Publics, technologies and interventions in reproduction and early life in South Africa

The paper interrogates how specific medical and public health technologies applied during the first 1000 days (from conception through early childhood) shape maternal and child health in South Africa, and how they constitute different 'publics' that often privilege foetal and infant outcomes over women's health and rights. It situates maternal and child health as key indicators of health system quality and broader structural conditions, noting parallel trends of reliance on technological interventions and individualised, responsibilising approaches that sidestep social determinants. The authors adopt an expanded notion of technology, encompassing devices, procedures, protocols, institutions, and paradigms. They outline a focus on five technologies—policy paradigms around the first thousand days, ultrasound, caesarean section, ECMO, and the Road to Health Booklet—to examine their preventive and curative aims, everyday and exceptional uses, and their implications for wellbeing and public health in South Africa.

Background highlights increased longevity from medical and public health advances alongside rising chronic non-communicable diseases linked to globalisation, lifestyle, and food system changes. In South Africa, these epidemiologic shifts intersect with apartheid legacies, unemployment, inequality, and a quadruple burden of disease (maternal/child mortality, NCDs, infectious diseases including HIV/TB/malaria, and violence/injury). About 20% of adults live with HIV and ~30% of pregnant women are HIV positive; obesity is prevalent and diabetes often undiagnosed. The health system is bifurcated into a high-end private sector and a public sector emphasising primary care; birth is highly medicalised with >80% professional attendance and UNICEF-recognised 'baby friendly' hospitals. Literature on DOHaD and life-course epidemiology links maternal factors (preconception weight, gestational weight gain, gestational diabetes, hypertension) and in utero environment to offspring growth, cognition, and later-life cardiometabolic risk, positing intergenerational epigenetic effects. Evidence is mixed: some studies stress maternal obesity/weight gain, others highlight low preconception weight and broader life-course windows for intervention. Cohort work in South Africa (Birth-to-Twenty; Soweto 1000 Days) intensively monitors maternal/foetal health (biometrics, ultrasound, behaviour), but often pays less attention to socioeconomic determinants (poverty, food insecurity, housing, water/sanitation, pollutants, IPV). Ethnographic work shows postpartum resource allocation can disadvantage mothers, undermining breastfeeding; policy incoherences (e.g., 6-month exclusive breastfeeding goal vs. 4-month unemployment insurance) exacerbate challenges. The literature also documents a drift from structural to individualised interventions and the racialised effects of medicalisation.

Conceptual and critical analysis drawing on: (1) South African health policies and clinical protocols related to maternal and child health and the first 1000 days; (2) exemplars of technologies and practices (ultrasound, caesarean section, ECMO, Road to Health Booklet); (3) secondary analyses of epidemiological and cohort studies (e.g., Birth-to-Twenty, Soweto 1000 Days) and global standards (WHO Child Growth Standards); and (4) existing ethnographic and qualitative studies of caregiving, breastfeeding, and clinic record use. The authors synthesise evidence and policy/practice documentation to examine how technologies are introduced, interpreted, and operationalised in clinical and community settings, and how they constitute different publics and responsibilities. No primary data collection is reported; rather, the article offers an interpretive, theory-informed synthesis linking technologies to public health framing, structural determinants, and ethical/resource considerations.

- Ultrasound and antenatal monitoring: Routine and increasingly portable ultrasound enables surveillance of foetal growth and maternal conditions (e.g., gestational diabetes, pre-eclampsia), guiding interventions (inductions, caesareans). It is embedded in a broader suite of monitoring tools (scales, BP cuffs, urine tests) that also surveil maternal behaviours. Ultrasound data are mobilised within DOHaD frameworks to anticipate offspring’s long-term cardiometabolic risk and intergenerational effects, reinforcing attention to maternal weight control and lifestyle while often sidelining socioeconomic drivers. - Evidence base and contestation: Cohort and epidemiologic studies link maternal weight/behaviour to offspring growth and later disease risk, but findings are mixed regarding critical windows and the relative importance of preconception vs. gestational factors. Calls to focus exclusively on perinatal windows may overstate their primacy compared to life-course and structural interventions. - Caesarean section: South Africa shows very high c-section rates in the private sector (~80%) and elevated rates in the public sector (~26%), exceeding WHO recommendations. Drivers include elective preferences, defensive medicine, and risk interpretations based on technologies (e.g., ultrasound/dopplers). VBAC is rarely supported in private care. C-sections are associated with reduced breastfeeding initiation and duration, increased maternal postpartum complications (depression, infection, pain) and risks in subsequent pregnancies (e.g., abnormal placentation, uterine rupture, hysterectomy). In LMICs, maternal and perinatal mortality post-c-section can be disproportionately high. For infants, c-section-associated microbiome differences correlate with elevated risks of obesity, type 1/2 diabetes, and respiratory/allergic diseases. The broader distribution of resources remains a stronger determinant of public health than birth mode alone. - ECMO (neonatal cyborgs): ECMO is used as a last resort for neonates with severe respiratory/cardiac compromise (e.g., PPHN, RDS, infection) and for certain adults. While lifesaving for some individuals, ECMO is high-cost and high-risk (hemorrhage, clotting, transfusions, nosocomial infections), with antimicrobial resistance compounding risks and system burdens. Its public health benefit is limited, raising ethical questions about resource allocation versus broader, preventive investments. - Road to Health Booklet: Expanded from a simple clinic card to a 46-page patient-held booklet covering nutrition, love, protection, health care, and extra care, with growth charts (WHO standards), developmental milestones, immunisation, deworming, vitamin A, dental records, and social risk factors. Despite its potential, completion accuracy is suboptimal; cards are often lost; private sector use may be limited; and supply chain issues (vaccine/medication stock-outs) undermine effectiveness. Language barriers and HIV stigma lead caregivers to hide booklets; some advice is impractical given employment and material constraints. The booklet increasingly functions as a pastoral, responsibilising tool assessing caregivers, while maternal wellbeing (especially postnatal mental health) is under-addressed. - Overarching patterns: Technologies tend to privilege foetal/infant outcomes over maternal health and rights, individualise responsibility, and adopt standards developed in the global North as universal. Publics are variously constituted (mother–infant dyad, future adults, intergenerational populations, individual neonates), producing tensions in public health aims and equity.

The analysis shows that technologies deployed in the first 1000 days simultaneously pursue short-term clinical goals (e.g., live birth, neonatal survival) and long-term population objectives (reducing future cardiometabolic disease) but often at the cost of overlooking structural determinants and maternal wellbeing. Ultrasound-enabled risk framing, high c-section rates, and ECMO illustrate how clinical logics can recalibrate what counts as normal birth and acceptable risk, responsibilise pregnant women as neoliberal subjects, and divert resources toward high-cost individual rescue with limited public health yield. The Road to Health Booklet exemplifies a shift from professional monitoring to caregiver surveillance and guidance, constituting a public of informed, responsible carers, yet with practical and equity constraints (language, stigma, system capacity, supply chains). Across cases, women's health and rights postpartum, including mental health, receive insufficient attention; men's roles remain under-examined. The reliance on global standards and universalising metrics can misclassify risk in resource-constrained settings and reinforce racialised inequalities. These findings address the research aim by revealing how 'publics' are materially and discursively produced by technologies and by highlighting the contradictions between individualised technological solutions and needed structural interventions.

The paper synthesises how five technologies—ultrasound, weight management/DOHaD framing, caesarean section, ECMO, and the Road to Health Booklet—produce distinct publics and reconfigure responsibilities in South African maternal and child health. Common features include: (1) the maternal body as an incubator of population health across generations; (2) growing individualisation and responsibilisation of wellbeing; and (3) reliance on standards from the global North treated as universal. Outcomes are mixed: overuse of c-sections undermines breastfeeding goals; postpartum focus on infants elides maternal health needs; neonatal rescue technologies raise ethical and resource allocation questions; and patient-held records can both empower and surveil while being constrained by systemic and social factors. The authors call for critical appraisal of universalist approaches, attention to structural determinants and inequalities, inclusion of broader social forms (families/households) and men's roles, and policy designs that support reproductive rights and maternal wellbeing without re-medicalising social worlds or excluding vulnerable groups.

The article is a conceptual, interpretive synthesis without primary data collection; while it integrates policy documents, cohort findings, and ethnographic studies, it does not present new empirical results. Effects and generalisability are context-dependent (South Africa), and quantitative effect sizes or cost-effectiveness analyses of compared technologies are not provided. Limitations are not explicitly stated by the authors.