Health and nutrition
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This chapter explains the importance of supporting the physical and especially the mental well-being of parents within the domain of health and nutrition in the maternal well-being framework. It approaches the topic from a mental health perspective, as these challenges are strongly represented across the reviewed literature and linked to all other health-related factors. The following findings are based on a literature search that focused on psychosocial well-being. In literature addressing mental health disorders, emphasis was placed on the impact of these disorders on psychosocial well-being rather than on diagnostic definitions. This is reflected in both the findings presented and their interpretation.
The chapter highlights how the perinatal period influences the well-being of the mother, her partner and the child. It also describes how various risk factors, including negative childbirth experiences, are associated with poorer mental health outcomes. The purpose is to demonstrate why parental mental health is a central component of overall health and why focused support is needed.
The importance of good mental health during the perinatal period
The perinatal period is a psychologically vulnerable phase during which parents are exposed to various mental health challenges. Perinatal mental illness refers to psychiatric disorders that occur during pregnancy and up to one year after childbirth. According to Howard and Khalifeh (2020), perinatal mental disorders are among the most common complications of pregnancy, significantly affecting both maternal and child well-being. Perinatal mental disorders are linked to an increased risk of death due to suicide, substance misuse and the misinterpretation of serious physical symptoms as psychiatric issues in the woman.
Perinatal mental health problems cover a wide range of mental health challenges, from mild depression and anxiety to mental illnesses such as mania and psychosis. These mental health problems also include conditions that existed before pregnancy or that recur, as well as those that emerge during pregnancy or in the postpartum period. Postpartum mental health problems may appear immediately after the birth of the child or later, with variable timing. Women with mental illness are also more likely to face life-threatening complications, because these disorders can co-occur with a variety of other health and social determinants, such as poverty, poor physical health and interpersonal violence. A history of mental health problems is associated with maternal psychosocial well-being and mental health during the perinatal period. Because many mental health factors are interrelated, broad assessment is essential when evaluating maternal mental health (Howard & Khalifeh, 2020).
Depression in the perinatal period
Temporary declines in maternal well-being, commonly referred to as the baby blues, are experienced by 40–80% of mothers shortly after childbirth. Symptoms include mood lability, sadness, tearfulness, anxiety, poor concentration and insomnia (Sharma et al., 2021; O’Hara & McCabe, 2013). Baby blues is not considered a mental disorder due to its transient nature. It does not usually require professional attention and should be distinguished from depression.
Depressive symptoms during the perinatal period may arise from hormonal changes, psychosocial stressors, a lack of support and a history of mental health issues. Common symptoms include persistent sadness, fatigue, sleep disturbances, guilt, anxiety, irritability and difficulty bonding with the infant (O'Dea et al., 2023). Note that severe changes in the sleeping and eating pattern are common for most women in the perinatal period. Thus, the other symptoms are more specific related to depression in this period. However, sleep deprivation may increase the symptom burden. Peripartum depression (PPD) refers to an episode of unipolar depression that begins during pregnancy or shortly after childbirth. Although the official DSM-5 definition limits the onset to pregnancy or the first four weeks after childbirth, research evidence indicates that depressive symptoms can begin up to a year after childbirth (RiseUP-PPD, 2023).
Prevalence of depressive symptoms (mild to moderate) and clinical depression
According to Howard and Khalifeh (2020), depression is the second most common non-psychotic mental disorder during the perinatal period after anxiety disorders. Findings may vary depending on the depression scale used and whether prevalence figures are based on diagnosed depressive disorders or self-reported symptoms that exceed screening cut-off scores. Screening tools typically identify a larger proportion of women with clinically significant depressive symptoms, whereas confirmed clinical diagnoses are markedly fewer.
In Europe (mild to moderate) antenatal depression affects approximately 18% of women (RiseUP-PPD, 2023), and (mild to moderate) postnatal depression around 17% in high‑income countries (Howard & Khalifeh, 2020). In northern Europe, the prevalence of moderate-to-severe depressive diagnosis ranges from 3.5% during pregnancy to 3.3% postpartum (RiseUP-PPD, 2023). The prevalence is also dependent on cultural factors and the developmental level of the country (Grote et al., 2010; RiseUP-PPD, 2023). Helleyer et al. (2025) suggest that the pooled prevalence of postpartum depression in the second year after childbirth is estimated at 15%, which is nearly equal to the first year. In most of the studies, postnatal depression was assessed using screening tools (29 studies out of 32) and rarely with clinical interviews (3 out of 32) (Helleyer et al., 2025).
Chhabra et al. (2020) referred to earlier studies in which the prevalence of paternal depression ranged from 8% to 10% in Western countries. Smythe et al. (2022) found substantially lower pooled prevalence rates in parental dyads: 1.72% for antenatal depression, 2.37% for early postnatal depression (0–12 weeks) and 3.18% for later postnatal depression. These rates should be interpreted with caution, as variations in assessment methods across studies can substantially influence reported prevalences.
Risk factors associated with depressive symptoms or depression during the perinatal period
Biological processes during pregnancy and after childbirth, together with psychological and social factors, form a whole entity in which a single risk factor rarely acts alone; rather, depression is seen as the result of an accumulation and interaction of factors. Table 4 summarises risk factors associated with perinatal depressive symptoms or depression identified across different well-being domains in the reviewed materials. Assessment of their relative importance, causal pathways or interaction mechanisms falls outside the scope of this report.
Antenatal depression is shaped by complex psychological and social factors, of which stress and a lack of social support are the most consistently prominent. High levels of stress can predispose women to depression, while strong coping skills and social relationships, as well as self-esteem, quality of life and spirituality, can protect against the risk (Evans & Bullock, 2012; Lancaster et al., 2010). Life stressors and significant life events are known risk factors for depressive symptoms during pregnancy and are associated with adverse outcomes such as preterm birth, low birth weight, an unplanned caesarean section and a longer hospital stay (Lancaster et al., 2010). An unwanted or unplanned pregnancy is also a clear risk factor for perinatal depressive symptoms (Evans & Bullock, 2012; Lancaster et al., 2010). According to Lancaster et al. (2010), correlations during pregnancy included life stress, a lack of social support, intimate partner violence, maternal anxiety, previous depression and a lower economic status. Smoking in mothers has also been associated as a risk factor for depressive symptoms during pregnancy (Evans & Bullock, 2012; Lancaster et al., 2010).
Social isolation, single parenthood, a low socioeconomic status, an immigrant or refugee background and poor relationship quality increase the risk of depression throughout the perinatal period (Bedaso et al., 2021; Heer et al., 2024; Pillas et al., 2024; Smythe et al., 2022). Lifelong maternal maltreatment is associated with both antenatal and postpartum depressive symptoms , especially when childhood trauma and current violence occur simultaneously (Alvarez-Segura et al., 2014). In addition, parenting pressures and negative emotions can be reflected in both periods (Holopainen & Hakulinen, 2019). The cumulative effect of multiple stressors is moderately associated with higher levels of depressive symptoms (Lancaster et al., 2010).
The challenges of early parenthood, such as the burden of caregiving, sleep deprivation and limited social support, can prolong postpartum symptoms beyond the first year (Hellyer et al., 2025). Other factors associated with postpartum depression include childcare-related stress, prenatal anxiety, and maternity blues, which can increase vulnerability in the early weeks after birth (Hutchens et al., 2020). Research indicates a bidirectional link between infant excessive crying and maternal mental health. Excessive crying in infants and maternal depression often co-occur and can reinforce each other, while depression is more commonly a subsequent condition rather than a cause of infant excessive crying. In contrast, maternal anxiety tends to precede and accompany infant excessive crying, suggesting that early anxiety may predict later crying problems and even postpartum depression (Petzoldt, 2018).
Postpartum risks may also include body image challenges (Lee et al., 2023), overweight or obesity (Molyneaux et al., 2014) and low resilience (Hajure et al., 2024). During the COVID-19 pandemic, significantly high levels of prenatal depression and anxiety were reported (Tomfohr-Madsen et al., 2021). Various psychosocial factors are associated with postnatal depressive symptoms in fathers. Significant risk factors include relationship dissatisfaction, financial instability, unemployment, a low educational level and perceived stress (Ansari et al., 2021).
Factors associated with more severe depressive symptoms and clinical depression
Biological factors are also associated with antenatal depression. These include factors such as changes in brain structure during pregnancy, sensitivity to progesterone-allopregnanolone fluctuations, low BDNF levels and changes in cortisol levels, as well as genetic predisposition. After childbirth, the risk is also increased by the sharp drop in hormone levels (RiseUP-PPD, 2023). Genetic vulnerability can interact with psychosocial stressors to intensify postpartum depressive symptoms (Hutchens et al., 2020).
Pregnancy-related illnesses and complications, such as gestational diabetes and anaemia, increase the risk (Abrar et al., 2020; RiseUP-PPD, 2023). Traumatic birth experiences and obstetric violence significantly increase the risk of postpartum depression (Benyamini et al., 2024; Silva-Fernandez et al., 2023), as do perinatal losses (Burden et al., 2016; Westby et al., 2021). Operative delivery is also associated with postpartum depression (RiseUP-PPD, 2023).
A history of depression or other mental health disorders is one of the known risk factors (Evans & Bullock, 2012; Lancaster et al., 2010). Risk factors for postpartum depression include previous depression, current or previous abuse, a lack of social support, unplanned or unwanted pregnancy, high levels of stress and relationship dissatisfaction (Hutchens et al., 2020). Antenatal depression strongly predicts postnatal depression (Smythe et al., 2022). Depression during pregnancy increases the risk of postpartum depression in both parents (Smythe et al., 2022), and paternal depression is positively associated with maternal depression both before and after childbirth (Chhabra et al., 2020).
Lower socioeconomic status, certain occupational stressors, and some personality-related factors and low self-esteem have also been identified as significant risk factors, and a history of child sexual abuse, as well as disruptions in biological systems and pregnancy complications such as preeclampsia or HELLP, may further elevate the risk (Hutchens et al., 2020). Immigrant women are at particular risk when social isolation and a low social-economic status are combined with previous mental health challenges (Nilaweera et al., 2014).
In addition, the mother's previous traumatic experiences and adverse childhood experiences (ACEs) may contribute to the development of antenatal depression (Chamberlain et al., 2019; Hughes et al., 2021; Racine et al., 2021). Intimate partner violence during pregnancy has been repeatedly identified as a significant risk factor (RiseUpp, 2023; Alvarez-Segura et al., 2014; Howard et al., 2013).
Table 4. Summary of risk factors associated with perinatal depression or depressive symptoms aligned with six domains.
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Outcomes associated with depressive symptoms and depression
Depression incurs significant costs to society through the increased use of health and social services, diminished productivity, and the negative effects it has on children’s development and health throughout their life (RiseUP-PPD, 2023). Associated outcomes for the child will be addressed in chapter Even mild parental mental health symptoms can affect a child's well-being and health.
Depression during the perinatal period has been associated with adverse obstetric outcomes such as preterm birth and low birth weight (Evans & Bullock, 2012; Grote et al., 2010; Howard & Khalifeh, 2020; Lancaster et al., 2010), impaired bonding and parenting quality (O’Dea et al., 2023), an increased risk of child developmental challenges (Grote et al., 2010; O’Dea et al., 2023), as well as compromised maternal well-being and adverse effects on the mother–infant relationship (Frankham et al., 2023; Furuta et al., 2018). Depressive symptoms are also linked to exhaustion and strained parent–child interaction (Kurth et al., 2011; Petzoldt, 2018), chronic grief and avoidance behaviours following perinatal loss (Burden et al., 2016; Westby et al., 2021) and feelings of guilt and diminished self-worth under parenting pressures (Billings et al., 2024; Holopainen & Hakulinen, 2019.
Postpartum depression impairs the mother's well-being and increases feelings of guilt, shame, irritability and loss of interest, which makes it difficult to cope with everyday life. It also increases the risk of harmful health behaviours and non-adherence to treatment (RiseUP-PPD, 2023). Failure to identify and treat women who have a high risk of depression may result in prolonged distress and health risks for both the mother and child. Healthcare providers are well positioned to assess and support mothers with depressive symptoms, as obstetric visits occur regularly over several months (Lancaster et al., 2010).
Maternal depression and depressive symptoms increase the burden on the spouse, which can lead to weakened relationship satisfaction and increase the risk of depression in the spouse (Chhabra et al., 2020). Depression is associated with a deterioration in coping and interaction skills, which can further strain the partner relationship. These family-level effects, including impaired bonding and parenting quality, exhaustion and strained parent–child interaction, and chronic grief and avoidance behaviours (Burden et al., 2016; Frankham et al., 2023; Furuta et al., 2018; Kurth et al., 2011; Petzoldt, 2018; Westby et al., 2021), increase the risk of conflicts and stress within the family system and can negatively affect children’s emotional, cognitive and behavioural development (RiseUP-PPD, 2023).
Anxiety and stress are common during the perinatal period
Anxiety and stress are common during perinatal period. Anxiety is one of the most prevalent mental health concerns in the perinatal period, occurring more frequently than in the general adult population (Dennis et al., 2017) and with high comorbidity with depression (Howard & Khalifeh, 2020). Many women experience significant symptoms such as worry and avoidance that impair functioning, even without a full diagnosis. The strongest risk factor is a prior history of anxiety or depression, and symptoms often persist from before pregnancy. Severity and impact can fluctuate throughout pregnancy and postpartum. (O’Hara & Wisner, 2014).
According to Bina et al. (2024), perinatal mood and anxiety disorders (PMADs) affect up to 20% of pregnant and postpartum women. Anxiety disorders such as generalised anxiety, obsessive–compulsive disorder (OCD), panic disorder and social anxiety are frequently reported during pregnancy, although prevalence rates vary significantly across studies. Post‑traumatic stress disorder (PTSD), specific phobias and social anxiety disorder each have a pooled prevalence of around 3% (Viswasam et al., 2019).
Across pregnancy, self-reported anxiety symptoms are common and tend to increase towards delivery. Dennis et al. (2017) found that anxiety symptoms affect approximately 18.2% of women in the first trimester, rising to 24.6% in the third trimester (22.9% overall). Postpartum, the prevalence remains high, at 17.8% in the first four weeks after birth and around 15% thereafter.
Prevalence estimates vary, with anxiety disorders reported at 15–20% during pregnancy and around 10% postnatally (Howard & Khalifeh, 2020). Clinically diagnosed anxiety disorders occur in approximately 18% of women in the first trimester, decreasing to around 15% later in pregnancy and to 9.3–9.9% during the first postpartum year. Generalised anxiety disorder (GAD) specifically affects roughly 4% of women during pregnancy and 4.2–5.7% postpartum (Dennis et al., 2017; Viswasam et al., 2019). The prevalence of paternal anxiety has varied substantially across studies. Philpott and colleagues (2019) reported rates ranging from 3–25% during the antenatal period and from 2–51% postpartum. In a review by Leach and colleagues (2016), prevalence estimates were somewhat narrower, ranging from 4–16% antenatally and from 2–18% postpartum.
Risk factors associated to anxiety and anxiety disorders
During the perinatal period, women experience different levels of anxiety and stress due to concerns about their own or their infants’ health, as well as pressures related to fulfilling the expectations of pregnancy and motherhood. Unrealistic social norms and expectations contribute to women’s perinatal anxiety and stress, especially when personal experiences do not align with societal ideals (McCarthy et al., 2021).
Stress, exhaustion and a lack of social support act as factors that both exacerbate symptoms related to anxiety disorders and predispose individuals to them (Bedaso et al., 2021; Kurth et al., 2011). Stress is amplified by relationship problems and mental health issues of the partner (Ansari et al., 2021; Chhabra et al., 2020), single parenthood, a low socioeconomic status, an immigrant/refugee status and a sexual or gender minority status (Ammerman et al., 2010; Heer et al., 2024; Kirubarajan et al., 2022). Fatigue, sleep deprivation, neuropsychiatric challenges (Elliot et al., 2024) and low resilience (Hajure et al., 2024) are additional stressors. Poor sleep quality in pregnant women is associated with perinatal mood disturbances (González-Mesa et al., 2019). Pregnancy-related anxiety (PrA) centres on concerns related to pregnancy, foetal health, childbirth and birth outcomes, but also on the mother’s ability to cope with the challenges of motherhood (Evans & Bullock, 2012).
Concerns about maternal and infant health are also major stressors, with anxiety often linked to fear of complications and the unknown (McCarthy et al., 2021). Medically complicated pregnancies may increase the risk of high-level anxiety symptoms among pregnant women (Abrar et al., 2020). Unexpected findings during prenatal ultrasound examinations can also evoke intense negative emotions in parents, such as feelings or a state of shock (Johnson et al., 2020). Anxiety is commonly associated with fear of childbirth (Molgora et al., 2019), traumatic birth experiences (Benyamini et al., 2024) and obstetric violence (Silva-Fernandez et al., 2023). Poor healthcare experiences, including perceived low-quality care and limited access to services, further intensify these symptoms (McCarthy et al., 2021). A history of serious illnesses may also cause stress and, for example, mothers with cancer have reported concerns and fears about how their own health might affect their infant's health (Leung et al., 2020).
Previous mental health disorders are frequently associated with concurrent conditions, particularly depression, anxiety and eating disorders, which often co-occur (Wiswasam et al., 2019). Other related risk factors include eating disorders (Ecob et al., 2025), negative body image (Lee et al., 2023) and perinatal loss (Burden et al., 2016). In the literature reviewed for this report, post-traumatic disorder (PTSD) was associated with perinatal loss and negative childbirth experiences, which are addressed later in this chapter.
Paternal anxiety during the perinatal period has been reported to increase stress, depression and tiredness and to lower paternal self-confidence (Philpott et al., 2019). Parenting stress associates significantly with paternal anxiety in the perinatal period. Several factors appear to be particularly relevant to fathers’ experiences during this time, including gender‑role‑related stress, domestic violence and mismatched expectations regarding pregnancy and childbirth (Chhabra et al., 2020).
Table 5 summarises risk factors associated with perinatal anxiety symptoms or anxiety disorders identified across different well-being domains in the reviewed materials. Assessment of their relative importance, causal pathways or interaction mechanisms falls outside the scope of this report.
Table 5. Summary of associated risk factors for perinatal anxiety symptoms and anxiety disorders aligned with six domains.
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Outcomes associated with anxiety and anxiety disorders
Pregnancy-related anxiety and high stress levels are associated with an increased risk of antenatal depressive symptoms and anxiety disorder (Evans & Bullock, 2012; Lancaster et al., 2010). Such anxiety and stress also elevate the likelihood of adverse pregnancy and birth outcomes, including preterm birth, low birth weight, an unplanned caesarean section and a longer hospital stay (Lancaster et al., 2010). Anxiety may begin early in pregnancy, particularly among those with a history of adversity, and is associated with poorer child socioemotional and cognitive outcomes (Racine et al., 2021).
Stress and worry during the perinatal period may also result in sleep disturbances, fatigue and parental exhaustion (Kurth et al., 2011; Petzoldt, 2018). Moreover, maternal psychological strain during pregnancy and childbirth increases vulnerability to postpartum mental health problems and can hinder early bonding and interaction with the infant, with perinatal stress and anxiety shown to be associated with attachment difficulties and reduced parent–infant interaction (O’Dea et al., 2023; Staneva et al., 2015). Parental perinatal anxiety has further been linked to poorer socioemotional and cognitive development in children (Kingston et al., 2012; Racine et al., 2021).
Obsessive–compulsive disorder during the perinatal period
Obsessive–compulsive disorder (OCD) involves persistent, intrusive thoughts that cause significant distress, leading the person to perform repetitive behaviours or mental acts to reduce anxiety. These compulsions are rigid, time‑consuming and interfere with daily functioning, even though the individual typically recognises the thoughts as unrealistic (APA, 2024).
The prevalence in women panic disorder (PD) and OCD occur during the pregnancy with rates of 3% for each. The onset of OCD during pregnancy is not uncommon: 13–39% of all OCD cases begin during this period. These findings suggest that pregnancy may be a specific risk factor for the occurrence or exacerbation of PD and OCD (Viswasam et al. 2019). There is some evidence of an increased rate of disorders requiring outpatient contact and/or psychotropic treatment in the postnatal period, particularly for depression and (OCD) (Howard & Khalifeh, 2020).
Only one study has particularly addressed OCD during the perinatal period. Burton et al. (2022) reviewed how women with OCD experience maternity care and mental health care during pregnancy and postpartum. Such women may face delays in appropriate treatment if their symptoms are misdiagnosed as relating to other mental health illnesses, most commonly post-partum depression or generalised anxiety, or if there is a lack of knowledge and recognition among professionals. Health professionals may mistakenly perceive mothers with perinatal OCD as a danger to their infants, especially when they lack knowledge about their condition and fail to distinguish intrusive thoughts from actual intent to harm. Mothers themselves may fear they pose a risk to their babies, and this fear can be reinforced by OCD symptoms and external actions such as referrals to social services. The true risk lies not in the obsessions but in the consequences of untreated OCD, such as avoidance behaviours that disrupt caregiving and bonding (Burton et al., 2022).
Eating disorders during the perinatal period
Eating disorders (EDs) refer to psychiatric disorders characterised by abnormal eating or weight-control behaviours. Perinatal eating disorders are relatively rare, but there is a history of an eating disorder in up to 15% of pregnant women (Howard & Khalifeh, 2020). Disordered eating during pregnancy is strongly associated with depression and anxiety symptoms during pregnancy (Ecob et al., 2025; Baskin & Galligan, 2019). Maternal EDs are also linked to postpartum anxiety (Ecob et al., 2025). Baskin and Galligan (2019) reported a positive association between eating disorders and compulsive symptoms, as well as conflicting findings regarding ambivalent feelings about pregnancy, relationship support and social support. Their review did not allow an assessment of the direction of causality, and the results suggest that mental health and psychosocial factors and eating disorder symptoms may be bidirectional or cyclical, with negative emotional distress increasing eating disorder symptoms, which in turn impairs mental health and social functioning.
Eating disorders during the perinatal period can pose significant risks to both the mother and infant. They also raise the risk of pregnancy and delivery complications, such as hyperemesis gravidarum, prolonged labour, caesarean section and conditions such as anaemia, hypertension and diabetes. For the infant, EDs are associated with restricted foetal growth, preterm birth, abnormal head size and an increased risk of perinatal mortality (Ecob et al., 2025). Early identification, timely support and access to specialised care, alongside attention to the mother–infant relationship, are essential for effective prevention, assessment and treatment of perinatal mental health and eating disorders (Ecob et al., 2025).
Maternal serious mental illness requires urgent attention
Parents with serious mental illness (SMI), such as severe depression, acute psychosis, schizophrenia or bipolar disorder, face complex challenges in parenting. These difficulties, combined with social, emotional and economic burdens, increase the risk of adverse outcomes such as disrupted attachment, social exclusion and child emotional problems (Harries et al., 2023). Thus, psychotic disorders and bipolar disorders are serious mental health conditions that can complicate pregnancy and parenting.
Postpartum psychosis (PPP) is a rare mental disorder, affecting between 1 and 2 per 1000 women, and usually occurs within 1–14 days after childbirth and can last from weeks to months. Risk factors include bipolar disorder or previous postpartum psychosis, hormonal changes, postpartum depression, genetic predisposition, and a possible link to early adverse childhood experiences (Friedman et al., 2023). Severe mental illness in the perinatal period may occur as a continuation of chronic psychotic illness or a new onset, often shortly after childbirth. Postpartum psychosis can emerge suddenly as a severe psychiatric episode (Jones et al., 2014). Approximately 40% of those affected have no previous history of serious psychiatric illness (Friedman et al., 2023). Studies suggest a significant genetic influence on the manifestation of these serious mental disorders, with candidate genes linked to serotonin, hormonal and inflammatory pathways. Although childbirth is a powerful trigger for psychotic episodes, stressful life events do not appear to be a significant risk factor for the onset of postpartum psychosis (Jones et al., 2014).
Postpartum psychosis within the first year after delivery is more likely in mothers with prior psychopathology and especially with bipolar disorder (Ramsauer & Achtergarde, 2018). The postpartum period is a highly vulnerable phase: the risk of relapse for women with bipolar I disorder is estimated at 39%, and the risk especially increases when preventive medication has been discontinued. Approximately 38% of these relapses are manic or mixed episodes, which can be difficult to recognise because they are often accompanied by psychotic symptoms. A new onset of bipolar disorder during pregnancy is relatively rare (Jones et al., 2014; Sharma et al., 2024).
Early identification and individualised prevention strategies are essential. Potential triggers of mania, such as sleep disruption, antidepressant use and substance use, should be addressed proactively (Sharma et al., 2024). Multidisciplinary care and preconception planning play a crucial role in reducing risks and supporting the safety of both the mother and child. Medication management during pregnancy and postpartum is important and requires specialised knowledge (Jones et al., 2014).
Associated outcomes of serious mental health illnesses
Mother
Postpartum psychosis can have substantial consequences for the mother. It is associated with an elevated risk of self-harm, accidents and significant functional impairment, and the rapid onset of symptoms means that even brief delays in receiving care can increase adverse outcomes (Friedman, 2023). Confusion, memory disturbances and psychotic symptoms may impair a mother’s ability to care for herself or her infant. SMI are a risk factor for suicide, which is among the most common causes of maternal mortality in high-income countries, including the Nordic countries, and on very rare occasions can lead to infanticide (Milia & Noonan, 2022; Jones et al., 2014). Although most mothers recover well with appropriate treatment, approximately one-third experience recurrent symptoms outside the peripartum period. Long-term effects may include fear, shame, sadness related to missed early bonding moments and a need to process traumatic memories. Severe mental disorders can also impair women’s ability to form and maintain relationships and increase the risk of unintended pregnancies.
Suicide is one of the leading causes of maternal death in the western countries
In Swedish nationwide register-based study women with clinically diagnosed perinatal depression were associated with an increased risk of death, particularly during the first year after diagnosis and because of suicide. Women who are affected, their families, and health professionals should be aware of these severe health hazards after perinatal depression. (Hagstahla et al., 2024). The study including data from Denmark, Norway and Finland found that despite the maternal mortality rates are relatively low, major contributors to maternal deaths in all countries were cardiovascular diseases and suicide (for maternal mortality up to one year) (Digusto et al., 2022).
Partner and family
Partners and family members often experience postpartum psychosis as highly distressing. Reported experiences include profound feelings of helplessness and fear, difficulty accessing accurate information or having their concerns acknowledged, and the burden of managing multiple responsibilities that include caring for the infant, maintaining daily routines and supporting a partner in acute crisis (Friedman, 2023). Emotional strain, fear of child removal and stigma are frequently present, and these experiences tend to be especially intense in families with young children (Harries et al., 2023). Some couples report strain or relationship dissolution, although others describe positive developments such as increased empathy, deeper understanding and shared growth in navigating mental health challenges. The effects of a parent’s serious mental health disorder on a child are discussed in the chapter Serious parental mental illness and infant health risks.
Efforts to support families are often hampered by inadequate policies, fragmented services, crisis-oriented models and concerns about child protection involvement. Evidence indicates the need to move from risk-focused and professionally driven frameworks toward compassionate, strengths-based and collaborative approaches that incorporate the family’s broader social environment. Achieving this requires action at multiple levels, including the implementation of family-focused practices and socially connected approaches that emphasise community support (Harries et al., 2023).
A bidirectional link between parents' mental health
Parental mental health and relationship dynamics are closely interlinked in the perinatal period, with evidence indicating a bidirectional relationship between parental psychological well-being and the quality of the couple relationship. Marital conflict and a lack of cooperative co‑parenting have been demonstrated to increase paternal depression and anxiety (Chabra et al., 2020; Philpott et al., 2019), while depressed fathers report disappointment regarding changes in the partner relationship after childbirth and insufficient support from their partner (Holopainen & Hakulinen, 2019).
Conversely, parental mental health problems can negatively influence the couple relationship: for example, childbirth‑related PTSD has been associated with poorer parental relationships and challenges in parenting (Delicate et al., 2018). Maternal perinatal mental health disorders may heighten the vulnerability of partners to psychological distress (Darwin et al., 2021), and maternal or partner depression is a significant risk factor for paternal perinatal depression or anxiety (Chhabra et al., 2020; Philpott et al., 2019). Paternal symptoms similarly tend to increase when mothers experience perinatal mental health difficulties (Darwin et al., 2021). Relationship quality is also linked to maternal well-being, with poor relationship satisfaction identified as a risk factor for depressive symptoms during pregnancy (Lancaster et al., 2010).
Various psychosocial factors are associated with postnatal depressive symptoms in fathers. A lack of support and low parenting self-efficacy are also associated with paternal postpartum depressive symptoms (Ansari et al., 2021). Significant risk factors include dissatisfaction in the relationship, financial instability, unemployment, a low educational level and perceived stress (Ansari et al., 2021). Addressing social determinants of health and relationship dynamics is essential to identify and support at-risk parental dyads (Smythe et al., 2022). Ansari and colleagues (2021) found that prior mental illness poses a high risk for the development of depressive symptoms in fathers, and paternal mental illness is linked to maternal depression.
Severe maternal mental illness, such as postpartum psychosis, can substantially affect the partner’s psychosocial well‑being. Fathers report a sense of loss in different aspects of their lives, such as the relationship with their partner and the future they have planned. They also report fear and shock, attributed to their lack of knowledge and awareness of postpartum psychosis (Lyons et al., 2024). Partners frequently experience a lack of knowledge about recognising postnatal mental distress and accessing help, which may compromise their own health, their relationship with the mother and the infant, and their willingness to disclose distress (Atkinson et al., 2021). Together, these findings demonstrate a reciprocal interplay between parental mental health and relational functioning, underscoring the importance of addressing the well‑being of both parents within the broader family system.
Neuropsychiatric challenges
Parental neurodivergence also influences the type of support needed and the accessibility of information in perinatal services. There is a significant research gap regarding the perinatal healthcare needs of neurodivergent individuals (e.g., ADHD and autism spectrum disorders), and current perinatal care practices do not sufficiently address the unique challenges faced by neurodivergent people (Elliot et al., 2024).
Elliot et al. (2024) reviewed the literature on the perinatal experiences of neurodivergent parents, particularly those on the autism spectrum and with ADHD, and concluded that neurodivergent parents are at risk of psychosocial challenges during the perinatal period. The transition to the perinatal period and parenthood brings changes in routines and hormone levels, which can be challenging for neurodivergent parents. Neurodivergence has also been reported as a strength, for example in terms of unique sensory sensitivity, adaptability and motivation (Elliot et al., 2024). Intense sensory experiences, experiences with parenting difficulties and mental health problems have also been identified as perinatal challenges among autistic women (Hernández González et al., 2024).
Promotive and protective factors for parental mental health
The literature review identified factors that can support parental mental health and prevent depression, anxiety and stress symptoms. Positive experiences of parenthood, self-esteem and autonomy are essential for the well-being of all mothers, fathers and children (Arnold et al., 2025; Bell & Andersson, 2016; Finlayson et al., 2020; Palioura et al., 2023; Silva-Fernandez et al., 2023). Prenatal education and high-quality support for families promote the transition to parenthood, reduce anxiety and strengthen family well-being (Suto et al., 2017; Walker et al., 2019). Social support from the partner, family, friends, peers and professionals has a key role in protecting against depression and anxiety, promoting recovery and preventing long-term mental health problems (Almeida et al., 2024; Alvarez-Segura et al., 2014; Evans & Bullock, 2012; Lancaster et al., 2010; Westby et al., 2021).
Adequate and sensitive support during childbirth can prevent negative experiences and PTSD, while open communication and partner involvement increase trust and emotional stability (Ayers et al., 2016; Bell et al., 2016; Shorey & Chan, 2020). High-quality care relationships and targeted support programmes, such as home visits for young mothers, support adaptation to motherhood and prevent postpartum depression (Atzl et al., 2019; Chamberlain et al., 2019; Hymas & Girard, 2019). Prenatal education could offer a valuable opportunity to support the transition to parenthood and well-being of the whole family. According to Suto et al. (2017), fathers who participatedm in prenatal education reported lower parenting stress three months postpartum and reduced postnatal anxiety shortly after birth compared to fathers who did not participate. They were also more likely to be present in the delivery room and expressed higher satisfaction with the childbirth experience. Additional evidence suggests these programmes may help reduce postpartum anxiety and improve relationship quality between partners (Suto et al., 2017).
In addition, financial assistance, secure housing and equal access to high quality services create a foundation for psychological well-being. Long-term support programmes and stress management strengthen resilience and protect maternal health, especially in situations of social and economic vulnerability (Dela Cruz et al., 2023; DiTosto et al., 2021; Harville et al., 2011; Heer et al., 2024; Siddika et al., 2023).
A healthy postpartum lifestyle is important for the promotion of optimal maternal health (Makama et al., 2021). McKeough, Blanchard and Piccini-Vallis (2022) explored the perceptions of pregnant and postpartum women regarding the barriers to and facilitators of physical activity during pregnancy and identified its health benefits for both mental and physical well-being. However, although physical activity during pregnancy is known to offer health benefits, pregnant women have reported pregnancy symptoms, a lack of knowledge of what constitutes safe activity and the opinions of women’s social circles as barriers to physical activity (McKeough et al., 2022).
Table 6 summarises factors promoting parental perinatal mental health across different well-being domains in the reviewed materials. Assessment of their relative importance, causal pathways or interaction mechanisms falls outside the scope of this report.
Table 6. Protective and promoting factors for parental mental health aligned with six different domains.
Health and nutrition | Relationships and connectedness | Security, safety and sustainable environment |
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Autonomy, agency and resilience | Culture and values | Provision and experience of care |
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Even mild parental mental health symptoms can affect a child's well-being and health
The literature review identified studies that examined the link between maternal mental health and negative outcomes in pregnancy and the health of the infant. Parental mental health issues and psychological issues are significant not only for the parent's own well-being but also for the child's psychological development and the early parent–infant relationship.
Child developmental and psychological outcomes
Maternal perinatal mental health challenges are linked to risks for the child’s mental and physical health and development (Howard & Khalifeh, 2020; Mudiyanselage et al., 2024). Perinatal mental disorders, especially depression and anxiety, are linked to increased risks of psychological, emotional, and developmental disturbances in children. They can impact child development from foetal life through adolescence. It is well established that women with both common mental disorders and severe mental illness have an increased risk for adverse obstetric and pregnancy outcomes, including preterm births and foetal growth impairments (Howard & Khalifeh, 2020).
Prenatal and postpartum psychological stress in the mother has been found to have some impact on the infant’s cognitive, behavioural and psychomotor development (Kingston et al., 2012). The mother’s prenatal and postpartum psychological stress has been found to have a small impact on the infant’s cognitive, behavioural and psychomotor development (Kingston et al., 2012). Maternal psychological stress is associated with postpartum mother–infant bonding problems (O'Dea et al., 2023). After childbirth, exhaustion caused by, for example, the infant's crying has been shown to decrease the parent's ability to concentrate, trigger depressive symptoms, and burden the interaction between parent and child (Kurth et al., 2011).
Gentile (2015) found that untreated maternal depression during pregnancy may lead to foetal stress responses, neurochemical changes in newborns, and later behavioural issues. Evidence suggests that in utero exposure to depression is linked to biological changes in the developing foetus, affecting the serotonergic system and the hypothalamic–pituitary–adrenal axis, hypothesised to be related to maternal–placental–foetal stress mechanisms, including maternal immune activation (Howard & Khalifeh, 2020). Depression during pregnancy has been found to increase the risk of preterm birth and low birth weight (Grote et al., 2010), and research has demonstrated a significant association between preterm birth and depression and anxiety symptoms and disorders, as well as perceived stress during pregnancy (Staneva et al. 2015). Maternal eating disorders are associated with restricted foetal growth, preterm birth, abnormal head size and an increased risk of perinatal mortality (Ecob et al., 2025).
Perinatal mental health disorders, especially depression and anxiety, are associated with increased risks of psychological, emotional and developmental difficulties in children (Grote et al., 2010; O’Dea et al., 2023). Stein et al. (2014) report effects on cognitive, emotional and behavioural development, with severity depending on the duration and intensity of the parent's condition. Direct and indirect effects of prenatal depression, anxiety and stress pose risks to later maternal and infant psychological well-being, such as impaired attachment, postpartum adjustment and physiological consequences for the child (Staneva et al., 2015). Children exposed to maternal depression during pregnancy and the first year of life have been found to be more likely to experience early developmental and emotional, behavioural and learning difficulties (RiseUP-PPD, 2023).
Maternal depression during the perinatal period is linked to poorer neurodevelopmental outcomes (Duan et al., 2019; Howard & Khalifeh, 2020), including an increased risk of ADHD and attention-related difficulties (Tucker & Hobson, 2022). Postpartum and birth-related post-traumatic stress disorder (PTSD) can significantly impact maternal well-being, the mother–infant relationship and child development (Frankham et al., 2023; Furuta et al., 2018).
Maternal mental health problems correlate consistently with reduced child well-being in early childhood and lead to increased use of health services, causing financial and personal burdens for both families and society. Mothers experiencing depression tend to seek more medical care for their children, possibly due to stress or anxiety (Mudiyanselage et al., 2024).
Paternal mental health and child outcomes
Untreated paternal perinatal depression is associated with developmental and psychological problems in children, including conduct disorders and social difficulties (Gentile & Fusco, 2017). Paternal anxiety has been associated with impaired parenting skills (Philpott et al., 2019). Paternal postpartum depression and parenting-related stress may lead to children’s sleep problems and bedtime difficulties (Ragni et al., 2020). A supportive parent–child relationship can buffer negative effects if only one parent is depressed; however, when both parents’ experience depression, the child faces substantially higher risks of poor mental and physical health (Smythe et al., 2022).
Serious parental mental illness and infant health risks
For infants, risks are often associated with genetic vulnerability, parental functioning and the broader family environment rather than infant characteristics. The evidence points to the impact of parenting quality on mental health outcomes in both generations.
Maternal psychosis may involve inconsistent caregiving, neglect or acute safety concerns (Friedman, 2023). Severe mental illnesses are recognised risk factors for child well-being and early parent–child interaction (Harries et al., 2023; Ramsauer & Achtergarde, 2018; Vilaseca et al., 2025). Parents with severe mental illness frequently report overwhelming distress, suicidal ideation and feelings of inadequacy in caregiving. Impairment in social cognition may reduce the ability of mothers to interpret and respond to infant cues (Vilaseca et al., 2025).
Mothers with psychotic disorders, such as schizophrenia, show significantly reduced sensitivity, warmth and responsiveness in interactions with their infants, leading to less mutual engagement and more avoidant behaviour in the child. These mothers also struggle with emotional recognition, which can result in unusual or frightening communication patterns (Vilaseca et al., 2025). Mothers with schizophrenia tend to face more challenges in parenting and are at higher risk of being separated from their child after treatment compared to mothers with acute postpartum psychosis or other disorders. Despite similar actual risks to the infant across diagnostic groups, mothers with schizophrenia are often judged more harshly, possibly due to stigma associated with chronicity, unpredictability and perceived violence (Ramsauer & Achtegarde, 2018).
Research indicates that maternal psychosis may reduce maternal responsiveness, leading infants to display more negative or fearful behaviours. Findings vary across acute and chronic presentations, and some mothers with psychosis report stronger emotional bonding than mothers with postpartum depression (Ramsauer & Achtergarde, 2018). The evidence points to the impact of parenting quality on mental health outcomes in both generations. Despite these challenges, most mother–infant interactions improve with treatment, and most families are discharged together from mother and baby units (Friedman, 2023).
Children in child welfare systems
Severe mental health disorders and/or substance use in parents increase the risk of out‑of‑home placement for their children. Children aged 0–5 years in child welfare systems often have trauma backgrounds and are at elevated risk of mental health issues and developmental delays. Mental health needs, developmental needs and placement are strong predictors of service use (Keyser & Ahn, 2017). These children require particular attention given their heightened vulnerability.
Substance use and smoking during the perinatal period
In the Nordic countries, the risks associated with parental substance use are well recognised in national maternal and child health programmes, as substance use during pregnancy is considered a significant threat to foetal growth, infant neurodevelopment and early child health. However, despite this, the literature review identified only a few studies specifically examining the combined impact of dual-parent substance use on infant outcomes.
Smoking during pregnancy is a well-established risk factor for adverse maternal and infant health outcomes, including long-term complications (Kumar et al., 2021). Despite smoking often being linked to physically weaker outcomes, studies have also identified some psychosocial connections. Maternal smoking has been identified as a risk factor for depressive symptoms during pregnancy (Evans & Bullock, 2012; Lancaster et al., 2010). ln addition, perinatal depression is associated with smoking and substance abuse during the perinatal period (RiseUpp, 2023; Baron et al., 2017). McHale et al. (2022) reported that maternal physical health (including BMI) and smoking may mediate the effect of socio-economic status on preterm birth. Living in a deprived environment increases the risk of adverse health behaviours, such as smoking, low physical activity, substance use and poor diet, and also contributes to elevated chronic stress (Siddika et al., 2023).
A range of factors are associated with an elevated risk of subsequent substance use. Stillbirth and the delivery of a deceased infant have been linked to an increased psychosocial burden, with evidence indicating a higher likelihood of substance‑related difficulties, particularly among fathers (Burden et al., 2016; Peters et al., 2015). Post‑loss mental health symptoms, such as avoidance behaviours, anxiety, chronic pain and reductions in quality of life, may further increase vulnerability to substance use as a coping strategy (Burden et al., 2016; Peters et al., 2015). Perinatal mental disorders are likewise associated with heightened susceptibility to harmful substance use, a relationship that may be reinforced by co‑occurring adversities including poverty, poor physical health and interpersonal violence (Howard & Khalifeh, 2020). In addition, adverse childhood experiences and particularly exposure to intimate partner violence, as well as harmful alcohol use, illegal drug use and anxiety within the household, are associated with an increased likelihood of later substance use (Hughes et al., 2021).
Substance use during the perinatal period is associated with a series of adverse outcomes. Perinatal mental disorders are linked to increased mortality attributable to suicide and substance misuse, and substance use may contribute to diagnostic overshadowing, leading to the misattribution of serious physical symptoms to psychiatric causes (Howard & Khalifeh, 2020). Substance use is also identified as a potential precipitant of manic symptoms, necessitating careful management among individuals at risk of perinatal mania (Sharma et al., 2024). Furthermore, co‑occurring parental substance use and psychiatric personality disorders are associated with reduced treatment responsiveness in mother–infant units (Adhikary et al., 2024). Hammer and Rapp (2022) explored reasons for alcohol use during pregnancy among women (excluding people with alcohol dependence and problematic users), which included inadequate or inconsistent information about the risks of alcohol, varying personal attitudes toward alcohol use, and sociocultural norms and attitudes influencing alcohol consumption.
Perinatal substance use poses significant risks to child development and may diminish the effectiveness of early interventions. Perinatal substance use (alcohol, opioids, cocaine, cannabis, amphetamines) is associated with child maltreatment and child protection involvement, although influenced by socioeconomic and demographic factors (Austin et al., 2022). Alcohol exposure increases the risk of attentional and behavioural disorders (Khoury et al., 2018, and foetal cannabis exposure is associated with later neurocognitive and psychiatric disorders (Roncero et al., 2020). Reasons for alcohol use include inconsistent risk information and sociocultural norms (Hammer & Rapp, 2022).
The consequences of prenatal alcohol exposure and the prevalence of FASD in the Nordic countries
Foetal Alcohol Spectrum Disorders (FASD) refers to a range of permanent and individually varying effects caused by prenatal alcohol exposure, encompassing FAS, ARBD, and ARND (Frederiksen & Nissinen, 2022; Nissinen et al., 2021). FASD can manifest, for example, as growth abnormalities or functional disorders of the central nervous system, but most commonly it presents as invisible neurocognitive difficulties that challenge learning, memory, and behavioural regulation. The symptom profile varies depending on the amount, frequency, and timing of exposure, and the risk is also increased by other stressors during pregnancy and early life (Frederiksen & Nissinen, 2022; Nissinen et al., 2021). Diagnosis is complicated by the lack of uniform international guidelines, and the Nordic countries use differing criteria, which undermines the comparability of prevalence estimates. According to estimates, the prevalence of FASD varies significantly: 360 per 10,000 in Denmark, 124 per 10,000 in Finland, 70 per 10,000 in Iceland, 178 per 10,000 in Norway, and 74 per 10,000 in Sweden, but these estimates are uncertain and likely underestimated (Frederiksen & Nissinen, 2022; based on Lange et al., 2017). See more: Identifying use of alcohol and other substances during pregnancy
Perinatal trauma, loss and the effects of birth experiences on parental well-being
Perinatal trauma covers psychological and emotional stress factors experienced during pregnancy, childbirth and early infancy that can affect parental well-being, the formation of attachment and the functioning of the entire family. Perinatal trauma can be caused, among other factors, by perinatal loss, fear of childbirth, medically or emotionally difficult birth experiences, experiences related to the quality of care and a history of previous trauma or mental health issues. Perinatal loss and negative or traumatic experiences have long-term effects on parental well-being.
Effects of perinatal loss
The review identified that various loss-related experiences, such as miscarriages and stillbirths, can have a profound impact on parental well-being. For example, multiple or repeated miscarriages have been shown to increase the risk of depression and anxiety among women (Inversetti et al., 2023). Stillbirth and the experience of delivering a deceased child are major risk factors for parental mental health and psychosocial well-being. Following stillbirth, parents may experience avoidance of memories, anxiety about other children, chronic pain and changes in healthcare use. Fathers have been less studied, but findings suggest that they also experience a significant risk of distress that is prone to manifesting as avoidance behaviour (Westby et al., 2021). Fathers often suppress grief and face work- or substance-related challenges, while mothers are more likely to struggle with body image and reduced quality of life (Burden et al., 2016; Peters et al., 2015).
Experiencing stillbirth can have long-term effects on parental well-being in later pregnancies and parenthood (Burden et al., 2016). Stillbirth is associated with a higher risk of depression, anxiety and symptoms of post-traumatic stress disorder (PTSD). In a review by Westby et al. (2021), mothers were particularly vulnerable, with some studies reporting over 60% meeting the diagnostic criteria for PTSD. Risk factors for depression, anxiety and PTSD in mothers included being unmarried, a lack of social support and negative self-perceptions. Social stigma and isolation compound these challenges, and delayed delivery after diagnosis is linked to anxiety (Westby et al., 2021).
The fear of loss or loss-related concerns may also negatively affect parental well-being. Alsallum and colleagues (2025) found that mothers of newborns admitted to intensive care units were at greater risk of developing PTSD, especially if they had prior experiences of miscarriage or birth complications. A medically complex pregnancy further increases anxiety symptoms (Abrar et al., 2020).
Protective factors after loss
Perceived social support from family and friends can reduce the risk of depression and anxiety. Positive coping resources and supportive relationships help buffer against loneliness and emotional strain. A committed partnership strongly predicts lower depressive symptoms. Healthcare professionals should offer empathetic bereavement care and support that promote recovery, including respecting families’ wishes regarding contact with the stillborn child and memory-making, which may reduce depression and anxiety (Westby et al., 2021).
Fear of childbirth
The literature search yielded only one article directly addressing the impact of fear of childbirth on psychosocial well-being, but the topic appeared in other articles. Fear of childbirth is a common experience among expectant mothers, but in severe cases it can become a clinical condition affecting daily functioning and coping during childbirth.
Research on fear of childbirth and emergency caesarean section (CS) has yielded mixed results, with severe fear more consistently linked to emergency CS. Among first-time mothers, the association was stronger (Molgora et al., 2020). Fear of childbirth has a relatively strong association with post-partum post-traumatic disorders (PTSD) (Ayers et al. 2016), and strong fear has been linked to diminished resilience (Hajure et al., 2024).
Nordic estimates of fear of childbirth and birth-related trauma
The prevalence of childbirth fear is quite similar in the Nordic countries, although the figures are not directly comparable. In Finland, 2.5% to 8% of first-time mother have reported fear of childbirth (Silvan et al., 2025), while the prevalence of intense childbirth fear for all women in Sweden was determined to be 15.8% (Nieminen et al., 2009), 12% of women in Norway reported fear of childbirth (Henriksen et al., 2020) and around 7% of Danish women reported fear in some stage of pregnancy (Laursen et al., 2008). In a recent study by Haga et al. (2026), the prevalence of childbirth-related post-traumatic stress disorder (CB-PTSD) in a Norwegian sample was 8.7%, which exceeds the 4.7% reported in the meta-analysis of Heyne et al. (2022). Additionally, 22% of participants experienced childbirth as traumatic according to DSM 5 criteria.
Psychosocial risk factors for adverse pregnancy and birth outcomes
Maternal adverse childhood experiences (ACEs) increase the risk of pregnancy complications and are associated with adverse obstetric outcomes, including preterm labour and prematurity and low infant birth weight. A higher cumulative exposure to ACEs, together with lifelong socioeconomic disadvantage and current adverse social conditions, is linked to poorer maternal and birth outcomes (Mamun et al., 2023).
A lower socioeconomic status is associated with a higher likelihood of preterm birth. Factors frequently observed in connection with both socioeconomic disadvantage and adverse birth outcomes include poorer maternal physical health, such as higher or lower body mass index, smoking during pregnancy, maternal mental health problems and alcohol use (McHale et al., 2022). In addition, characteristics of the physical and social environment, including neighbourhood deprivation, exposure to violence or crime and limited access to health services, are associated with an increased risk of preterm birth and other adverse outcomes (Siddika et al., 2023). A physically demanding job is also associated with an increased risk of preterm labour (Adane et al., 2023).
Maternal mental health symptoms and clinically diagnosed disorders during pregnancy, including symptoms of depression, anxiety and post-traumatic stress, are associated with adverse obstetric and perinatal outcomes. These conditions are more common among women with prior trauma exposure and social adversity and are linked to higher rates of preterm birth, low birth weight and pregnancy complications (McHale et al., 2022; Pastor-Moreno et al., 2020). Depressive symptoms or disorder, as well as perceived stress and anxiety during pregnancy have been found to increase the risk of preterm birth and low birth weight (Grote et al., 2010; Staneva et al., 2015).
Even moderate symptoms can impact birth outcomes, but complexity and other influencing factors such as chronic medical conditions, domestic violence and socioeconomic status should also be considered (Staneva et al. 2015). Intimate partner violence during pregnancy is associated with multiple adverse perinatal health outcomes. A systematic review by Pastor-Moreno and colleagues (2020) reported associations with preterm birth, low birth weight, miscarriage, perinatal death and premature rupture of membranes. Intimate partner violence frequently co-occurs with psychosocial stress, mental health problems, substance use and barriers to accessing care, which are also associated with poorer maternal and birth outcomes.
Nordic perinatal statistics
Approximately 265 000 live births occurred in the Nordic countries in 2022. The number of live births has decreased in all Nordic countries, and first-time mothers are becoming older and the BMI of women giving birth has risen which are associated with several risks. Interventions related to childbirth, such as caesarean sections, have also become more common in the Nordic countries over the past four decades. In 2022, the proportion of births delivered by caesarean section was highest in Denmark (20.1%), followed by Finland (19.6%) and Sweden (19.1%). The proportion of preterm deliveries (before the 37th week of gestation) of all deliveries was 4.8–6.3% in the Nordic countries in 2022 and has remained relatively stable in recent decades. Newborn mortality rates are among the lowest in the world, at 1 in 1000 (Heino & Gissler, 2024).
Risk factors for adverse birth outcomes for the child
It is well established that women experiencing common or severe mental disorders are at higher risk of adverse obstetric outcomes, including preterm birth and foetal growth impairments (Howard & Khalifeh, 2020). Several studies have highlighted the link between parental health and well-being, particularly that of the mother, and premature birth. Preterm birth is associated with negative health, social and educational outcomes for children (McHale et al., 2022).
Even moderate mental health symptoms can affect birth outcomes, although multiple contributing factors must be considered, such as chronic medical conditions, domestic violence and socioeconomic adversity (Staneva et al., 2015). Poor maternal general health, including physical, mental and social domains, and chronic or autoimmune conditions are associated with poorer long-term outcomes for children (Mudiyanselage et al., 2024).
Depression during pregnancy has been found to increase the risk of preterm birth and low birth weight (Grote et al., 2010). Research has demonstrated a significant association between preterm birth and depression, anxiety and perceived stress during pregnancy (Staneva et al., 2015), and pregnancy-specific stress, which combines anxiety and elevated stress, is a strongly predictive factor (Evans & Bullock, 2012). Maternal eating disorders have been associated with restricted foetal growth, preterm birth, abnormal head size and increased perinatal mortality (Ecob et al., 2025).
Untreated maternal depression during pregnancy may lead to foetal stress responses, neurochemical alterations in newborns and later behavioural problems (Gentile, 2017). In utero exposure to maternal depression is linked to changes in the serotonergic system and the hypothalamic–pituitary–adrenal axis, probably mediated through maternal–placental–foetal stress mechanisms, including immune activation (Howard & Khalifeh, 2020). Maternal antenatal anxiety has been linked to increased preterm birth rates, lower Apgar scores, shorter birth length and poorer developmental trajectories (Dennis et al., 2017).
Risk factors for negative or traumatic experiences
Individuals with prior mental health issues may be more prone to intense stress responses, which can worsen childbirth-related trauma. Conditions such as anxiety, depression or trauma are known risk factors for postpartum PTSD (Orovou et al., 2025). A difficult birth experience may also increase the risk of relapse among individuals with a history of mental health disorders, such as bipolar disorder (Sharma et al., 2024). Mothers who give birth to twins or triplets are more likely to experience postpartum depression and stress compared to those giving birth to a single child (Van den Akker et al., 2016).
The mode of delivery has also been found to play a role as a risk factor for PTSD (Silva-Fernandez et al., 2023). The prevalence of maternal PTSD following emergency caesarean sections ranged from 2% to 41% in a review by Orovou and colleagues (2025). High PTSD rates following emergency caesarean sections are influenced by the clinical urgency of the procedure, its unexpected nature and pre-existing maternal vulnerabilities (Orovou et al., 2025). Other risk factors for PTSD include childhood trauma (Racine et al., 2021), intimate partner violence (Howard et al., 2013), disaster exposure (Harville et al., 2010), perinatal loss (Burden et al., 2016), fear of childbirth (Molgora et al., 2019) and traumatic or negative birth experiences, including obstetric violence (Frankham et al., 2023; Silva-Fernandez et al., 2023).
Impacts of negative birth experience
Traumatic births significantly impact emotional and psychological health, resulting in shame, low mood avoidance of memories and reminders and persistent intrusive memories. These factors can contribute to the development of trauma-related symptoms, post-traumatic stress disorder (PTSD) and postpartum depression (Bell et al., 2016), as well as anxiety and stress (McCarthy et al., 2021). Mothers may struggle to bond with their babies, while relationships with partners, family and friends can deteriorate. (Shorey et al., 2022). Postpartum and birth-related PTSD can severely impair maternal well-being and early bonding (Furuta et al., 2018).
Childbirth experiences have also been examined from the father’s perspective. A negative birth experience can be a risk factor for psychological trauma in fathers after childbirth. Stress, anxiety and fear during labour are associated with paternal PTSD symptoms and other forms of mental health challenges, and they can lead to difficulties in relationships with the partner and infant. These may be further aggravated by the lower ability of fathers to seek help for mental health issues (McNab et al., 2022). To cope, fathers often rely on avoidance and emotional suppression, although some couples have strengthened their bond through shared traumatic experiences (Shorey et al., 2022). Fathers have reported that poor communication with healthcare professionals, a lack of preparation and exclusion during childbirth are associated with their negative childbirth experiences (McNab et al., 2022). Parents have used various coping strategies after negative experiences, including acknowledging and discussing their trauma, seeking information about birth events and turning to religious faith. Many mothers use positive emotions and childcare activities as way to prevent their trauma symptoms from impacting their infants. Both parents have reported valuing social and professional support, while informal networks such as peer groups and online forums provide a sense of community (Shorey et al., 2022).
Negative birth experiences and the quality of care
In addition to the negative birth experiences described earlier, the quality of interaction in care and services in general is significant for maternal well-being. Negative birth experiences may result from a contradiction between childbirth expectations and actual experiences, a lack of control during labour, negative interactions with healthcare professionals and inadequate pain management (Benyamini et al., 2024). Common themes associated with traumatic experiences across studies include feelings of disappointment, unmet expectations and emotional distress following childbirth (Bell & Andersson, 2016). Shorey & Wong (2022) pointed out that parents have expressed various factors that led to their traumatic birth experiences. Parents commonly reported dismissive attitudes of healthcare providers, feelings of powerlessness and fear for the safety of the mother and infant. Their constant battles to overcome traumatic experiences have also affected their relationships. To deal with the trauma, some mothers displayed avoidance behaviours while others relied on social support.
Poor communication, limited information-sharing, insufficient decision-making involvement of midwives and a lack of support and trust in midwives have been identified as risk factors for developing postpartum PTSD (Patterson et al., 2019). Parents with traumatic birth experiences described a lack of agency, coercion, routine- or outcome-centred care, unexpected interventions and experiences of obstetric violence as factors leading to traumatic experiences. Physical pain led to trauma and difficulties, and unexpected medical interventions or experiences of obstetric violation could have serious postpartum implications for women during childbirth. Healthcare professionals should provide empathetic communication, involve fathers actively during childbirth and offer counselling to both parents. Postpartum interventions should include education about normal and emergency birth scenarios, emotional support and access to peer groups. Recognising avoidance behaviours early and addressing them through professional care can prevent long-term psychological harm (Shorey & Chan, 2020).
Healthcare professionals are in a critical role in shaping birth outcomes and need to recognise and systematically assess pregnancy-specific psychological trauma (PSPT) across all perinatal individuals to improve care and outcomes (Shorey & Wong, 2022). Adequate and sensitive support during birth can prevent negative experiences and PTSD. It could be easily implemented in different care settings and can be even more important for women with a history of trauma or instrumental birth (Ayers et al., 2016). This emphasises the need for trauma-informed care practices during labour and delivery (Givrad et al., 2025).
A lack of decision-making opportunities during childbirth increases the risk of later mental health issues (Arnold et al., 2025). Some studies have pointed out the concept of ‘obstetric violence’ as a significant risk factor for parental mental health disorders, including an increased risk of postpartum depression and PTSD (Silva-Fernandez et al., 2023). Obstetric violence is understood as a violation of women’s rights during childbirth, including disrespect, inhumane treatment and verbal, psychological or physical abuse. Reports from high-income countries include a lack of pain relief, ignoring requests for help, yelling and scolding (Fraser et al., 2025).
The importance of adequate support
A positive birth experience is associated with the mother’s possibility to participate in decision-making during birth (Arnold et al., 2025), and with support, guidance and positive interaction from healthcare professionals (Benyamini et al., 2024). A sense of being respected and valued has produced positive perceptions among mothers (Miyauchi et al., 2022). A positive birth experience is identified as a protective factor against postpartum depression (Bell & Andersson, 2016; Silva-Fernandez et al., 2023). A positive experience can also protect against birth-related PTSD and can be supported by safe communication with healthcare professionals and showing respect for the birth plan (Silva-Fernandez et al., 2023).
The importance of good preparation for childbirth is emphasised in contributing to a better experience of childbirth for mothers and their partners (Benyamini et al., 2014). Continuity of care through a familiar midwife alongside the mother’s perinatal care is associated with reduced depression and anxiety symptoms during the perinatal period (Cibralic et al., 2023). An early connection with midwives and the availability of postnatal home midwifery services were found to be positive factors in the successful transition to motherhood (Walker et al., 2019). A harmonic relationship and negotiating with mothers outside strict protocols also positively influence the relationship with professionals (Curtin et al., 2023). For fathers, inclusion and good communication with midwives support more positive birth experiences. Feeling included contributes to more positive parenthood, improved partner relationships and better family well-being (McNab et al., 2022; Palioura et al., 2023).
Breastfeeding protects and challenges a mother's mental health
Breastfeeding and nutrition were excluded from the literature search, but breastfeeding emerged as theme related to the psychosocial well-being of the parents. Breastfeeding appears to have both supportive and challenging effects on maternal well-being. The relationship between perinatal depression and breastfeeding appears to be bidirectional. Depressive symptoms are associated with poorer breastfeeding outcomes, and breastfeeding challenges are sometimes reported as contributing to postnatal depressive symptoms (Billings et al., 2024). Available evidence suggests that parental perinatal depressive symptoms are negatively associated with breastfeeding exclusivity and duration. These associations may influence infant nutrition and have implications for both maternal and infant mental and physical health (Butler et al., 2021). Although anxiety is more common than depression in the perinatal period, less is known about its association with breastfeeding.
Mothers with mental health challenges have reported pressure to succeed in breastfeeding and feelings of inadequacy and guilt when breastfeeding does not meet expectations. Positive breastfeeding experiences can be associated with reduced feelings of guilt, strengthened self-esteem, enhanced mother–infant bonding and decreased stress due to emotional closeness. Some mothers have also described breastfeeding as offering a sense of healing after a traumatic birth (Billings et al., 2024).
Other disorders may also affect breastfeeding. For mothers with eating disorders, stopping breastfeeding may allow ways to resume control over their body and eating. Women with obsessive–compulsive disorder may experience contamination fears related to breastfeeding (Billings et al., 2024). The physical changes associated with pregnancy and the lack of control during childbirth may trigger memories for women with a history of childhood sexual abuse (Chamberlain et al., 2019; LoGiudice, 2016). Concerns about medication safety and breastfeeding have led some women to rule out breastfeeding as a viable option. For women with severe mental illness, the complexity of their mental health needs can make breastfeeding feel irrelevant, and it was often de-prioritised in favour of addressing more acute care needs. Professionals can support mothers by offering consistent and individual guidance, acknowledging mental health complexities, reducing societal pressure and fostering a nonjudgmental environment that encourages help-seeking (Billings et al., 2024).
Findings from the psychosocial intervention review for the health and nutrition domain
In the Nordic countries, several psychosocial intervention programmes have been implemented, targeting mothers or parents who either exhibit mental health symptoms or are at risk of developing them. An important objective of these interventions, in addition to supporting parental mental health, is to safeguard the physical and psychological well-being of the newborn or expected child, thus providing a strong foundation for lifelong health and development.
Based on the psychosocial intervention information portal mapping*, none of the interventions that met the inclusion criteria were targeted at physical health and/or nutrition of the parents. However, a secondary objective of several interventions was to safeguard the overall health of the unborn child. Several interventions aimed to promote or support the mother's mental health. In practice, nearly all psychosocial support during the perinatal period seeks to enhance the mental health and well-being of both parents and the unborn child, extending beyond the specific objectives of each intervention (e.g., by tackling risk factors connected to mental health). A total of 22 psychosocial interventions targeted mental health or related risk factors (see Tables 7 and 8). Most of the mapped psychosocial interventions evaluated as effective specifically targeted the support of mothers with depression or anxiety or stress related (also exhaustion and tiredness) disorders. Only single psychosocial interventions targeted bipolar disorders, PTSD, parental trauma, fear of childbirth or parental substance abuse. Some psychosocial interventions were targeted more at the child’s point of view, concerning low birth weight or preterm birth and the child’s traumatic or abusive experiences or high risk of these.
No psychosocial interventions targeted mothers with negative childbirth experiences or parents with perinatal loss. Also, none of the interventions were targeted at parents of children with developmental disorders. Developmental difficulties in newborns are usually treated in specialized healthcare, which may explain the absence of psychosocial interventions. Moreover, parents with physical disabilities or neurodiversity were not target groups in any psychosocial intervention programmes, and neither were parents with eating disorders, OCD, schizophrenia or other psychotic disorders. Again, the treatment of these is usually concentrated in specialized healthcare.
Only one of the interventions in the domain of health and nutrition was universal in nature, while 13 were targeted at risk groups and 8 were therapeutic interventions. Mothers were mostly mentioned as the target group, but other care givers/fathers may be included, depending on the intervention and possible adaptations.
Table 7a. Identified effective psychosocial interventions in Health and nutrition domain: interventions targeted to mental health-related factors.
Intervention | |||||||
Mental health problems during the perinatal period | Depression | Stress, exhaustion, and tiredness | Anxiety disorders | Eating disorders | OCD | Parental trauma (not specified) | |
CBT | X | ||||||
IPT (interpersonal therapy) + IPT G (group) | X | ||||||
Mamma-Mia | X | ||||||
Marte Meo | |||||||
Mellow Bumbs (MB) | |||||||
Nurture and Play | |||||||
Parent–Baby Intervention | X | ||||||
Parent–Child Interaction Therapy (PCIT) | X | ||||||
Transdiagnostic Cognitive Behavioral Group Treatment (TCBGT) for Pregnant Women | X | X | |||||
IPP Infant-parent psychotherapy | X | X | X | ||||
Mom Power® | |||||||
Parent-Child Assistance Program (PCAP) | |||||||
Promoting First Relationships (PFR) | |||||||
Table 7b. Identified effective psychosocial interventions in Health and nutrition domain: interventions targeted to mental health-related factors.
Intervention | |||||||
PTSD | Neuro-psychiatric challenges | Bipolar disorder | Schizophrenia | Postpartum psychosis | Other psychotic disorders | Parental substance use | |
No interventions with Nordic effectiveness grading were identified. | |||||||
IPP Infant-parent psychotherapy | |||||||
Mom Power® | |||||||
Parent-Child Assistance Program (PCAP) | |||||||
Promoting First Relationships (PFR) | |||||||
Table 8. Identified effective psychosocial interventions in Health and nutrition domain: targeted to other health related needs.
Intervention | Health and Nutrition* | ||||||||
|---|---|---|---|---|---|---|---|---|---|
Experiences of perinatal loss | Negative or traumatic childbirth experiences | Fear of childbirth | Child developmental problems | Child's traumatic or abusive experiences or the risk of them | Low weight / preterm babies | Disabilities and physical limitations | Overweight | ||
Attachment and Behavioral Catch-Up (ABC) | |||||||||
Child-Parent psychotherapy (CPP) | |||||||||
Modified Mother–Infant Transaction Program (MITP) | |||||||||
Newborn Individualized Developmental Care and Assessment Program (NIDCAP) | |||||||||
Nyyttigroup | |||||||||
Safe Environment for Every Kid (SEEK) | |||||||||
Child First | |||||||||
Family Nurse Partnership | |||||||||
IPP Infant-parent psychotherapy | |||||||||
* Reminder: The selected portals only include interventions that have been evaluated within the assessment systems according to specific criteria, with an emphasis on research-based evidence of effectiveness. The interventions that demonstrate at least some research-based evidence of effectiveness are presented. The assessment systems operate dynamically, and the information presented in this report may therefore be updated quite rapidly. Regular monitoring of the relevant portals of these assessment systems is recommended. The checkmarks reflect what was indicated as the primary target group or objective in the portal descriptions of each intervention. Many interventions have multiple secondary goals and effects, so additional checkmarks could apply in practice.
Based on the findings from the literature review, positive effects of certain other approaches also emerged concerning parental mental and physical health. For example, yoga-based interventions may reduce stress levels, anxiety and depression scores, as well as the pain response during pregnancy (Kwon et al., 2020). Some systematic reviews also mentioned yoga-based methods as increasing overall postnatal well-being (Munns et al., 2024; Sheffield et al., 2016). Mindfulness-based methods have some effects in stress reduction in the post-natal phase (Hall et al., 2016), and relaxation and massage interventions have also been found to result in positive sleep outcomes among women in the perinatal phase (Mueller et al., 2021; Tan et al., 2021; Tsai et al., 2020). Based on these findings, some methods emphasizing relaxation and stress management may be worth considering as universal preventive approaches.
Miller et al. (2021) described interventions that are not programmes included in the intervention portal. These interventions, targeting post-traumatic stress disorder following childbirth, include psychotherapeutic therapy, grief counselling, expressive writing, midwifery counselling and debriefing. Traditionally, midwifery-led psychological debriefing is offered to women in the days and weeks following the birth of their baby. It has been described as an opportunity for the mother to describe her experience, express her emotions and feelings in relation to the negative event and “fill in the gaps”.
The review results from Jones et al. (2023) suggest that parenting interventions for parents experiencing CPTSD symptoms or who have experienced childhood maltreatment (or both) may slightly improve parent–child relationships but have a small, unimportant effect on parenting skills. There is currently a lack of high-quality evidence regarding the effectiveness of interventions in improving parenting capacity or parental psychological, or socio-emotional well-being in these parents.
The co-occurrence of psychological distress and bonding problems is common, and there is an identified need for universal screening tools to assess the impact of these factors (O'Dea et al., 2023). Perinatal mental health disorders are linked to many increased risks, such as psychological, emotional and developmental disturbances in children throughout life.
Registry research increases knowledge and improves care
In the Nordic countries national registers cover both healthcare and also, for example, socioeconomic and partner status. These high-quality, nationwide and population-based data sources and the possibility to link individual data between each of them render the Nordic countries. Based on these datasets, Nordic cohort studies are uniquely positioned to fill current evidence gaps in the field of perinatal mental health (Karalexi et al., 2022).
Ongoing pregnancy or birth cohort studies:
- The Norwegian MoBa and ABC Studies and www.fhi.no/ps/studier/autismestudien/om-autismestudien/
- The Swedish BASIC and Mom2B studies
Key observations from Nordic expert discussions concerning the health and nutrition domain
Experts across the Nordic countries emphasised a similar desired direction: improving early identification and intervention through maternity and child health clinics; strengthening staff training throughout maternity services; enhancing multiprofessional collaboration and home‑based family support; addressing the implementation gap, despite existing effective interventions; and ensuring equal access to care, despite regional disparities.
Emerging evidence on neurobiological, hormonal and temperamental vulnerabilities was highlighted: Some individuals have a neurobiological or hormonal profile that makes them particularly vulnerable to mental disorders. Concerns were also raised about the possible increase in parental physical health problems. Additional child risk factors requiring attention include negative family interactions, violence or neglect, out‑of‑home care, parental marginalisation or criminality, developmental difficulties, prematurity, sensory impairments, a lack of vaccination and chronic illness or disability. Child temperament was also discussed as both a risk and a protective factor that should be identified early.
Screening data indicate rising maternal anxiety and stress, often linked to pregnancy or infant care. Broader attention is needed to parental mental health problems such as perinatal depression, fear of childbirth, substance use and cognitive difficulties. Experts noted links between maternal PTSD and an increased ADHD risk in children, underscoring the importance of early trauma identification. Major risk factors include current or prior psychiatric illness, active symptoms during pregnancy or postpartum and any signs of suicidality.
Further research is needed on complex trauma, early care pathways, mothers with obsessive–compulsive traits or high self-demands, neurodivergent parents and burnout among highly educated mothers. Many women experiencing elevated stress or anxiety do not meet psychiatric thresholds and risk falling outside current systems, highlighting the need for expanded psychological support in primary care.
Partner mental health assessment was identified as essential due its impact on the partner’s well-being during the perinatal period, on infant health and development and the relationship with the parent, and its bidirectional impact on maternal outcomes and family functioning. Evidence‑based interventions such as internet‑delivered CBT and structured peer support remain underutilised. Improved treatment pathways for severe perinatal mental health issues and the establishment of mother–baby units are needed. A stepped‑care model with clearly defined pathways between psychosocial support and medical care was strongly recommended.