Making decisions about prescribing medication for mental disorders in childbearing women is a task that may have profound and long-lasting implications for a mother and her family, and it is important that prescribers have access to up-to-date summaries and interpretations of research that examines how safe these medications are in pregnancy and lactation.

Because it is not possible to test a drug’s reproductive safety in randomised controlled trials, research has to rely on less rigorous study designs. The inherent difficulties and other methodological problems have meant that interpretation of the evidence has often been difficult. However, the volume and quality of research has dramatically increased in recent years. Current findings concerning antidepressant, antipsychotic and mood-stabilising medication during pregnancy and lactation are summarised in this chapter, and recommendations for clinical practice are made referring to published guidelines where they are available.

This chapter examines recent evidence concerning the need to explicitly intervene with the mother-infant dyad in order to ensure optimal outcomes for the infant where there are concerns about postnatal mental health problems. The chapter describes the importance of dyadic interaction in terms of the capacity of the infant for later affect regulation and wider aspects of development, in addition to evidence concerning the impact of perinatal mental health problems on such interaction. A number of different methods of assessing mother-infant interaction in order to identify whether an intervention is needed are described, in addition to a range of dyadic methods of working that are explicitly focused on improving the interaction.

The perinatal frame of mind is a concept aiming to capture the unique mental state, context and experiences of individuals planning a pregnancy and during the perinatal period. It implies that every aspect of the physical, social, psychological and psychiatric care of women in this period requires a deep understanding of them as individuals. This encompasses many aspects of a woman’s life experience: from childhood to her current context, including traumatic and more positive experiences, cultural factors, relationships, mental and physical illness and their risks and relevance to the perinatal context, her journey to becoming pregnant, and her strengths. The term asks that we think not only about the woman, her well-being and needs, but also those of the fetus or infant, the intimate partner and/or co-parent, and other family members. We should consider the relationships between the parents and the infant, as well as within the couple and among other family members. So, we don’t just think about the woman, but the community and cultural context surrounding her, which includes the partner, family, friends, and often, and importantly, health and social professionals and services, who can provide the right kind of support to help navigate any mental health challenges.

Women with intellectual disabilities have children more frequently than in the past. This is partly a result of changes in attitudes towards people with intellectual disabilities. Institutional care in many parts of the world is less common and sterilisation of women with intellectual disabilities is less frequent. However, women with intellectual disabilities experience greater social disadvantage than other women, negative attitudes towards their having children, and judgements about their abilities to parent successfully. They have poorer pregnancy and neonatal health outcomes due to health inequalities and socio-economic deprivation and are more likely to have their children removed from their care. The rate of mental disorders in women with intellectual disabilities is high leading to increased utilisation of healthcare services during the perinatal period and after delivery. Recognising perinatal mental disorders in women with intellectual disabilities can be challenging for clinicians because of communication difficulties in the woman and a lack of training for the clinician. Assessment and support to women with intellectual disabilities and mental disorders has to be adapted to take account of their individual needs. Training of clinical staff in understanding intellectual disabilities is essential in enhancing the care they receive and ensuring equity of access to services.

This chapter is an essential guide to recognising and treating ADHD in the perinatal period, an increasingly common scenario which specialist community and inpatient perinatal services face. We explore issues specific to assessing and treating women with ADHD. The features of how the disorder is classified are discussed, including information on how ADHD may present differently in women. The challenges of identifying ADHD in females are considered along with common comorbidities. A summary of guidance on treating this disorder in adults is included, with information on pharmacological and non-pharmacological treatment options. An outline of the essential investigations required before initiating medication for a woman is provided, along with details on the necessary ongoing physical health monitoring. Both stimulant and non-stimulant medicines are discussed with details on the various formulations available in the UK and practical tips on prescribing in the perinatal period. Specific issues to explore at follow-up are outlined. Special consideration is given to recognising and treating ADHD in the perinatal period. This includes during the pre-conceptual period, prescribing in pregnancy and the postnatal period including breastfeeding. The impact of ADHD on parenting is also considered. This is essential reading on a commonly misunderstood disorder for all perinatal clinicians.

Mothers who kill their own children are unusual women whose offences often elicit fear, horror and condemnation in others. Psychiatrists may be asked to assess such women to explore the relationship between the offence and maternal mental illness, and the potential risk to other children. In this chapter, I discuss some available data on mothers who kill, in terms of criminal justice statistics, and review accounts of motives for such killings. I briefly discuss the legal processes that mother who kill must face, and the role of the psychiatrist. I then discuss some recent research about the role of maternal attachment security in relation to attitudes towards children and the transition to motherhood and the potential for psychological disorder that arise during that transition. I also comment on social factors, such as the role of partners and fathers. I conclude with some discussion about the management of cases where mental illness is a risk factor for filicide, and the associated child protection issues that may arise in such cases.

This chapter contains an outline of fetal development, describing general organogenesis in the first trimester, and then brain development in the second and third trimesters. The effects of maternal well-being, therapeutic medication, tobacco and alcohol on the developing fetus are explored. Finally, the current format of antenatal care, screening and fetal medicine in the UK National Health Service is described. There is a glossary of common conditions that are diagnosed antenatally, which are not specific to women who take prescribed or recreational drugs. The majority of such women have normal pregnancies and give birth to healthy babies at term.

Many types of antenatal stress, not only a diagnosed mental illness, can alter fetal development with a long-lasting effect on the child. There is an increased risk of many types of neurodevelopmental disorder in the child, as well as some physical problems such as asthma, although most children are not affected; the underlying biological mechanisms include alterations in the function of the placenta, the HPA axis and immune system, and epigenetic changes in the child; the impact may be even greater in lower- and middle-income countries, with added stresses due to poverty, food insecurity and high levels of domestic violence among other factors; the implications are that the mental well-being of all pregnant women should be considered and causes of stress addressed where possible. These stresses include the relationship with the partner, pregnancy-related anxiety, exposure to a disaster, or early childhood trauma.

Published studies examining medically unexplained symptoms (MUS) in perinatal women are thin on the ground. Keyword searches of research databases bring up titles such as ‘Psychosomatic Obstetrics and Gynaecology – a neglected field?’ However, whilst there is little research on this narrow topic, there is an extensive literature on MUS in other populations. This chapter draws mainly upon that literature and attempts to apply it to pregnancy and the puerperium in a way that will, it is hoped, prove clinically useful.

Difficult lessons from the Confidential Enquiries into Maternal Deaths remind us that thorough clinical assessment, detailed mental state examination and an appreciation of the dynamic nature of risk and its management are central to the effective treatment of women with perinatal mental illness. This is underpinned by the establishment of a trusting, respectful and honest relationship with the woman, which sees her as a partner in decision-making, and a detailed knowledge of the distinctive presentations and risks associated with illness in pregnancy and after childbirth, and its consequences for the woman and her infant.

Eating disorders can have a profound impact on women during the pre-conception, antenatal and postnatal periods, and this has implications for their care and treatment. This chapter describes the rate, course and risk factors for eating disorders within the context of the perinatal period. It covers what is known from current research and clinical evidence about the effect of the most common eating disorders on pre-conception health, pregnancy and birth outcomes. Drawing on existing clinical guidance and research evidence, it provides an overview of the guidance and recommendations for the assessment, management and treatment of eating disorders from pre-conception through to the postnatal period.

Millions of women and girls worldwide experience violence. Violence against women and girls takes many forms, including physical, emotional and sexual violence and abuse, which is associated with a range of adverse impacts on women, their families and society as a whole. Health professionals supporting women during the perinatal period should assess the risks posed by exposure to previous or current violence and how this may affect them during pregnancy. As an important risk factor in a woman’s mental health presentation, psychiatrists working with pregnant and postpartum women should consider the presence of violence in their formulation; it can increase the risk of anxiety, depression and post-traumatic stress disorder (PTSD). Domestic violence and abuse increase the risk of domestic homicide and may play a role in many perinatal suicides. Sensitive assessment and effective management of women exposed to violence can improve engagement with mental health services and response to treatment.