The COVID-19 pandemic presented an unprecedented health system shock to the world between January 2020 and May 2023. Although first detected in Wuhan, China, on 31 December 2019 (1), the virus—a respiratory disease with high mortality risk for individuals with pre-existing comorbidities (2)—spread quickly, worldwide. Concerns about the mortality and spread of the novel virus prompted a global, co-ordinated implementation of social and physical distancing restrictions. Meanwhile, research efforts turned towards vaccine development (3) and understanding the health system shock and the possible ramifications for short-, medium-, and long-term health, especially as the world braced itself for the further pandemic of mental health issues caused by the virus and associated fears, bereavements, and restrictions (4). Maternity care was significantly disrupted during government-mandated lockdown restrictions (5). Social and physical distancing restrictions interrupted access to routine maternity care and adversely impacted perinatal mental health (6, 7) and child development (8, 9). Worryingly, these restrictions saw increased instances of child neglect, child abuse, and domestic abuse risk (10); restricted access to reproductive healthcare including abortion services (11); increase in maternal morbidity (12); and serious adverse obstetric events such as stillbirths (13, 14). Further, the potential for maternity staff to experience work-related trauma and subsequent post-traumatic stress disorder (PTSD) was likely to have been exacerbated beyond levels already recognised as significant (15–17). The extent of the long-term impacts of the pandemic, however, has yet to be fully realised and may take years to be understood completely.

This article presents a consensus statement on amassed evidence from research and syntheses on perinatal mental health undertaken during the COVID-19 pandemic. We suggest recommendations in the form of what healthcare policy, services, and professionals should retain, reinstate, and remove from their care provision in the immediate period of post-pandemic recovery and re-build. We also provide guidance on longer-term recommendations for practice.

This consensus statement was originally conceived by a collective of cross-disciplinary researchers (Psychologists, Psychiatrists, Sociologists, Anthropologists, Midwives, Obstetricians, Obstetric Physicians, Physiologists, and Patient Advocates; mainly based in London and Liverpool, UK) who, in late 2020/early 2021 wanted to synthesise evidence from research they had conducted during the early stages of the pandemic about how it had affected perinatal mental health outcomes, services, and care. They secured funding from the Society for Reproductive and Infant Psychology—via a Research Development Workshop Grant (ref:- SRIP/DWA/01)—to do so, which contributed to the second origin—a policy-oriented research dissemination event held at The Royal Society of Medicine (The RSM) in London on 22 September 2022. The RSM event was hosted by PIVOT-AL, a national collaborative in the UK of over 60 researchers, academics, policymakers, and members of third sector organisations from more than 25 institutions (see Figure 1). During the pandemic, the collaborative undertook research focused on the impact of the pandemic on maternal, child, and family health, healthcare professionals, and service provision. A formal synthesis of this evidence on perinatal mental health was presented as a key part of the programme at The RSM event. This consensus statement provides a summary of this evidence and identifies priorities for future research, policy, and healthcare practice.

A recognised approach for deriving consensus statements is usually to construct a panel of experts amongst whom ideas are shared with a focus on establishing priorities for research, healthcare practice, and policy (18). Discussions at this event were based on the expert knowledge of attendees and enhanced by patient and public involvement and engagement (PPIE) at both the event and in writing the statement. The cross-disciplinary nature of the group allowed for a breadth and depth of perspectives to be represented. The authors recognise that whilst this synthesis is extensive, it is not exhaustive of all the research efforts which took place in perinatal mental health services across the UK during the COVID-19 pandemic. Neither does it have a reach into global literature—which is equally important, but would be inappropriate to incorporate as part of an assessment into UK policy and practice. Therefore, this statement does not aim to provide a comprehensive nor systematic review of the literature base, but rather represents an overview of issues and priorities discussed by attendees at the dissemination event. Indeed, the statement presents the consensus reached by academics and clinical experts who authored the literature included in the synthesis and by those present at the dissemination event.

The perinatal mental health research captured by The PIVOT-AL National Collaborative primarily focused on post-partum mental health and the transition into new motherhood during the COVID-19 pandemic. However, extensive efforts have also spanned the psycho-social experiences of pregnancy and childbirth, incidences of domestic abuse and violence, and support requirements of perinatal mental health staff and services during mandated social and physical distancing restrictions.

One of the earliest PIVOT-AL investigative efforts was The Pregnancy and Motherhood Study [PRaM; (19)]. A large, online, national survey was distributed to pregnant and post-partum women during initial mandated lockdown restrictions (20), during the initial easing of social distancing restrictions (21), and post-“Freedom Day” [defined as the easing of all legal restrictions on social contact; (22)]. The PRaM Study involved the distribution of a battery of psychometric measures (19, 23), with nested qualitative interviews in accordance with the corresponding mandated lockdown restrictions (24, 25).

Quantitative findings indicated that 43% and 61% of post-partum women were experiencing clinically relevant levels of depression and anxiety symptoms, respectively (19). Perceived psychological change, resulting from the introduction of social distancing measures, predicted unique variance in the risk of clinically relevant maternal depression (30%) and anxiety symptoms (33%), respectively (19). These data were consistent with UK data found in global comparisons of perinatal mental health data as reported by a consortium of the RISEUP-PPD Network, where the UK consistently ranked highly amongst reports of increased symptoms of perinatal anxiety and depression (26). The PRaM Study also rapidly developed and validated a research short form of the Postpartum Specific Anxiety Scale for use in global crises [PSAS-RSF-C (23);]. This short form was translated into Chinese, Dutch, French, Italian, and Spanish (23), and validations are underway including in Persian [PSAS-IR-RSF-C; (27)].

Qualitatively, the PRaM Study found post-partum women continued to experience distress throughout the pandemic, despite the easing of social distancing restrictions (24). A lack of support for the schooling of older children was particularly inflammatory to maternal mental health and wellbeing disturbance (24). Antenatally, respondents were consistent across timepoints in feeling their pregnancy was overshadowed by uncertainties pertaining to the pandemic, which left respondents grieving for the loss of the kind of transition to motherhood that they would have had in the absence of mandated lockdown restrictions (25).

Echoing these findings, an analysis of qualitative data from women recruited to The King's Together Fund Changing Maternity Care Study identified tensions between good and poor practices, which affected perinatal psycho-social wellbeing (28). Results included dyadic pairs of experiences as women struggled to navigate the uncertainties of the pandemic and pregnancy, alone. The dyadic pairs included the following: “lack of relational care vs. good practice persisting during the pandemic”; “denying the embodied experience of pregnancy and birth vs. trying to keep everyone safe”; and “removed from support network vs. importance of being at home as a family” (28). Consistent with other PIVOT-AL works, the realities of maternity care were disappointing compared with expectations and experiences before the pandemic, which exacerbated distress (28). The lack of access to relational care, the introduction of telemedicine and reliance on virtual appointments, and the exclusion of partners from routine care were particularly challenging for emotional wellbeing. This was despite an acknowledgement of the pressures placed on healthcare professionals and on NHS services during the unprecedented times of the pandemic (28). A lack of access to emergency and gynaecological care was also flagged as being detrimental to the care of early pregnancy loss and later perinatal deaths (29, 30).

A critical review and mapping of service provision suggested that perinatal distress had increased, which was attributable to the increasing inaccessibility of support services (31). However, this was occasionally countered by services providing reconfigured and/or extended perinatal mental health services. As healthcare transitioned from pandemic to para-pandemic circumstances, it was imperative to provide support for perinatal mental health professionals within the context of developing new post-pandemic services (31). Some women struggled to engage with virtual mental health assessments in perinatal mental health services (32). This was especially concerning for circumstances whereby virtual appointments prevented disclosure of urgent needs and risks, e.g., in cases of domestic abuse (32). However, for women who struggled with the practicalities of attending face-to-face consultations, e.g., due to travel time, virtual appointments offered a flexible and well-received alternative (32).

Maintaining perinatal mental health services was found to be challenging for ethnic minority women, who experienced many difficulties and disruptions in accessing perinatal mental healthcare, which exacerbated pre-existing challenges such as living in insecure social housing and experiencing financial hardship (33). Most had a strong preference for face-to-face consultations and experienced high levels of social isolation and heightened anxiety as the pandemic continued (33). A large study was also conducted that utilised linked maternity and mental health records held within the Early Life Cross-Linkage in Research (eLIXIR) database (34). Data from three NHS Foundation Trusts (including one Mental Health Trust) in South London constitute the eLIXIR database (34, 35). Research using an interrupted time series study design found that the rate of recording domestic abuse and violence during national lockdown restrictions was reduced by 78% in mental healthcare settings. There was also an increased prevalence of positive screening on the Whooley depression screening measure, by 40%, in the same period (35).

A large body of international work investigating the effects of the pandemic on new, expectant, and bereaved parents [COCOON; (36)] is underway, complete with a nested qualitative study [PUDDLES; (30)] which focuses on the experiences of women bereaved by pregnancy loss (e.g., early elective abortion, pregnancy of unknown location, miscarriage, ectopic pregnancy, molar pregnancy, or termination of pregnancy due to foetal anomaly) or perinatal death (stillbirth and neonatal death). Results specifically linked to the mental health outcomes are pending, but they will provide important insight into another aspect of perinatal mental health, not otherwise covered by the information synthesised above.

Whilst there has been much evidence to support worsening conditions for perinatal mental healthcare and support during the pandemic, the ending of the global health crises allows a period of reflection and reset for recovery and re-build from the health system shock. What follows are recommendations for immediate action, followed by long-term recommendations for policy, service provision, and research.

Post-partum distress was elevated during mandated social distancing restrictions imposed during the COVID-19 pandemic (19, 26). Qualitative and critical review literature contextualised these findings. Specifically, perinatal women struggled to navigate scaled-back maternity care and felt that their experience of maternity had been overshadowed by uncertainties and health anxiety pertaining to the pandemic (24, 25, 28, 31, 33). For families facing additional adversities (e.g., those experiencing domestic abuse and violence), the depletion of face-to-face care proved a particularly grievous threat to wellbeing (35). Finally, The Postpartum Specific Anxiety Scale—Research Short Form was produced and validated in English for use in global crises (23), allowing for a rapid assessment of post-partum anxiety in future global health crises.

Recommendations for immediate action were suggested under aspects of care to retain, reintroduce, and to remove. Maintaining access to essential reproductive and perinatal health services (37, 38), ensuring quality healthcare delivery (28, 31, 33), and giving perinatal mental health parity of esteem with physical health concerns (39), as well as providing specialist, tailored services for perinatal women (40–42), are recommended for retention as we recover and re-build services after the pandemic. Remote care should be retained (32, 33) but not at the expense of face-to-face consultation (24, 25, 35), nor should it be the dominant provision. Partners and family members, who women and birthing people want to be present, should be prioritised in healthcare settings (28, 31). Reinstating trust in the professional judgement of healthcare staff (32), ensuring adequate and timely communication amongst central NHS management, individual trusts, and healthcare professionals (31), and protecting staff from unnecessary redeployment (28, 31) are recommended for reinstation, whilst recognising the importance of social care being able to visit families rather than offering remote assessments and follow-up. Blanket policies made without considering demographic and accessibility variation should be ceased (30, 33, 56). Efforts should be made to investigate the long-term impacts of the COVID-19 pandemic on women, birthing people, and their families.

It is envisioned that this statement will provide a foundation for future research, policy implications, and service provision and care practices in perinatal mental health as we emerge from the pandemic, recover our healthcare systems and services, and build back a better provision for perinatal mental healthcare in the future. The services of the future must be resilient, adaptable, tensile, and plastic enough to weather future health system shocks when they inevitably arise—in order to provide the safest, most up-to-date, and best possible perinatal mental healthcare in the future.