The dominant cultural narrative around pregnancy is one of joy. Glowing skin, excited announcements, nursery preparation, the glow of impending motherhood. This narrative is real for many women, much of the time. But it coexists with a reality that is far less discussed: pregnancy is one of the periods of highest risk for mental health problems in a woman's life.
Up to 20% of women experience depression or anxiety during pregnancy or in the first year after birth. Perinatal mental health problems are the leading cause of maternal death in the UK over the year following childbirth - suicide and substance misuse related to mental illness account for more maternal deaths than haemorrhage or pre-eclampsia combined.
And yet mental health screening in maternity care remains inconsistent. The conversation about how a woman is actually feeling emotionally - not just physically - is often brief, cursory, or absent. For Black and African women, the picture is further complicated by specific barriers to recognition and disclosure that mean many women suffer significantly longer before receiving any support.
Why Black and African women are at higher risk
The disparity in perinatal mental health outcomes for Black women in the UK is starkly documented.
The maternity care disparity: Black women in the UK are four times more likely to die in pregnancy and childbirth than white women. This disparity reflects - among other things - a pattern in which Black women's concerns are more likely to be dismissed, their pain undertreated, and their symptoms normalised. The experience of disrespect in maternity care creates trauma that is itself a significant mental health risk. A woman who goes into labour already frightened that she will not be listened to is not in a good position to manage the inevitable uncertainties of childbirth.
Social risk factors: Social isolation, financial stress, poor housing, immigration uncertainty, lack of close family support, and experiences of racism are all independently associated with perinatal mental health problems. Black women disproportionately carry these burdens.
Cultural pressure: Cultural norms in many African communities emphasise that pregnancy and motherhood are blessings to be received with gratitude. Expressing distress about pregnancy - even severe, clinical distress - can feel like ingratitude, weakness, or a spiritual failing. This is not unique to African cultures but it is particularly pronounced in communities where mental health discussion is already stigmatised.
Fear of social services: Perhaps the most significant specific barrier to disclosure. Many Black women fear that admitting mental health difficulties during pregnancy will trigger social services involvement and potential removal of their baby. This fear - even when it is disproportionate to the actual risk - keeps women silent and suffering.
What perinatal mental health problems actually look like
Antenatal depression: Low mood, loss of interest in activities, fatigue, difficulty imagining the future, feelings of worthlessness or excessive guilt, difficulty bonding with the unborn baby, changes in appetite and sleep. Frequently mistaken for normal pregnancy fatigue or dismissed as hormones. Significantly undertreated.
Antenatal anxiety: Persistent, excessive worry about the pregnancy, the baby's health, the birth, or the ability to cope as a mother. Can become severe enough to affect daily functioning. Often presents with physical symptoms - nausea, palpitations, headaches - that are attributed to the pregnancy rather than anxiety.
Tokophobia: Severe fear of childbirth. Can range from significant anxiety about labour to complete avoidance of pregnancy or antenatal care. Treatable with specialist psychological support.
Perinatal OCD: Intrusive, unwanted thoughts about harm coming to the baby - often involving fear of accidentally hurting the baby or fears about the baby's safety. The presence of these thoughts does not mean a mother wants to harm her baby; OCD is characterised by distress about the thoughts and compulsive behaviours to manage them.
Birth trauma and PTSD: Following a traumatic birth experience - emergency caesarean, obstetric complications, feeling unheard or mistreated - some women develop post-traumatic stress symptoms. Flashbacks, nightmares, avoidance of anything associated with the birth, hypervigilance. Significantly underdiagnosed.
Postnatal depression (PND): Distinct from the baby blues (a normal emotional response peaking at days 3-5 and resolving within two weeks). PND is more persistent, more severe, and significantly impacts functioning. Low mood persisting beyond two weeks postpartum, difficulty bonding with the baby, feelings of hopelessness, inability to enjoy the baby or oneself, excessive guilt about being a bad mother. Affects approximately 10-15% of women after birth.
Postpartum psychosis: The most severe perinatal mental health emergency. Rare (approximately 1-2 per 1,000 births) but can be life-threatening. Develops within days of birth - often suddenly. Symptoms include rapid mood changes, confusion, hallucinations (hearing or seeing things that are not there), delusions (fixed false beliefs, often involving the baby), severely disorganised thinking and behaviour. Requires immediate inpatient psychiatric admission. With rapid treatment, most women make a full recovery.
What should happen in maternity care - and what to ask for
Every woman should be asked specifically about her mental health at her booking appointment, at 28 weeks, and at the postnatal check. The Edinburgh Postnatal Depression Scale (EPDS) - a validated 10-item questionnaire - takes 5 minutes to complete and should be offered routinely.
If you are struggling emotionally during or after pregnancy, you are entitled to:
Referral to a specialist Perinatal Mental Health team: These exist in most areas of England, providing specialist psychological and psychiatric support to women with significant perinatal mental health needs. If your GP or midwife does not mention this, ask for it specifically.
Psychological therapy: CBT and other evidence-based therapies are safe and effective in pregnancy and breastfeeding. Waiting times can be long on the NHS; if urgent, ask for an expedited referral or contact NHS Talking Therapies directly.
Medication if needed: Many antidepressants, particularly sertraline, have extensive evidence for safety in pregnancy and breastfeeding. The risks of untreated significant depression or anxiety to the mother and the developing baby - including effects on the baby's stress response system in utero - generally outweigh the small risks of medication in most situations. This decision should be made collaboratively with your prescriber, with full information.
Honesty about your concerns regarding social services: Many women avoid disclosure because of fear of children being removed. A useful conversation to have with your midwife or GP: "I want to be honest about how I am feeling, but I am worried about what will happen if I tell you. Can you explain what the process would be?" In most cases, disclosing mental health difficulties leads to support, not removal.
Sources: NICE Clinical Guideline CG192 - Antenatal and Postnatal Mental Health (2014, updated 2020); MBRRACE-UK - Saving Lives, Improving Mothers Care 2023; NHS England - Perinatal Mental Health programme; Knight M et al, BJOG 2019 (maternal mortality); Maternal Mental Health Alliance - Everyone's Business campaign; Royal College of Psychiatrists - Perinatal Mental Health patient resources.
