Despite the proven benefits of newborn hearing screening and early intervention, universal screening is not yet mandatory in South Africa and is only available in some public hospitals.
Thousands of children are born with hearing loss in South Africa each year, however, most are not diagnosed, often after the critical formative years for language learning.
Hearing loss is the most common sensory impairment in children and researchers estimate that more than 6,100 children each year in South Africa are born with or develop a hearing loss after birth. According to the World Health Organization (WHO), approximately 34 million children globally have hearing loss. It states that early intervention is critical for successful rehabilitation outcomes and delay has a negative impact on language development and communication. This is why early detection of hearing loss in children is important for them to develop as well as their peers who have normal hearing.
“We actually start hearing before we're born,” says Sarah Lang, head of audiology at the Carel du Toit Centre. “We've been listening for a few months since we were born.” The Carrel du Toit Center is a special foundation stage teaching institute in the grounds of Tygerberg Hospital where spoken language is taught to hearing impaired children.
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Lang says our brain is designed to form neural pathways. In simple terms, these are the pathways through which information passes so that the brain can process information and control actions. She explains that the brain forms these neural pathways for easy communication by about three years of age. Lang says that with intervention and hard work, the brain can build these pathways by about age five or six. She says, “A very young brain has a lot of plasticity, meaning it can easily learn, change, and make neural connections… The older the brain gets, the more difficult it is to do this.”
If a baby is only seeing things, and never hearing anything, for the first three years of his life, his brain will learn best through his visual cortex, says Lang. If intervention does not occur soon, the visual cortex takes over the auditory cortex in the brain. In other words, if one sense is not being used or stimulated, it may fade away from the other senses.
Thus early intervention is important to help these children develop communication skills so that they can connect with their families and peers. This is especially important because most hearing-impaired children are born to parents who can hear.
In 2016, the Carel du Toit Center partnered with Tygerberg Hospital to begin screening all infants at high risk of hearing loss. Factors such as maternal infection, low birth weight, premature birth, jaundice and a newborn spending time in intensive care all indicate a higher risk. In 2025, the screening program was expanded to include all newborns (not just high-risk ones), making Tygerberg Hospital one of the few public hospitals in the country that screens all infants as part of routine care.
two screening tests
One obvious challenge with newborns is that they cannot easily tell what they can hear and what they cannot hear. Since it is not ideal to wait until hearing problems become noticeable in daily life, screening tests have been developed to help with early diagnosis.
There are two common screening tests. The first is called otoacoustic emissions (OAE) screening. Cape Town-based ENT specialist Dr Jessica McGuire explains that OAE screening is a non-invasive and painless test in which a probe is placed in the child's ear.
“You put the probe in the ear, it sends a sound, the cochlea hears the sound, processes the sound, it produces an echo, and then the machine has a microphone that captures the distorted sound,” says McGuire who runs the universal newborn hearing screening program at Mowbray Maternity Hospital through her nonprofit HEAR-Hope.
OAE testing does not measure the entire auditory pathway.
She explains, “You have an outer ear, a middle ear, and an inner ear, and then you have your brain and the pathways to the brain… You need the whole system to work to be able to hear.”
McGuire says that in medically high-risk infants, the problem is often associated with their nerves and pathways to the brain. She adds, “So (for these children) the cochlea works fine, but after the cochlea, sound is not able to reach the brain through the nerves.” These newborns require a different type of testing.
That test is called an automated auditory brainstem response (AABR) test. “We place headphones and electrodes on the child's ears and forehead,” explains Lang. “The headphones send sound into the ear and the electrodes measure the hearing response from the brain… which will then tell us whether the ear is hearing sound within normal limits.” She says the AABR is the only screening test used for newborns at Tygerberg Hospital. This is because it gives fewer false positive results than the OAE test.
According to Lang, they currently have four machines for screening at Tygerberg Hospital. By the end of December 2025, the program had screened 31,500 infants since its inception. As for Mowbray Maternity Hospital, McGuire says 9,000 to 10,000 babies are born there annually. She says their newborn screening program has a 90% coverage rate, and has four screening technicians who perform screening tests.
Gold standard for newborn hearing screening
The Joint Committee on Infant Hearing (an American organization of experts on audiology, pediatrics, and speech-language pathology) has developed international guidelines for early hearing identification and intervention (EHDI). According to these guidelines, EHDI is a four-component process that includes early detection through screening (in other words, newborn hearing screening), followed by clinical assessment to diagnose hearing loss, amplification through hearing technology, and finally rehabilitation therapy.
The committee's guidelines suggest that newborn hearing screening should be based on the “1-3-6” principle. This means that all infants should be screened within their first month of life, hearing loss should be diagnosed by three months of age, and rehabilitation should ideally begin before six months of age.
“You have to diagnose hearing loss within three months and if you intervene from a language perspective, by six months, those children's language, emotional and social development will be on par with their peers,” McGuire says. “But if they don't, children often have behavioral problems and social development is seriously affected because language is related to reading other people, which is very important.”
In South Africa, the Health Professions Council of South Africa (HPCSA) issued a position statement on early hearing detection and intervention in 2007, and published guidelines in 2018. These guidelines adapt the international 1-3-6 principle to the South African context, taking into account the high burden on the public health care system. According to HPCSA guidelines, infants should be screened at 6 weeks, hearing loss should be diagnosed at 4 months, and intervention should begin at 8 months of age.
Ideally, all babies should be screened before discharge to their birth hospital as this is the ideal setting to ensure compliance. However, this is not always possible because some babies who require special care may be transferred to other hospitals.
Despite these guidelines, hearing loss in South Africa is often diagnosed too late. One study reporting on the age of detection of hearing loss present at birth found that on average children were diagnosed with hearing loss at around 30 months of age (two and a half years of age).
Implementation Challenges
There are various challenges to the successful implementation of universal newborn hearing screening in South Africa. Studies have shown that the distribution of resources is limited and often unequal.
First, there is the issue of expensive equipment. According to McGuire, the machines used for screening cost between R100 000 and R250 000.
The second limitation has been the high loss to follow-up rate. McGuire says that while his program screens about 90% of babies born at Mowbray Maternity Hospital and only 0.7% are referred for further diagnostic testing, their loss to follow-up is very high. This means that the parents are not taking care of their child after they are sent for diagnostic testing for hearing loss and are lost contact with them after they are discharged.
To help overcome this, McGuire says they offer vouchers to parents if they can prove they have complied regardless of the test results. “(The vouchers) cover the time they spend taking the child to follow-up as well as the transportation costs,” McGuire explains. “And we think that's a huge barrier to their follow-up because it could be the difference between getting dinner that night or not.”
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In Lang's view, another part of the problem is that the referral pathway is not working as well as it could. She says babies are often born in hospitals far from the areas where they live and they may also live in places where diagnostic testing is not available.
Lang says there's no point in screening children and letting parents know there may be a problem if there's no way to follow up. She further adds that once hearing loss is diagnosed and hearing technologies are provided, rehabilitation services are important.
“Technology alone is not a solution,” says Lang. “These children will need rehabilitative and therapeutic services…Can you provide the rehabilitative services that are necessary for a deaf child to learn to listen and speak or to communicate through sign language? Do you have enough sign language schools, skilled sign language users or therapists to assist that family? There is an impact everywhere,” she says.
Ultimately, Lang says that addressing the challenges of universal hearing screening in South Africa must start with greater awareness among patients, their families and health care professionals about the importance of early hearing detection and intervention.
New guidelines are being developed
For its part, the National Department of Health says it recognizes the importance of early identification of hearing loss as part of comprehensive maternal, newborn and child health services. “Early identification is important to support language development, learning and long-term developmental outcomes,” department spokesperson Foster Mohale told Spotlight.
They say that universal newborn hearing screening, defined as screening of all newborns before discharge, is available in some facilities, and coverage varies depending on available resources, equipment, and trained personnel. Mohale explains that “in line with World Health Organization guidance, countries are encouraged to progressively expand coverage based on capacity” and so the department is working towards strengthening early hearing detection services.
According to him, the department is in the process of finalizing the national preliminary hearing screening guidelines in collaboration with partners. “These guidelines will contribute to the development of a comprehensive strategy for ear and hearing care across the lifespan,” says Mohale.