Computer linkage of an obstetric register and a psychiatric case register made it possible to investigate the temporal relationship between childbirth and psychiatric contact in a population of 470 000 people over a 12-year period: 54 087 births resulted in 120 psychiatric admissions within 90 days of parturition [corrected]. The 'relative risk' of admission to a psychiatric hospital with a psychotic illness was extremely high in the first 30 days after childbirth, particularly in primiparae, suggesting that metabolic factors are involved in the genesis of puerperal psychoses. However, being unmarried, having a first baby, Caesarian section and perinatal death were all associated with an increased risk of psychiatric admission or contact, or both, suggesting that psychological stresses also contribute to this high psychiatric morbidity. Women with a history of manic depressive illness, manic or depressive, had a much higher risk of psychiatric admission in the puerperium than those with a history of schizophrenia or depressive neuroses, and the majority of puerperal admissions met Research Diagnostic Criteria for manic or depressive disorder. Probably, therefore, puerperal psychoses are manic depressive illnesses and unrelated to schizophrenia.

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A hundred and ten women admitted to a psychiatric hospital within 90 days of childbirth were individually matched for age, psychiatric syndrome, and year of admission with women admitted to the same hospital with illnesses unrelated to childbirth. Both groups were followed up after a mean interval of nine years, and 72 matched pairs of patients for whom adequate information was obtained were then compared. The previous and subsequent psychiatric morbidity of these two groups, their subsequent obstetric careers, and the psychiatric morbidity of their first-degree relatives were all very similar. However, the puerperal women had significantly fewer relapses in the follow-up period, fewer committed suicide, and the psychiatric morbidity of their relatives tended to be lower. This better outcome was most marked in puerperal subjects with major depressions; those with manic disorders fared no better than controls. These results suggest that puerperal psychoses are basically the same as affective illnesses occurring at other times but, because childbirth is a uniquely potent precipitant of affective illness, some of those who develop puerperal episodes have a lesser genetic predisposition to affective illness than the generality of women with affective disorders.

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