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 factors 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.