Women suffering major mental illness such as schizophrenia or bipolar affective disorder are vulnerable to a host of challenges in pregnancy to their social, economic, and emotional well-being. Each woman faces a decision at this point as to whether or not to continue her antipsychotic medication in pregnancy. This decision must be an individualised one made by each woman and her treating team, balancing the risks associated with relapse of psychiatric illness in the peripartum against the risks to the developing baby from antipsychotic medication treatment. In order to fully inform this decision, clinicians need access to the most sophisticated information available on the safety profile of antipsychotic medications. Fortunately, most current research suggests that antipsychotics do not increase the rate of congenital malformations significantly beyond the background population rates of these events, though this field is evolving with the use of increasingly large data sets. A growing body of evidence suggests that antipsychotic medication treatment in women of childbearing age, and during pregnancy, may contribute to obesity in pregnancy and gestational diabetes. These conditions also increase the risk of other adverse obstetric and neonatal outcomes. Additionally, it seems that babies of women taking antipsychotic medications are vulnerable to medication withdrawal symptoms and to distress symptoms at delivery, suggesting that they should be delivered in centres with access to neonatal support. Available evidence supports the view that babies exposed to antipsychotic medications in pregnancy develop in line with their peers at 1 year postpartum. Emerging evidence in relation to risks of neurodevelopmental disorders diagnosed later in childhood, including autism spectrum disorders and attention deficit-hyperactivity disorder, suggests that genetic and epigenetic vulnerabilities may play a substantial role in the increased risk for babies of women with major mental illness.