Clinical overview
Gender-based violence (GBV) and perinatal mental illness are two of the most prevalent, most under-detected, and most consequential conditions you will encounter in any antenatal clinic — and they travel together. In South Africa they sit at the centre of the burden of maternal morbidity and mortality. The Saving Mothers reports (NCCEMD) consistently list non-pregnancy-related infections (predominantly HIV), obstetric haemorrhage and hypertension as the leading direct and indirect causes of death, but suicide and homicide of pregnant and recently delivered women are recognised contributors that are systematically under-counted, and depression, intimate-partner violence (IPV) and substance use form a syndemic that sits behind late booking, non-attendance, poor adherence and avoidable death. Pregnancy is not protective against violence; for many women it is the period of highest risk, with escalation around disclosure of pregnancy and in the early postpartum.
Your task as a registrar — captured by the objective verb discuss — is to know how to evaluate a pregnant woman for both: how to ask, when to ask, what to look for, how to assess risk and severity, and how to act safely on what you find. This is a high-order skill (HOTS) because the diagnosis is rarely volunteered, the cues are easily dismissed as "social", and the consequences of missing it — femicide, suicide, infanticide, a relapse of psychosis — are catastrophic and largely preventable. Routine, universal, structured enquiry is the single most effective tool you have. This chapter sits alongside respectful-care, antenatal-booking, substance-use-in-pregnancy, high-risk-pregnancy-risks and the gynaecology survivor pathway in gender-based-violence.
Core knowledge
What GBV is, and why pregnancy matters
GBV in this context is overwhelmingly intimate-partner violence — physical, sexual, emotional/psychological and economic abuse by a current or former partner — but also includes non-partner sexual assault, controlling behaviour and reproductive coercion (sabotaging contraception, forcing or preventing pregnancy or termination). South Africa has among the highest reported rates of IPV and femicide in the world; a substantial minority of women experience violence during the index pregnancy. Recognise the dynamics: violence often begins or escalates in pregnancy; the abuser frequently attends consultations and answers for the woman; and abuse clusters with HIV (coerced sex, inability to negotiate condom use or disclose status), substance use and poverty.
The obstetric consequences are direct and indirect. Direct trauma causes abdominal/blunt injury, placental abruption (antepartum-haemorrhage), preterm labour, ruptured membranes and fetal injury or loss. Indirectly, IPV drives late booking, missed visits, poor nutrition, untreated infection, depression and suicidality, and is strongly associated with low birthweight and fetal growth restriction (intrauterine-growth-restriction). A woman presenting with unexplained injuries, repeated "accidents", a controlling companion, or recurrent unexplained obstetric complications should prompt active consideration of abuse.
The spectrum of perinatal mental illness
"Mental health issues in pregnancy" spans a graded spectrum from common and mild to rare and life-threatening. Hold the whole spectrum in mind because the assessment differs sharply by severity.
- Baby blues — a transient, self-limiting mood lability in the first postnatal week affecting a majority of women; not a disorder, but must be distinguished from depression that does not resolve.
- Antenatal and postnatal depression — the commonest serious perinatal disorder, affecting a large minority of South African women in many community studies (rates well above high-income-country figures, driven by poverty, HIV and violence). It is frequently antenatal in onset, not merely postnatal, and is the diagnosis you will most often make.
- Anxiety disorders — generalised anxiety, panic, tokophobia (pathological fear of childbirth), post-traumatic stress disorder (often rooted in prior abuse or a previous traumatic birth), and obsessive-compulsive symptoms (intrusive thoughts of harming the baby — distressing but, in OCD, ego-dystonic and low-risk, to be carefully distinguished from psychotic command thoughts).
- Severe mental illness (SMI) — pre-existing or new bipolar affective disorder and schizophrenia. Pregnancy and the puerperium are periods of high relapse risk, especially if medication is stopped abruptly.
- Postpartum (puerperal) psychosis — a psychiatric emergency. Classically of rapid onset in the first two weeks postpartum, with confusion, mood instability, delusions, hallucinations and disorganised behaviour. It carries a markedly elevated risk of suicide and infanticide and mandates urgent admission. Bipolar disorder and a previous episode of puerperal psychosis are the strongest predictors.
Why the perinatal period is high-risk
Pregnancy and the puerperium combine biological, psychological and social destabilisers: large hormonal shifts, sleep deprivation, the psychological reorganisation of becoming a mother, social and financial strain, and — critically in South Africa — frequent coincidence with an HIV diagnosis, with disclosure, stigma and adherence demands. Antidepressant or mood-stabiliser discontinuation at the positive pregnancy test is a common and dangerous trigger for relapse. Suicide is a leading cause of maternal death in many settings and is consistently under-ascertained; the method in the perinatal period is often violent, reflecting high intent. The take-home is that mental illness in this window is more, not less, dangerous, and must be assessed with the same seriousness you bring to bleeding or sepsis.
Figure I20.1 — GBV, perinatal mental illness and obstetric harm form a syndemic; routine private enquiry is the clinical safety net.
Assessment
Create the conditions to ask
Detection is impossible without privacy and safety. The cardinal rule for GBV enquiry: see the woman alone, at least once, at every booking. Find a structural reason to separate her from any companion ("we always do part of the examination privately") and use a professional interpreter — never the partner, a relative or a child. Frame enquiry as routine and universal so no one is singled out: "Because violence is so common, I ask every woman these questions." A non-judgemental, unhurried manner and the principles of respectful-care are the substrate of honest disclosure.
Asking about GBV
Routine antenatal enquiry about IPV is recommended; NICE antenatal care guidance (NG201) supports asking about domestic abuse as part of booking, and the SA National Integrated Maternal and Perinatal Care Guideline (NDoH, 2024) embeds psychosocial screening into antenatal care. Ask directly and specifically rather than with vague openers:
- "Has your partner or anyone at home ever hit, slapped, kicked or otherwise physically hurt you?"
- "Has anyone ever forced you into sexual activity you did not want?"
- "Are you ever frightened of your partner? Do you feel safe at home?"
- "Does anyone control your money, your movements, or stop you seeing family or coming to clinic?"
- Screen for reproductive coercion: interference with contraception, pressure about continuing or ending the pregnancy.
Note clinical cues that should raise suspicion even without disclosure: injuries inconsistent with the explanation, multiple injuries of differing ages, a delay in presentation, a partner who will not leave or who answers for her, recurrent terminations, late booking, repeat unexplained obstetric loss, poor adherence, and depression or substance use. If she discloses, your immediate priorities are validation, an assessment of immediate danger (weapons in the home, threats to kill, escalating frequency, strangulation history, children at risk) and a safety plan — not an instruction to leave, which is the moment of highest lethality.
Screening for mental illness
The SA guideline and NICE NG201 both endorse routine mental-health enquiry at booking and across the perinatal period. Two complementary approaches:
- The Whooley questions (case-finding for depression): "During the past month, have you often been bothered by feeling down, depressed or hopeless?" and "…by having little interest or pleasure in doing things?" A "yes" to either prompts fuller assessment. A useful third anxiety question asks whether she feels anxious, on edge or unable to stop worrying.
- A validated tool such as the Edinburgh Postnatal Depression Scale (EPDS) — a 10-item self-report scale validated for antenatal and postnatal use and translated into South African languages — quantifies severity and, importantly, item 10 directly screens for self-harm/suicidal thoughts. Treat any positive self-harm item as requiring immediate, explicit suicide-risk assessment, regardless of the total score. (EPDS cut-off scores vary by language and validation study; apply locally validated thresholds rather than a single universal number.)
Beyond case-finding, take a structured psychiatric history: onset and trajectory of symptoms; past psychiatric history including any previous episode of puerperal psychosis or bipolar disorder (the strongest predictors of severe perinatal illness); family history of severe perinatal mental illness; current and recently stopped psychotropic medication; substance use (substance-use-in-pregnancy); HIV status and adherence; and the social scaffold — partner support, finances, housing, and GBV. Always perform an explicit risk assessment: thoughts of self-harm or suicide (and any plan, intent or means), thoughts of harming the baby, neglect, and — for psychosis — command phenomena and delusional beliefs involving the infant.
Figure I20.2 — Safe screening workflow for GBV and perinatal mental illness, from private enquiry to immediate risk triage.
Examination and investigations
Examination is targeted: document injuries factually and on a body map (with measurements and, with consent, photographs), assess for abruption and fetal wellbeing where trauma is suspected (decreased-fetal-movements, ctg-interpretation), and screen for the medical comorbidities that cluster here — HIV (hiv-in-pregnancy), other STIs, anaemia and substance use. There is no blood test for depression or GBV; the "investigation" is the structured interview and validated tool. For sexual assault, the evaluation becomes medico-legal (see Management). Mental-state examination — appearance, behaviour, speech, mood and affect, thought form and content, perception, cognition and insight — is the core "investigation" for suspected severe illness, and any feature of psychosis or active suicidality converts the encounter into an emergency.
Management
Evaluation must lead to action; the registrar's job is to respond safely, not merely to detect. South African practice rests on multidisciplinary referral, statutory frameworks and the levels-of-care system (primary → district → regional → tertiary, with mental-health and GBV support concentrated at higher levels and in dedicated centres).
Responding to GBV disclosure
- Validate and ensure immediate safety. Believe her, affirm that the abuse is not her fault, and ask whether it is safe to go home today. Assess lethality markers (threats to kill, strangulation, weapons, escalating violence, recent separation, children at risk).
- Safety planning, not directives. Help her identify a safe place, a packed bag, important documents, a code word, and who to call. Respect her autonomy and timing — leaving is the highest-risk moment.
- Refer into the SA survivor pathway. Thuthuzela Care Centres (TCCs) provide integrated, one-stop care for sexual-assault survivors (medical, forensic, psychosocial and legal). Engage social workers, and for sexual assault complete the medico-legal examination and the J88 form.
- Statutory and post-exposure care. Sexual assault triggers HIV post-exposure prophylaxis (PEP), STI prophylaxis and emergency contraception per SA protocols, and forensic specimen collection with consent. Where children are at risk, child abuse and neglect are mandatorily reportable under the Children's Act 38 of 2005; sexual offences fall under the Criminal Law (Sexual Offences and Related Matters) Amendment Act 32 of 2007. Document factually and contemporaneously. The legal and consent dimensions are developed in gender-based-violence, informed-consent and sa-og-law.
Managing perinatal mental illness
Match intensity to severity, and remember that untreated maternal mental illness carries its own substantial risks to mother and fetus — these must be weighed against any medication risk, never assumed to favour "no treatment".
- Mild–moderate depression/anxiety: psychological therapy first-line where available (problem-solving, structured psychosocial support, CBT-based approaches), mobilisation of social support, treatment of comorbid anaemia, HIV and substance use, and close follow-up. Many community programmes in South Africa deliver counselling through trained lay health workers given the scarcity of specialists.
- Moderate–severe depression / relapse of SMI: combine psychological and pharmacological treatment with psychiatric referral. Decisions about antidepressants, antipsychotics and mood stabilisers in pregnancy are specialist territory and require an explicit benefit–risk discussion; do not abruptly stop established medication in a woman with bipolar disorder or schizophrenia, as relapse risk is high. Some agents (notably sodium valproate, and consideration around lithium and certain others) carry specific teratogenic or perinatal concerns — refer for specialist guidance rather than improvising; consult current SA EML and psychiatric advice before initiating or changing any psychotropic.
- A previous episode of puerperal psychosis or bipolar disorder warrants a proactive perinatal mental-health plan, specialist input and intensive postpartum monitoring even when the woman is currently well.
Emergency: the acute psychiatric crisis
EMERGENCY DRILL — active suicidality, infanticidal thoughts, or puerperal psychosis.
- Do not leave the woman (or the baby) alone. Ensure constant observation; remove access to means.
- Assess and stabilise any acute medical or obstetric problem and rule out organic causes (sepsis, eclampsia, hypoglycaemia, intoxication/withdrawal, thyroid storm) — delirium can masquerade as psychosis.
- Escalate immediately to psychiatry and senior obstetric staff; arrange urgent admission (a mother-and-baby facility where one exists; otherwise the highest available level of care).
- Protect the infant: assess the baby's safety and involve social services.
- Use the Mental Health Care Act 17 of 2002 framework for involuntary assessment/admission where the woman lacks insight and poses a danger to herself or others.
- Document the risk assessment, the plan and the people informed.
Treat new-onset confusion, severe agitation, command hallucinations, delusions about the baby, or a clear plan and intent for suicide as you would any obstetric emergency: a problem that kills if you defer it. Never discharge a woman with active suicidal intent or untreated psychosis "to follow up in clinic".
Figure I20.3 — Management pathways after disclosure or psychiatric crisis: validate, safety-plan, refer and escalate urgently when risk is active.
Red flags / pitfalls
- Never interview a woman about violence in front of her partner, family or a child, or use them as the interpreter. This is the single most common — and most dangerous — error. Always create a private moment.
- "She didn't disclose" is not "she's safe." Most women do not disclose at first asking. Document the offer, keep the door open, and re-ask at later visits — disclosure often follows a trusting relationship.
- Do not order a woman experiencing IPV to leave. Separation is the period of greatest lethality; offer safety planning and resources and respect her timing.
- Do not dismiss late booking, repeated DNAs, "clumsy" injuries, poor adherence or recurrent loss as mere "social problems." They are classic red flags for IPV and depression.
- A positive EPDS self-harm item (item 10) overrides the total score. Any endorsement of self-harm thoughts demands an explicit, same-visit suicide-risk assessment.
- Confusion or agitation in the early puerperium is psychosis until proven otherwise — and "otherwise" includes ruling out eclampsia, sepsis and metabolic causes. Missing puerperal psychosis or an organic delirium is a fatal error.
- Do not stop a mood stabiliser or antipsychotic abruptly because a woman is pregnant. Refer; abrupt cessation precipitates relapse with worse outcomes than the medication's risk in most cases.
- Distinguish ego-dystonic intrusive thoughts (OCD — distressing to the mother, no intent) from psychotic command thoughts (high risk). They demand very different responses.
- Do not forget the medico-legal obligations after sexual assault (J88, forensic specimens, PEP/STI prophylaxis/emergency contraception, Thuthuzela referral) and the mandatory reporting of child abuse.
- Screening without a referral pathway is unethical. Only ask if you know where you will send her; ensure social work, psychiatry/psychology and GBV services are mapped before you screen.
Evidence anchors
- National Integrated Maternal and Perinatal Care Guideline for South Africa (NDoH, 2024), NDoH — the SA obstetric source of truth; embeds psychosocial and mental-health screening and GBV enquiry into routine antenatal care, and defines referral across levels of care.
- Saving Mothers / NCCEMD (latest triennial report) — frames the SA maternal-mortality burden (HIV/non-pregnancy-related infection, haemorrhage, hypertension) and the syndemic of mental illness, substance use and violence underlying avoidable deaths.
- NICE NG201 — Antenatal Care (2021) — supports routine enquiry about domestic abuse and mental-health case-finding at booking and across pregnancy.
- South African statutory framework — Children's Act 38 of 2005 (mandatory reporting of child abuse/neglect) and the Criminal Law (Sexual Offences and Related Matters) Amendment Act 32 of 2007 (sexual offences, J88, Thuthuzela Care Centres); Mental Health Care Act 17 of 2002 (involuntary assessment/admission); National Health Act 61 of 2003 and HPCSA ethical guidance on consent and confidentiality (see informed-consent, sa-og-law).
- South African EML (Hospital and Primary Care levels, current edition) — for psychotropic availability and prescribing; psychotropic choice in pregnancy is specialist-guided.
- South African National HIV/ART Consolidated Guidelines (2023) and WHO HIV testing/PEP guidance — for the HIV PEP, STI prophylaxis and emergency-contraception components of post-sexual-assault care (see hiv-in-pregnancy).
Author's notes on uncertainty (hedged, not fabricated): the Whooley questions, the EPDS as a validated antenatal/postnatal screening tool, the "baby blues" timing, the early-postpartum onset and risk profile of puerperal psychosis, FASD and abruption associations, and the general benefit–risk framing of psychotropics in pregnancy are stated as standard teaching, not attributed to a line-itemed source. Specific EPDS cut-off scores are deliberately not quoted because validated thresholds vary by language/validation study; apply locally validated values. Statements about valproate/lithium perinatal risk are kept general and explicitly deferred to specialist guidance and the current SA EML rather than tied to a specific dose or threshold. Saving Mothers is cited generically ("latest triennium") per VERIFIED-SOURCES.