When Mia* was referred to me, she was 32 weeks pregnant and had not slept properly in two months. Her GP had told her it was “just pregnancy insomnia”. Her obstetrician said it was normal and suggested she try going to bed earlier with a pregnancy pillow. By the time she sat in my consulting room, hands clenched around a damp tissue, she had been quietly planning how her partner and baby would be better off without her.

Mia is not a real person. She is a composite – an amalgam of the hundreds of women I see each year in my perinatal psychiatry practice. But her story is so common it could be a template. A woman develops psychological symptoms during pregnancy or the postpartum period. She mentions them, tentatively, at an antenatal appointment. She is reassured that what she feels is normal. Weeks or months pass. By the time she reaches specialist care, she is freefalling into a crisis.

Mental illness is the number one complication of pregnancy and the postnatal period. Not gestational diabetes. Not pre-eclampsia. Up to one in five women will experience a diagnosable mental health condition during the perinatal window – the period from conception to one year after birth. Depression and anxiety are the most prevalent, but the spectrum extends to post-traumatic stress disorder after birth trauma, obsessive-compulsive presentations centred on intrusive thoughts of infant harm, and the rare but devastating psychotic episodes that constitute a psychiatric emergency.

These are not small statistics. If a physical complication affected one in five pregnancies, we would screen for it universally, fund treatment pathways generously and train every clinician involved in maternity care to recognise it. We do none of these things consistently for perinatal mental health.

The gap between prevalence and response is where women such as Mia fall through. Australia has pockets of excellence – dedicated mother-baby units, specialist perinatal psychiatry services, the work of organisations like Panda and the Centre of Perinatal Excellence. But access is uneven and weighted towards metropolitan areas and those who can afford private care. In the public system, waitlists stretch for months. A woman who is deteriorating at 28 weeks cannot wait until her baby is three months old for an assessment.

Part of the problem is structural, but part of it is cultural. We have romanticised the transition to motherhood to the point where distress feels like failure. The term “matrescence” – coined to describe the profound identity shift of becoming a mother – is gaining traction in public conversation, which is welcome. But there is a risk that the normalising language of matrescence inadvertently minimises clinical illness. There is a vast difference between the disorientation of new parenthood and a major depressive episode that leaves a woman unable to care for herself or bond with her infant. Both deserve attention. Only one requires urgent psychiatric treatment.

In my practice, I hear versions of the same sentence every week: “I thought I was just a bad mother.” That sentence is a diagnostic failure. It means that somewhere along the way, a woman’s suffering was reframed as inadequacy – by her own internalised expectations, by a well-meaning relative, by a system that checked her blood pressure and haemoglobin but never asked, with any real intent to hear the answer, how she was coping.

Screening alone will not fix this. Australia’s national guidelines recommend routine psychosocial screening in the perinatal period, and many services use the Edinburgh Postnatal Depression Scale. But a screening tool is only as good as the pathway behind it. Flagging risk without a clear, timely referral route simply identifies women we then fail to help. In some services, a high score on a screening questionnaire generates a letter to the GP recommending “supportive counselling” – a recommendation that lands in a landscape where psychologists have six-month waitlists and Medicare-funded sessions are capped.

What would meaningful change look like? Three things stand out from my years in this field. First, integrated mental healthcare within maternity services – not as an add-on or a referral to a separate building, but psychiatrists, psychologists and mental health nurses embedded in antenatal clinics, seeing women where they already are. Second, workforce investment. Australia has a small number of perinatal psychiatrists relative to demand, and training pathways into this subspeciality remain limited. Third, public literacy. We need expectant parents and their families to understand that perinatal mental illness is common, treatable and not a reflection of character.

Mia did get better. She started medication that was safe in pregnancy, engaged with a perinatal psychologist and had a supported birth plan that accounted for her mental health needs. Her recovery was not linear – it rarely is – but she was supported by a team that understood what she was going through.

Not every woman who walks the path Mia walked finds that team. Until she can, we are failing the most common complication of pregnancy and pretending we do not know it.

*All clients are fictional amalgams

In Australia, support is available at Beyond Blue on 1300 22 4636, Lifeline on 13 11 14, and at MensLine on 1300 789 978. In the UK, the charity Mind is available on 0300 123 3393 and Childline on 0800 1111. In the US, call or text Mental Health America at 988 or chat 988lifeline.org.