This chapter gives an overview of perinatal mental health services in Asia, Africa and South America. These are areas where service delivery, training and funding in perinatal mental health remain a major challenge. Investing in perinatal mental health services is vital for any country to ensure physical and mental well-being of mothers and the upcoming generations.

This chapter examines the key principles of applying mental health and capacity legislation in the perinatal period. The four nations of the United Kingdom have different legislative frameworks. England and Wales are governed by the same legislation – the Mental Health Act 1983 (MHA) and the Mental Capacity Act 2005 (MCA), although with some minor variations. Scotland has an entirely different framework – the Mental Health (Care and Treatment) Act 2003 and the Adults with Incapacity Act 2000. Northern Ireland is in a (slow) transition from having mental health legislation (the Mental Health (Northern Ireland) Order 1986) sitting alongside, in effect, no formal framework for thinking about capacity, to ‘fused’ legislation (the Mental Capacity Act (Northern Ireland) 2016) with no stand-alone mental health legislation. This chapter focuses on the position in England and Wales, primarily because it has the largest body of case law to help understand how to think through the dilemmas covered; for those in other parts of the United Kingdom grappling with those dilemmas, the most useful resource is the BMA’s Ethics Toolkit which has specific sections for each of the nations.

For many people the journey to becoming a parent is not a straightforward one. The following chapter examines how experiences with infertility, assisted conception and perinatal loss can impact on an individual’s mental health, relationships with others and future children. The chapter is divided into two sections: the first examining infertility and assisted conception, and the second focusing on perinatal loss. Each section will briefly define key concepts, definitions and prevalence before describing the psychosocial impact of these difficulties and treatment options.

Although this chapter is divided into two sections, it should be noted that women who experience infertility and utilise artificial reproductive techniques (ART) are also highly likely to have experienced some form of perinatal loss. The experience of infertility alone is its own form of loss and individuals who experience it may have a grief response and share similar psychological difficulties to those who experience pregnancy loss or baby loss. The aim of this chapter is to increase awareness around the often complex and lengthy journey to parenthood, and to support clinicians in understanding the experiences of those they come across at various stages of this journey and how they can best support them.

Perinatal anxiety is characterised by intense symptoms of anxiety and fear and includes affective, cognitive and behavioural components. Anxiety disorders include generalised anxiety disorder, panic disorder, specific phobias and social anxiety disorder. Obsessive compulsive disorder and post-traumatic stress disorder are also included here to remain in line with the majority of published evidence, and because of agreement that anxiety is a central characteristic of these disorders. Some level of antenatal anxiety is common but when it becomes extreme or persistent it can be associated with maternal, fetal and infant morbidity, as well as emotional and cognitive problems in children and teenagers and risk of the child developing an anxiety disorder.

This chapter provides an overview of the different anxiety and associated disorders. It focuses on issues to consider in perinatal anxiety, namely the consideration of symptoms versus disorders, normal versus pathological anxiety and pregnancy-specific versus general anxiety. The subsequent sections of the chapter focus on each of the anxiety and associated disorders in turn: their epidemiology, aetiology, presentation, course and outcomes including for the infant and family; and, finally, their management.

The aim of this chapter is to help readers to understand the different options for psychological therapy when parents are experiencing perinatal mental illness and consider what therapeutic approach might be appropriate and for whom.

Psychological therapies are of key importance in the perinatal period. There are significant psychological adjustments associated with the transition to parenthood, there are adjusted risks and benefits of prescribing at this time, parents state they prefer psychological approaches and therapy may also be important to address problems in the parent-infant relationship. It is important that psychological therapies are based on a perinatal frame of mind and can be accessed promptly when needed.

This chapter describes different types of evidence-based, guideline recommended psychological therapies that target improvements in parental mental health symptoms. Psychological therapy is most effective and accessible when it is adapted to take account of the perinatal context and issues related to pregnancy, childbirth or parenting. The evidence base for psychological therapies specifically in the perinatal period is growing and is reviewed.

The pre-birth planning meeting is an essential aspect of the care of any pregnant woman who has a current or previous severe or complex mental illness. It brings together the pregnant woman, her partner and/or other family members and all the professionals involved. The meeting ensures that relevant information is shared so that everyone has a good understanding of the concerns, risks and strengths. At the meeting a perinatal mental health care plan is devised collaboratively. This outlines the woman’s care for the remainder of her pregnancy, her maternity admission for the birth of her baby and for the early postnatal period. It also includes a crisis plan. This process helps all the professionals to work in partnership with the woman and her family and to ensure she and her family have the best possible care and outcomes.

There is a strong evidence base for the management of perinatal mental illness and all healthcare professionals should be aware of that; women can be offered hope of recovery with treatment.

NHS England and Scotland have published pathways of care for perinatal mental health care, but these do not deal with illness below the threshold of specialist care. Each area needs to develop effective local pathways of care that cover the full spectrum of disease and include all services.

The purpose of this chapter is to describe the building blocks that contribute to the rest of the pathway for women with perinatal mental illness. Although the chapter mainly covers the situation in England, it also gives information about the devolved nations, Scotland, Wales and Northern Ireland.

What follows covers principles of teamwork and stepped care.

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.