Substance misuse is defined as the harmful or hazardous use of psychoactive substances, including alcohol and nicotine. Substance misuse in the perinatal period may also increase the risk of adverse maternal and child sequelae. These include reduced engagement with antenatal care and obstetric and neonatal complications such as low birth weight and prematurity. Substance misuse has also been implicated in maternal deaths in the UK; 23% of those who died between 2019 and 2021 were smokers and 14% were using other substances. Clearly, studying longer-term outcomes in offspring is challenging, with small sample sizes and unmeasured confounding factors characteristic of many of the studies in this area. Despite this there is some evidence from prospective, longitudinal birth cohorts that maternal substance misuse is associated with a range of emotional and behavioural difficulties in exposed children and even in a recent US cohort with future substance misuse at age 30.

In this chapter we discuss how psychiatrists and other healthcare professionals can support families affected by substance misuse, from the pre-conception period, through pregnancy and in the postpartum.

Optimising women’s mental health at the time of conception, as a means of improving pregnancy outcomes, is of increasing interest. Women with pre-existing or new onset mental illness in the perinatal period, like those with pre-existing or new onset physical health conditions, are considered as high-risk pregnancies. Strategies to mitigate pre-conception risk factors are emerging from the evidence linking pre-conception health to pregnancy and birth outcomes. Yet data on the prevalence and effectiveness of psychiatric preconception health and care remain scant and inconclusive. The remits of pre-conception advice extend beyond the dilemma of prescribing psychotropic medication in childbearing women. Pre-conception counselling can inform women of the physiological and emotional changes occurring in pregnancy, explore expectations about parenthood and evaluate how the woman’s own experience of being parented may affect her parenting style. Equipping women and their partners with unbiased information through specialist advice will empower them to make an informed decision about their reproductive choices.

The aim of this chapter is to provide a best practice framework to guide pre-conception mental health advice to women with a mental illness. It will not detail the evidence on the association between the exposure of psychotropic medication and adverse outcomes.

Complex post-traumatic stress disorder (CPTSD) describes the mind’s response to severe and sustained environmental adversity, particularly in the early years of life when we are learning about, and developing adaptive responses to, our environment. There is now consistent evidence that our own early experiences predict outcomes in our children, and probably also our children’s children, and that part of this transmission is mediated by our mental well-being as parents during the perinatal period. In most of the published literature in this field, and in the perinatal mental health literature, the mental health problems studied across the generations have not included CPTSD or the symptom profiles associated with the diagnosis. This is mainly because even recently published studies were designed before the inclusion of CPTSD in the WHO International Classification of Diseases (ICD-11) or are using the USA’s Diagnostic and Statistical Manual (DSM-5), and/or simply because the researchers involved were not aware of the profound significance of CPTSD to intergenerational and perinatal mental health. We will briefly review what makes CPTSD so important, particularly in the perinatal period, for women and their families, for clinicians and researchers, and indeed for decision-makers across society.

Talking with women in the pre-conception or perinatal periods about psychotropic medication is an essential, sometimes difficult, part of the work of the perinatal psychiatrist. Understanding the current evidence base; knowing how and when to acknowledge the uncertainty inherent in current knowledge and how that translates to the individual woman; balancing risks of medication with risks of not treating and benefits of treating; sharing decision-making while not putting all of the responsibility on the woman; communicating with the woman, her partner, other professionals, services and agencies; and knowing when and how to seek further help or advice, are all essential components of good practice when prescribing in pregnancy and breastfeeding.

Pregnancy induces vast physiological shifts within several systems of the expectant mother’s body, including haemodynamic, haematological, renal, endocrine and metabolic functions. These are necessary to adjust conditions for optimal growth and development of the fetus but are finely tuned to avoid subsequent compromise to maternal health; an imbalance of which may present with medical complications to both mother and baby.

It is essential to understand normal physiological changes in pregnancy in order to appreciate pathology, which may arise. This chapter aims to outline the main changes that occur, and further, to delineate a few common obstetric emergencies and complications that may develop during pregnancy.

Depression is common in the perinatal period and is linked to negative consequences for pregnant and postpartum women and other childbearing individuals and their families, including the potential for long-term adverse outcomes in children. While the clinical approach to depression in pregnancy and postpartum is similar to that of the non-perinatal period in many ways, specific considerations include the role of reproductive hormones in the aetiology of the disorder, unique psychosocial stressors that may precipitate or perpetuate symptoms, and the safety of psychotropic medication in pregnancy and lactation. This chapter is an overview of depression in pregnancy and the first year postpartum, including a summary of its epidemiology, theories about aetiology, presentation, course, outcomes and an approach to management.

This chapter describes infant mental health and why it is important. Those working in perinatal mental health services have a key role in ensuring that it is attended to by assessing and supporting the developing mother-infant relationship. The journey into services and the roles of team members and others are presented. Effective interventions to support the primary and wider family relationships should be offered when required.

Autism research and clinical practice is a rapidly evolving branch of psychiatry. This chapter explores autism through the lenses of the neurodiversity paradigm, challenging the deficit-based model whilst remaining stark about significant healthcare inequalities and challenges that autistic people face. It considers the perinatal journey from an autistic perspective, highlighting some of the common challenges autistic mums (to be) can face, and makes suggestions for approaches to take when working with autistic patients.

Child safeguarding is an integral part of the work of perinatal mental health services and the health and social care services they work in partnership with. Serious case reviews repeatedly identify parental mental illness as one of the most significant risk factors for child maltreatment and infants under one year old as the most vulnerable group of children. This chapter describes the key issues that perinatal mental health clinicians, and the professionals and services they work in partnership with, should consider when working with women and families to ensure that children’s well-being is promoted and that they are protected from harm. Learning from child serious case reviews is highlighted. There is a focus on the processes and important considerations when there is a child, or unborn baby, who is the subject of a Child in Need or Child Protection Plan and when there are significant concerns about parenting capacity necessitating formal parenting assessment and/or care proceedings.

This chapter introduces the practice of infant observation; both as a module on psychoanalytic trainings, and as a helpful clinical skill in assessment and treatment within perinatal services. Babies need to be protected and nourished, but also, crucially, to be drawn into relationships with attentive, responsive adults. The chapter underlines the need to look at each baby as an individual and to observe how he is responding to the care he is receiving. The suggestion is made that in perinatal settings, paying attention to the baby’s experience is a vital part of the work.

This chapter focuses on writing medico-legal court reports in the context of being either a) the treating clinician or b) an independent expert, with a focus on reports for child safeguarding and family court processes. It highlights the range of parenting issues that might arise in the context of perinatal mental illness, as well as the roles and duties of writing a report, and areas to include within the report and its structure. The primary objective for family courts is to ensure that children remain with birth parents unless there are overriding risks of significant harm and neglect to the child. Psychiatrists and clinicians therefore have a duty to be able to write high-quality professional witness and expert witness reports which assist courts in the case of maternal/parental mental health conditions and their potential effects on developing infants and children. Whether a baby remains in the care of the birth mother (and family) or not, has profound effects on both, over lifetimes. However, it is ultimately the task of the judge in the family court to weigh up the available evidence submitted by different experts and parties and make the final recommendations.

The transition to parenthood brings much joy but also challenges and strains to all families. Where mothers are experiencing perinatal mental health disorders, this is an additional challenge which impacts the wider family system. Partners and other family members may have to take on additional responsibilities, manage worries about the mother’s mental health, and potentially deal with their own mental health difficulties. Indeed, partners – including fathers, co-mothers and step-parents – may be particularly vulnerable to poor mental health at this time.

The partners’ mental health is a crucial aspect of family functioning in the perinatal period that can impact on the whole family. Paternal depression and anxiety disorders have implications for family relationships, including the couple relationship, the co-parenting relationship and the relationship with the baby – with potential adverse consequences for child and family outcomes.

Practitioners have a role in supporting prevention of paternal mental health disorders and working to reduce barriers to help-seeking and uptake of support where needed. These practices not only serve to improve the well-being of fathers and partners; well-supported family members who feel included and have their own mental health needs met will also have a significant positive impact on maternal recovery and well-being.

Fundamentally, a psychiatric patient’s relationship with the health professionals treating her depends on developing trust and that trust relies on understanding on both sides: that is why it is so critical for a clinician to have as deep an understanding as possible of his or her patient’s perspective. It’s unusual for a patient with a physical ailment to feel a need to deliberately conceal things from her clinician but this is a common occurrence for women in a perinatal mental health setting. The main reason for this is fear; fear of having her children taken away, fear of being ‘judged’ for wanting to have a child while coping with a chronic mental illness. This chapter will provide an overview of the research I have conducted since 2010 to identify and record the experiences of women in receipt of perinatal mental health services or, in some cases, of women not in receipt of the services they needed.