Violence and neglect during pregnancy deepen South Africa’s maternal health crisis

South Africa’s maternal health system is in crisis, and violence is making it worse. With only 11 maternal and foetal medicine subspecialists serving the entire country, vast regions remain without expert care to manage high-risk pregnancies or respond to trauma linked to gender-based violence.

The 2025 South African Child Gauge warns that violence before and during pregnancy is leaving lasting scars, not only on mothers but on the next generation, with devastating health, developmental and social consequences.

The gauge reveals that exposure to violence during pregnancy increases the risk of miscarriage, premature labour, low birth weight and maternal death, while also shaping how children’s brains develop in the earliest, most critical years of life.

According to studies, more than 20% of South African women experience at least one act of physical, psychological, or sexual intimate partner violence (IPV) during pregnancy. Psychological abuse is the most prevalent and often continues through the first four months after birth.

The report warns that IPV is the most common form of violence experienced by women, though other forms of gender-based and obstetric violence during the first 100 days can intersect and deepen women’s vulnerability.

Dr Lesego Thomas, who was recently honoured by the Discovery Foundation for her work in maternal and foetal medicine, said no woman should die giving birth, yet the shortage of maternal subspecialists means many do.

“The challenge is that the country only has 11 subspecialists in maternal health, and in the North West, where I work, there are none,” said Thomas.

“This means that all the high-risk pregnancies and babies with abnormalities or disabilities die if not referred to a tertiary centre. Sadly, there is no hope for them.”

The hidden toll of violence on the developing brain

Professor Kirsten Donald, a paediatric neurologist at the University of Cape Town, said the first 1,000 days of life are a “sensitive window” when the brain develops at its fastest pace.

“During this period, exposure to violence or neglect may cause emotional harm but can also alter biology in ways that become embedded and difficult to change,” she wrote in the Child Gauge.

In the longer term, trauma in the early years may fuel a cycle of violence. Those who experience multiple forms of childhood violence are more likely to be involved in violent relationships as adults, either as victims or perpetrators,

—  Professor Kirsten Donald, paediatric neurologist at UCT

Violence against a pregnant woman activates her stress response, raising cortisol levels that cross the placenta and shape foetal brain development. After birth, witnessing or experiencing violence triggers an infant’s own “fight, flight, or freeze” response, disrupting emotional and physical development.

Donald said children exposed to violence show higher rates of emotional distress, learning difficulties, asthma, infections and chronic diseases later in life.

“In the longer term, trauma in the early years may fuel a cycle of violence. Those who experience multiple forms of childhood violence are more likely to be involved in violent relationships as adults, either as victims or perpetrators,” she said.

Early intervention, she added, offers a critical opportunity to break these intergenerational cycles and support healthy brain and social development.

Policy frameworks falling short

South Africa’s policy frameworks, including the National Integrated Early Childhood Development Policy (NIECD) and the National Strategic Plan on Gender-Based Violence and Femicide, recognise the importance of preventing violence early. Yet implementation remains weak.

The Child Gauge notes that while the department of health has a mandate to identify and respond to violence during antenatal, postnatal and child health visits, these services are not being effectively used as entry points for care and referral.

The NIECD outlines a package of services to support infants and caregivers and expands the health sector’s role beyond its traditional focus on nutrition and maternal care. But despite acknowledging the importance of violence prevention, it fails to prioritise it explicitly.

Key services such as home visits by community health workers, which could offer early support for at-risk mothers, remain underfunded and inconsistently implemented.

Investing early to protect women and children

The Child Gauge stresses that violence often begins early in pregnancy and within the first few years of life, a period when prevention efforts could yield the greatest impact.

“It is therefore important to intervene early to address risk factors for violence when they first emerge, to improve children’s health, education and social outcomes,” the report states.

Experts argue that integrating violence prevention into maternal and child health services could transform outcomes for women and children alike. Investing early not only promotes lifelong health and well-being but also upholds their fundamental rights to life, dignity and safety.