Indigenous mothers and birthing parents experience significant inequities during the perinatal period, with mental health distress causing adverse outcomes for mothers/birthing parents and their infants. Limited literature is available to inform our understanding of solutions to these issues, with research primarily focusing on inequities. Our aim was to conduct a systematic review of Indigenous approaches to treatment of perinatal mental health illness. Following the PRISMA guidelines for systematic literature reviews, an electronic search of CINAHL, Medline, PubMed, Embase, APA PsycInfo, OVID Nursing, Scopus, Web of Science, and Google Scholar databases was conducted in January and February 2022 and repeated in June 2022. Twenty-seven studies were included in the final review. A critical interpretive synthesis informed our approach to the systematic review. The work of (Yamane and Helm J Prev 43:167–190, 2022) was drawn upon to differentiate studies and place within a cultural continuum framework. Across the 27 studies, the majority of participants were healthcare workers and other staff. Mothers, birthing parents, and their families were represented in small numbers. Outcomes of interest included a reduction in symptoms, a reduction in high-risk behaviours, and parental engagement/attachment of mothers/birthing parents with their babies. Interventions infrequently reported significant reductions in mental health symptoms, and many included studies focused on qualitative assessments of intervention acceptability or utility. Many studies focused on describing approaches to perinatal mental health distress or considered the perspectives and priorities of families and healthcare workers. More research and evaluation of Indigenous interventions for perinatal mental health illness is required. Future research should be designed to privilege the voices, perspectives, and experiences of Indigenous mothers, birthing parents, and their families. Researchers should ensure that any future studies should arise from the priorities of the Indigenous population being studied and be Indigenous-led and designed.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00737-023-01310-7.