.

If an organisation setting up peer support does not have relevant experience among its staff and volunteers, it should consult people who do when developing the project or service. It should recruit staff and volunteers with relevant lived experience to deliver it.

It is important that people with lived experience have a leadership role where they have a voice and can influence the direction of the peer support. This includes involvement at project management level and representation on trustee boards. Peer leadership can take different forms depending on the focus of the peer support, and the size and structure of the organisation running or hosting the peer support.

Larger organisations with established structures might find it more difficult to promote people with lived experience into leadership positions, while smaller organisations and informal initiatives might have more flexibility in enabling peers to take the lead. While peers who have taken on additional responsibility need to be supported in their roles, this support can be offered by people who have both lived experience and professional skills.

If these roles cannot be filled by people who possess both relevant lived experience and professional skills, it is preferable to skill up people with lived experience to take on management positions rather than recruit trained professionals without lived experience. If this is not possible, peers should at a minimum be involved in the co-production and co-design of peer support projects and services as equal partners.

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Some of the benefits they might experience are increased confidence, a sense of purpose and feeling helpful. Peer support organisations should recognise this as valid outcomes of peer support. This will guard against over-professionalisation of peer support where peers in supporter and leadership roles fill the position of ‘service providers’ rather than that of people engaging in peer relationships.

Peer support organisations need to provide peer supporters with training that will support them in their role. This should address how to engage in peer support relationships including how to enable a safe and nurturing environment, listening skills, facilitation skills, communicating and negotiating boundaries, safeguarding, and when to share confidential information. This should also include training on maternity specific topics such as feeding and sleep, and training on a range of maternal mental health conditions and experiences that they may encounter such as postnatal depression, postpartum psychosis, perinatal OCD, baby loss, and birth trauma.

Peer supporters should be trained on understanding the remit and recognising the limits of their role and where to signpost women who are in crisis or in need of additional support. Where smaller organisations lack the capacity to provide training in house they may seek external support, for example through external training courses, engaging independent consultants or developing relationships with larger organisations.

Peer supporters need to be provided with regular opportunities to debrief and reflect and identify additional training and support needs. This can take the form of supervision meetings. In larger organisations this will form part of organisational management structures. Small peer-led initiatives without a formal organisational structure can develop relationships with larger organisations that might be able to provide them with supervision and support. If they are unable to access this support from larger organisations, peer supporters should debrief and reflect in pairs or in group reflection sessions.

Peer supporters should ideally also have to access clinical supervision. In larger organisations and NHS affiliated peer support, this could be provided in-house. Smaller initiatives could develop relationships with local clinical mental health services, such as a local perinatal mental health team or a hospital mother and baby unit, to provide them with clinical supervision.

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