Perinatal mental health

Pregnancy and childbirth are normal life events and can bring a range of emotions. However, throughout this journey, these emotions can be complicated by disturbances in mental wellbeing, described as ‘perinatal mental health’ (PMH).

PMH is the overarching term for mental health during pregnancy and the first postnatal year. It can be characterised by either an existing mental health issue or a condition that arises/is exacerbated during pregnancy or is related to pregnancy. In severe cases, a mother's distress can become so overwhelming, potentially leading to suicide. See: Maternal mental health.

According to the NHS, perinatal mental illness affects up to 27% of new and expectant mums in the UK and covers a wide range of conditions. Elsewhere, evidence from the World Health Organisation (WHO) suggests that worldwide about 10% of pregnant women and 13% of women who have just given birth experience a mental disorder, primarily depression. In developing countries this figure is even higher, for example 15.6% during pregnancy and 19.8% after childbirth. 

A mental health condition is considered a disability if it has a long-term effect on normal day-to-day activity. This is defined under the Equality Act 2010. The condition is ‘long term’ if it lasts, or is likely to last, 12 months. ‘Normal day-to-day activity’ is defined as something that is done regularly in a normal day. This includes things like using a computer, working set times or interacting with people.

Mental health in pregnancy

The following information is written for midwives, nurses and health care professionals caring for:

• anyone who has mental health problems during pregnancy
• any pregnant woman who has had a mental health problem in the past
• their partner, family and friends
• consideration should also be given to women planning pregnancy, in particular preconception, who may be concerned about mental health issues, and require support.

Mental health in pregnancy, produced by the Royal College of Psychiatrists (2018) provides useful information on:

• mental health problems in pregnancy
• how to stay well during pregnancy and after the birth of your baby
• how to decide whether or not to take medication in pregnancy
• what help and support there is during pregnancy and having a mental health problem. 

Women and mental wellbeing

According to recent statistics, one in five women (19%) experience a Common Mental Disorder (such as anxiety or depression), compared with one in eight men (12%).

Over a quarter (26%) of young women aged between 16-24 years old (Women's Mental Health Facts, Agenda Alliance) report having a common mental health problem in any given week. This compares to 17% of adults.

Severe mental illness support during pregnancy

In 2021, the charity Tommy’s partnered with Kings College London (KCL), NHS England (NHSE) and Public Health England (PHE) (since been replaced by the UK Health Security Agency and Office for Health Improvement and Disparities) to produce a suite of mental illness resources. These resources aimed to support women with a severe mental illness (SMI) to make informed decisions about when to get pregnant, what to watch out for and how to treat their condition during and after pregnancy.

The resources include a new online information and support hub for anyone with a SMI planning a pregnancy, as well as practical guidance for the frontline health care professionals who support them. Tommy’s also offers a Planning for Pregnancy tool so users with severe mental illness get specific tailored information and support. 

Factors that impact on mental wellbeing include:

• feelings, thoughts and actions
• age can be a factor; in particular, young mums
• physical health, wellness and experiences
• education and employment
• social/family relationships/domestic abuse 
• economic and social circumstances
• lifestyle choices
• culture and ethnic background
• gender and sexuality
• use of drugs or alcohol
• past experiences, such as abuse, neglect, and other adverse childhood experiences, as well as experiences of being in care
• any dependents, for example, a child or elderly relative.

Mental health issues during pregnancy and post birth could include:

1. Generalised anxiety disorder (GAD), social anxiety, panic disorder, obsessive-compulsive disorder (OCD)

2. Severe mental health issues such as:

• depression
• psychosis and bipolar disorders
• personality disorders
• tokophobia
• PTSD
• eating disorders.

3. Some developmental conditions are more likely to have mental health problems including: 

• autistic spectrum disorders
• attention deficit hyperactivity disorder.

4. Suicide and self-harm

PMH describes mental health during pregnancy and the first postnatal year. This could be characterised by an existing mental health issue or a condition that arises during pregnancy, including antenatal depression and postpartum.

Suicide continues to be the leading cause of direct maternal death between 6 weeks and 12 months after birth, accounting for a staggering 39% of deaths in this period. Some 37% of the women who died were known to have a previous or existing mental health condition.

Read the MBRRACE-UK Saving Lives Improving Mothers’ Care 2023: Lay Summary (pdf). 

• Do you have new feelings or thoughts that you have never had before, which make you disturbed or anxious? 
• Are you experiencing thoughts of suicide or harming yourself in violent ways? 
• Are you struggling to sleep? 
• Are you feeling incompetent, as though you can’t cope, or estranged from your baby? Are these feelings persistent? 
• Do you feel you are getting worse?  

During pregnancy, women may also be subject to specific mental health issues, generally identified as antenatal depression.

Antenatal depression can occur at any stage during pregnancy. There is a range of support available, including self-help, psychological therapy and medication to manage symptoms. The NHS provides further information on this: Depression in Pregnancy. If antenatal depression is not treated symptoms can get worse and may continue after the baby is born (‘postnatal depression’).

Postnatal (or puerperal) mental health issues include three main presentations:

• Maternity blues: Normally occurs around days three to four and affects 80% of women.
• Postnatal depression: Affects 10% of women.
• Puerperal psychosis: Rare but severe form of psychiatric illness.

MIND provides further information on:

• Perinatal depression
• Perinatal anxiety
• Perinatal Obsessive-Compulsive Disorder (OCD)
• Postpartum psychosis
• Postpartum Post Traumatic Syndrome Disorder (PTSD).

Key symptoms of depression

• emotional – sadness, irritability, anxiety, apathy, anhedonia
• cognitive – Inappropriate guilt, inattention, poor concentration, delusions, memory disturbances
• physical – disturbance in sleep, appetite, lethargy, fatigue, headaches or vague pains
• behavioural – tearful, withdrawn, irritable.

• recognising and understanding the woman’s mental wellbeing
• general support and understanding
• cognitive behavioural therapy or other talking therapies
• pharmacological/medication
• perinatal peer support.

Continuity of care is a key component of maternity care and care for mental wellbeing. These should include:

• identifying that there is an issue
• diagnosis
• early intervention
• appropriate care
• aftercare. 

NICE recommends asking Whooley questions, which are:

• “During the past month, have you often been bothered by feeling down, depressed or hopeless?”
• “During the last month, have you often been bothered by having little interest or pleasure in doing things?”

Also consider asking about anxiety using the Generalized Anxiety Disorder (GAD‑2) scale:

• Over the last two weeks, how often have you been bothered by feeling nervous, anxious or on edge?
• Over the last two weeks, how often have you been bothered by not being able to stop or control worrying?

If a woman responds positively to either of the depression identification questions, is at risk of developing a mental health problem, or there is clinical concern, consider:

• Using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ 9) as part of a full assessment or
• Referring the woman to her GP or, if a severe mental health problem is suspected, to a mental health professional.

See further here: NICE recommendations

When asking a woman ‘how are you feeling?' consider asking supplementary questions, such as:

• How could you take time to look after yourself, even just a few minutes a day?
• How are you coping?
• Would you say you are feeling low?
• How are you sleeping?
• How often are you eating and how is your appetite in general?
• Would you say you are tearful, angry and/or anxious?
• Do you have concerns about your emotional wellbeing and your mental health?
• Who could you talk to about your concerns and what impact is this having? (Here you can suggest local groups, especially if the mum has no trusted family or friends to call upon for support.)

View the resource: Guide for delivering preconception care to women with a serious mental illness.

“When a woman has a serious mental illness, thinking about having a baby can be both challenging and worrying for her. This excellent new guide brings together the latest evidence to support professionals and women in having conversations about properly planning a pregnancy and having a baby. It covers the importance of discussing fertility and sexual health, as well as considering physical health and mental health needs, including medication, and having a ‘think family’ approach.” Maternal Mental Health Alliance, 2024 (MMMA).   

Resources for women with SMI (serious mental illness) planning pregnancies

• A website hub - Planning a pregnancy when you have a severe mental health illness 
• A pregnancy planning tool - Planning for Pregnancy
• Information animation - Planning a pregnancy with a serious mental health condition. 

The Maternal Mental Health Alliance (MMHA) is a coalition of 130 UK organisations (including the RCN). This includes professional bodies such as Royal Colleges and organisations which represent or provide care and support to parents and families. The MMHA works across England, Scotland, Wales and Northern Ireland. Its vision is to see all women across the UK get consistent, accessible and quality care and support for their mental health during pregnancy and in the year after giving birth.

The MMHA has a wide range of contacts and resources on its website. 

Specialist teams in Scotland

Scottish Government investment in perinatal mental health (PMH) since 2019 has led to the expansion of specialist services throughout Scotland, meaning many more women, babies, and families can benefit from this critical care. While this is good news, continued investment to ensure sustainable services and quality standards are met must be a priority. 

There are two Mother and Baby Units (MBUs), both located in Central Scotland. 

Latest news: Scottish Government announces new round of perinatal and infant funding from October 2024.

Specialist Teams in Wales

In 2020 the Welsh Government’s Mental Health Delivery Plan identified specialist perinatal mental health (PMH) services as a priority, resulting in increased investment in this area. All seven of Wales’ Health Boards provide some level of community specialist PMH support, with one Mother and Baby Unit (MBU) located in Swansea. In addition, new and expectant mothers in North Wales will have access to a new MBU in Chester, set to open towards the end of 2024. 

Latest news: An update from Wales: Forthcoming new mental health strategy, Jan 2024.

Specialist Services in Northern Ireland

Attention and investment in specialist perinatal mental health (PMH) services has increased in Northern Ireland since 2019. There is now specialist PMH community provision in all five Health and Social Care Trusts. 

There is no Mother and Baby Unit (MBU) in Northern Ireland or the Republic of Ireland. However, at the end of 2023, the Department of Health announced plans to establish an MBU in Belfast.

Latest news: Update on community perinatal mental health services, Department of Health, November 2023.

Further useful links

• NHSE (2021) Supporting mental healthcare in a maternity and neonatal setting: Good practice guide and case studies
• NHSE (2024) Patient and carer race equality framework Patient and carer race equality framework (PCREF)
• Office for Health Improvement and Disparities (2024) Perinatal Mental Health Perinatal Mental Health - OHID