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BY 4.0 license Open Access Published by De Gruyter July 11, 2022

The role of specialist perinatal psychiatrists in modern medicine

  • Triya Chakravorty ORCID logo EMAIL logo


The perinatal period, from the beginning of pregnancy to one year after birth, is a time of considerable physiological and emotional change, where women face a significant risk of development or relapse of mental health disorders. Mental health disorders are one of the most common conditions faced in the perinatal period, but often go unrecognised. There are several barriers to accessing and delivering care, such as instances of structural bias, cultural diversity, stigma, lack of resources and the additional challenge brought by the coronavirus pandemic. Perinatal psychiatry is a dynamic and evolving field, which spans gender, age, ethnicity, socioeconomic background and many other characteristics, to care for people at a vulnerable time in their lives. This article explores the role of perinatal psychiatrists in today’s society, as well as the challenges faced in the field.


The perinatal period, from the beginning of pregnancy to one year after birth, is a time of considerable physiological and emotional change, where women face a significant risk of development or relapse of mental health disorders [1]. Mental health disorders are one of the most common conditions faced in the perinatal period, but often go unrecognised [2]. The most widely researched mental health disorder is postpartum depression, but a much broader range of disorders are faced, including postpartum psychosis and schizophrenia [2, 3]. In recent years, there has been interest in the prevalence of anxiety disorders, such as obsessive compulsive disorder and post traumatic stress disorder, which can appear for the first time in the perinatal period, and have features that are specific to pregnancy, childbirth and parenthood [4]. Perinatal mental health is critical, as it can not only impact maternal health, but also fetal and childhood growth and development, and have implications for the wider family [3].

Perinatal psychiatry was first established as a specialist field in the 1980s [5]. However, recognition of perinatal mental health conditions can be traced back to the 1800s [4]. At present, the field is rapidly evolving to fit the needs of the socially, economically and culturally diverse group of mothers in present society. There are several barriers to accessing and delivering care, such as instances of structural bias, cultural diversity, stigma, lack of resources and the additional challenge brought by the coronavirus pandemic. Therefore, perinatal psychiatrists need not only be doctors, but listeners, supporters and advocates for these vulnerable women as well.

Why is the perinatal period a vulnerable time for mental health?

There are several biological, psychological and social reasons that make the perinatal period such a vulnerable time in women’s lives. Popular theories consider the influence of genetic, hormonal, social and psychological factors. In order to care for women experiencing perinatal mental health issues, it is important to understand the biological and psychological changes that occur during pregnancy, childbirth and postnatally. A systematic review found that risk factors for perinatal mental health disorders included previous mental health disorders, past obstetric complications and sociocultural factors such as financial difficulties and domestic violence [6].

Impact of perinatal mental health issues

On women

Perinatal mental health disorders are associated with increased mortality and morbidity for women, through obstetric complications, suicide or self-harm and substance abuse [7]. Suicide is the leading cause of death in the perinatal period, and is particularly associated with severe depression, making identification of depression in pregnant women vital [1]. The risk of suicide is higher in women with a history of severe mental illness, hence women with pre-existing conditions benefit most from early interventions.

Within the perinatal period, the highest risk is postnatally [1]. A seminal 1987 study found that women were 22 times more likely to have a psychiatric admission in the month following birth compared to pre-pregnancy [8]. The role of the perinatal psychiatrist extends to the first year postnatally and even to future pregnancies. In 2012, the World Health Organisation (WHO) recommended in their International Classification of Diseases for Maternal Mortality (ICD-MM) that all suicides during pregnancy and one year postpartum be classified direct obstetric-related deaths. This displays the long-term impact that mental health disorders during the perinatal period have on women [9].

On obstetric and neonatal outcomes

Women with perinatal mental health disorders are at an increased risk of obstetric and neonatal complications such as an preterm birth and fetal growth impairment [1]. Furthermore, women with severe mental illness are at an increased risk of obstetric complications such as pre-eclampsia, antepartum and postpartum hemorrhage, placental abruption and stillbirth [1].

There are several proposed mechanisms for these increased risks. For example, women with perinatal mental health disorders are more likely to have concurrent obesity, hypertension and gestational diabetes, which may all contribute to obstetric and neonatal risk. They are more likely to be exposed to domestic violence and have a limited access to specialist antenatal care [1]. Mental health conditions, such as depression, are associated with smoking, drinking excess alcohol, or consuming recreational drugs which could impact fetal development [6].

On infants

Perinatal mental health disorders can also adversely impact children’s’ mental and physical health [3]. For example, evidence suggests that postpartum depression is associated with infant failure to thrive. In a cohort study with 171 individuals conducted in India, Patel et al. [10] found that children who were under the fifth centile for weight at 6 months of age were 2.3 times more likely to have a mother with postpartum depression at six weeks of age (p<0.01). This association remained when adjusting for factors such as birth weight, breast feeding practices, parental education and infant physical health [10].

Treating maternal mental health disorders not only benefits the mother’s health, but also that of their children. A systematic review conducted in 2013 found that psychosocial interventions to treat perinatal mental health conditions in lower-and-middle-income countries led to improved infant growth and vaccine uptake, as well as reduced maternal symptoms of depression [11].

The mechanisms by which maternal mental health impacts children is not fully understood. However, it is thought that biological mechanisms include hormonal changes during pregnancy, such as changes in the hypothalamic-pituitary axis as a result of stress [12]. There has also been recent interest in the role of epigenetic mechanisms which may impact child health. For example, through epigenetic mechanisms, maternal obesity and gestational diabetes can result in lifetime risk of obesity, cardiovascular disease and metabolic disease in the child. This has implications when prescribing medications that promotes weight gain or increases the risk of developing metabolic syndrome, as is the case for many antipsychotic medications [4]. However, it is most important to appropriately treat a mother’s psychiatric disorder effectively than to leave it untreated or undertreated due to concerns of weight gain. Another theory proposes that depression has a direct impact on the emotional quality of parenting. Mothers with depression may feel less engaged with or bonded to their children, which may impact the level of care and may impair psychological safety or stimuli provided [13].

What do perinatal psychiatrists do?

Perinatal psychiatrists aid in the diagnosis, management and treatment of women with perinatal mental health conditions, whether they present for the first time, or are already known to mental health services. The management of these disorders can be categorised into pharmacological, psychological and psychosocial options. Usually, women receive a combination of all three during their treatment. Perinatal psychiatrists often work in collaboration with a multidisciplinary team, involving psychologists, mental health nurses, social workers and more. Interventions are tailored towards the pregnant woman, taking into consideration risks to the fetus. However, the principles of treatment remain similar to those outside of the perinatal period. Involving the women in the decision-making is crucial to ensure high quality care [14].

Psychological interventions

Psychological interventions include cognitive behavioural therapy (CBT) and interpersonal therapy (IPT). A systematic review showed that psychological and psychosocial interventions are effective treatment options for postpartum depression [15]. CBT remains the treatment with the strongest evidence, which is similar in its effectiveness in treating mental health conditions outside of the perinatal period [1]. Furthermore, recent evidence supports new modalities of treatment delivery, such as online CBT [16]. This is of particular benefit in the pandemic, given the necessity to adapt to virtual consultations.

Pharmacological interventions

The use of pharmacological interventions in psychiatry often comes with unintended consequences. This is especially true in perinatal psychiatry. Perinatal psychiatrists are faced with the unique challenge of balancing the effectiveness of pharmacological options to the mother with potential for risk to the fetus. Many pharmacological interventions cross the blood-brain barrier for their intended effect, and as a result are also able to cross the placenta [17]. There is limited trial-based evidence in pregnant and breastfeeding women, due to a hesitancy to involve these women in clinical trials for fear of potential harm to offspring. This reflects a wider issue that sees the exclusion of pregnant women from many clinical trials, though data from drug registries do exist.

The fear and uncertainty of potential fetal harm leads to high levels of medication discontinuation during pregnancy [1]. However, a lot of this fear is unsubstantiated. A survey of over 9,000 pregnant women and new mothers conducted in 2015 showed that many women tend to over-estimate the teratogenic risks of medications [18]. Importantly, evidence-based counselling by healthcare professionals allows them to make informed decisions about the risks and benefits of medication if needed [19]. This is particularly important, given that medication discontinuation is associated with a high risk of relapse of mental illness [1]. For perinatal psychiatrists, having a familiarity with potential for recruiting mother’s for research studies and the rapidly updating evidence for best practice is a necessity.

The use of lithium as a mood stabilizer highlights the dilemma faced by perinatal psychiatrists. It was classically widely accepted that lithium use during pregnancy leads to a 400-fold increased risk of Ebstein’s anomaly, a congenital malformation of the tricuspid valve. This no doubt steered patients and doctors away from continuing lithium use during pregnancy. However, recent evidence suggests that this risk is at most 8-fold, and that the strikingly higher figure comes from biased retrospective reports [20]. As new evidence comes to light over the years, opinions change about the risks vs. benefits of medications. Yet fears remain when prescribing or taking the medication. A systematic review looking at studies of lithium use during pregnancy in women with bipolar affective disorder, found that the continuing lithium was associated with up to two-thirds lower risk of relapse of disease during pregnancy [21]. This example highlights two important points. Firstly, this demonstrates the necessity for good quality research to guide clinical practice. Secondly, it shows how a lack of robust evidence may worsen pregnant women’s mental health, by way of increased medication avoidance and therefore higher risk of relapse.

Barriers to care

The field of perinatal psychiatry faces several barriers that prevent women from receiving the care that they need. These include individual factors (such as knowledge about and stigma associated with mental health), organizational factors (such as access to services and lack of resources) and sociocultural factors (such as language barriers and cultural attitudes) [22]. Mental health stigma is a serious issue which can result in individuals avoiding seeking help [23]. The stigma includes fears of being labelled a ‘bad mother’, fear of babies being taken away and issues surrounding fulfilling the social expectation of motherhood [22]. A survey of 1,250 mothers reported that 50% of those who had completed the Edinburgh Postnatal Depression Scale screening tool for perinatal depression gave false answers in attempt to hide their mental health disorders, stating reasons such as fear of being labelled a ‘failure’ of a mother [24]. Perinatal psychiatrists, alongside other healthcare professionals, have a role in breaking down this stigma with each interaction with patients and their families. Furthermore, stigma can be combatted by engaging primary care and specialist midwives to provide holistic maternity care which incorporates psychiatric services, as well as providing educational programmes for other healthcare professionals.

Another challenge is the limitations with service provision. In the UK, access to specialised perinatal services remains inconsistent across different locations [4]. Furthermore, inpatient mother and baby units, designed for women to remain with their children, are also not evenly distributed [4]. In order to tackle this problem, efforts are being put into developing multidisciplinary community services that integrate parent and childcare with adult mental health services [4].

A lack of awareness about perinatal mental health issues in both the public and professional domain prevents women from accessing specialised care [22]. In order to be seen by a perinatal psychiatrist, women are usually referred by another healthcare professional, such as a primary care physician or midwife. Identifying those in need of mental health services is important, and all healthcare professionals need to be able to identify the symptoms and risk factors for such disorders. Therefore, educating other professionals and working collaboratively is an important part of a perinatal psychiatrist’s role.

Ideally, all women of reproductive age should be counselled for perinatal mental health issues even in brief clinical encounters. The involvement of perinatal psychiatry in preconception planning is important in order to reduce poor outcomes in perinatal mental health. This is useful to discuss issues such as medications, expectations and birth planning. These discussion are important for all women regardless of whether they are actively considering pregnancy, especially since unpanned pregnancies are more common in women with mental health disorders [25].

The impact of the pandemic on perinatal mental health

The coronavirus pandemic has brought about unprecedented social, economic and health consequences for all. The restructuring of healthcare services to cope with the pandemic has led to global disruptions in healthcare, with most serious impact in women’s health services, including pregnancy termination services, contraception clinics and maternal healthcare [26]. This disruption of services has the potential to impact women’s health long term, as disruptions in sexual and reproductive health are known to lead to an increase in maternal and neonatal mortality worldwide [27]. Not only have there been changes in healthcare delivery, but health-seeking behaviour and access to healthcare services has also been affected, as women feel unsafe or unable to reach out [28].

The pandemic has been a difficult time for women to become mothers. Many women have had to give birth and miscarry in isolation [29]. Given that pregnant women and new mothers are more likely to experience mental illness, this is an important issue for perinatal psychiatrists [30]. Social distancing and isolation practices implemented during the pandemic have led to an increase in psychological disorders in pregnant women and new mothers. A lack of social support, limited access to antenatal care and fear of infecting children have led to increased rates of depression and anxiety [31].

However, all mothers have not been affected to the same extent. The pandemic brought to light the pre-existing inequalities in maternal health for women from socio-economic deprivation and under-represented minority backgrounds. In the UK, women from ethnic minority groups have higher rates of maternal mortality compared to their white peers [32]. This is also seen in the pandemic, as pregnant women from ethnic minority groups are more likely to suffer adverse effects from SARS-CoV-2 infection [33]. There are several proposed reasons for these differential outcomes, including discrimination, co-morbidities, social behaviours, and a lack of empowerment [34]. It is likely that the short- and long-term consequences of the COVID-19 pandemic will only worsen pre-existing healthcare inequalities, meaning perinatal psychiatrists will experience an increase in demand, especially from these groups.

Transgender issues

Transgender and non-binary parents represent a population that are grossly underrepresented and underreported in the perinatal mental health community [35]. In recent years, it has been increasingly recognised that transgender and non-binary people are becoming parents, however, language and structures present in perinatal mental health services still reflect cis-gendered heteronormality, leading to feelings of exclusion [36].

This group face issues with gender dysphoria, lack of visibility and isolation which may make them more vulnerable to perinatal mental health disorders [35]. Furthermore, it is thought that they are disproportionally affected by violence and other forms of trauma, which also increases this risk [35]. Transgender and non-binary people are reported to have many negative experiences with healthcare providers, due to healthcare professionals’ lack of experience with trans issues and perceived transphobia. These perceived or anticipated experiences of poor perinatal care may also impact the psychological wellbeing of trans and non-binary parents, further contributing to their vulnerability [35].

Therefore, perinatal psychiatrists must also be inclusive in terms of gender. Future work needs to include routine collection of data on gender and intersectional characteristics in perinatal services, which is currently not commonly collected, as well as exploration into the perinatal mental health experiences of these groups. This work will inform future services to provide culturally appropriate and inclusive. Options include training sessions on transgender issues, gender neutral language in documentation and routine use of appropriate gender pronouns.

Fatherhood and perinatal mental health

A meta-analysis conducted in 2016 found that 8% of fathers experience perinatal depression [37]. Also, depression and anxiety affect both expectant fathers as well as mothers. Therefore, fathers fall within the remit of perinatal psychiatrists, and public education, screening programmes, prevention methods and appropriate treatments are required. Evidence suggests that a correlation between maternal and paternal perinatal mental health disorders exists [38]. Furthermore, a supportive partner positively impacts a mother’s mental health, making support for partners increasingly important [39]. Further research is required to understand more about paternal perinatal mental health issues, treatment efficacy, and whether these mental health disorders affect their families in the long term. Since 2015, in England, there has been the introduction of shared parental leave. Whether this has an impact on paternal perinatal mental health disorders will be interesting to observe [4].


Perinatal psychiatry is a dynamic and evolving field, which spans gender, age, ethnicity, socioeconomic background and many other characteristics, to care to people at a vulnerable time in their lives. Perinatal psychiatrists work in collaboration with many colleagues to provide personalised care, be that pharmacological, psychological or social. The work done to improve the mental health of individuals during the perinatal period not only impacts the individual themselves, but also their children and family.

Future directions should include expanding the definition of motherhood or parenthood to take into account the intersectional society that we live in, and collaboration with other divisions of psychiatry to ensure smooth transition of services. Perinatal psychiatrists also play an important role in shaping the public image of perinatal mental health issues, and have a role to reduce mental health stigma and increase awareness.

Due to the complexity of perinatal mental health illnesses, as well as the wider impact on family, it is likely that there will always be the need for specialised perinatal psychiatrists. However, collaborative multidisciplinary working with adult mental health psychiatry colleagues and other healthcare professions will be imperative for providing individualised inclusive and high quality care.

Corresponding author: Triya Chakravorty, The Queen’s College, University of Oxford, Oxford, UK, E-mail:

  1. Research funding: None declared.

  2. Author contributions: Single author contribution.

  3. Competing interests: Authors states no conflict of interest.

  4. Informed consent: Not applicable.

  5. Ethical approval: Not applicable.


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Received: 2021-10-06
Accepted: 2022-06-02
Published Online: 2022-07-11
Published in Print: 2022-11-25

© 2022 the author(s), published by De Gruyter, Berlin/Boston

This work is licensed under the Creative Commons Attribution 4.0 International License.

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