Maternal mortality under scrutiny
Institutional reform has been touted as a solution to reducing the number of pregnancy and birth related deaths.
I met Nonkulelo* while interviewing women in the Eastern Cape about their experience of pregnancy and the public health system. She told me about her daughter, Fezeka*.
A week after 20-year-old Fezeka had delivered a baby girl at a local health facility, she could not walk from her room to the toilet and was complaining of dizziness. She refused to breastfeed her baby. Fezeka was HIV positive but had not disclosed it to her family.
Fezeka started complaining of shortness of breath and chest pain. Nonkulelo called for an ambulance to take her to hospital, but an hour later it had not arrived. Without money to hire a private taxi, they took public transport to a community health centre, where Fezeka was put on a drip and referred to a district hospital. At the hospital they faced long delays before being seen by a doctor, who ordered blood tests and X-rays and asked a nurse to book Fezeka for admission.
Nonkulelo said that, instead of being taken to a ward, a porter took them to what looked like an examination room where they waited for more than six hours without medical attention. “Fezeka was in great pain and kept asking me to go and call the doctor, but I did not know where the doctor was and I did not want to leave her alone in that room,” Nonkulelo said.
“A nurse came in at about 4am and just started writing things. She did not even talk to us or ask us anything. The nurse took her blood pressure and said Fezeka’s legs were cold and left,” she said. Fezeka died shortly after that, leaving behind her tiny daughter and grieving mother.
No change since the 1990s
Since the 1990s South Africa has not reduced the number of women who die needlessly each year from preventable and treatable causes linked to pregnancy and childbirth.
Representatives of the world’s parliaments recently gathered in Kampala, Uganda, to discuss global political, economic and social challenges.
At the end of the meeting, the Inter-Parliamentary Union adopted a resolution on the role of parliaments in addressing the key challenges to securing the health of women and children. The resolution calls on parliamentarians to take measures to ensure that their governments meet national and international obligations to reduce maternal and child deaths by 2015, in line with their commitment to the United Nations millennium development goals.
South African parliamentarians have a unique opportunity to ensure that no woman suffers Fezeka’s fate by demonstrating their commitment to holding government accountable for the rise in maternal deaths.
Since becoming health minister in May 2009, Aaron Motsoaledi has made ending needless deaths during childbirth a priority. He has made it part of four “strategic outputs” the health sector must achieve by 2014, according to a service delivery agreement he and President Jacob Zuma signed in 2010.
Motsoaledi is under no illusions about South Africa’s deteriorating health system and has set out plans to “overhaul” it to be more responsive to the healthcare needs of all South Africans. These include refocusing the health system on primary healthcare and improving health infrastructure, administration, management, information systems and financing. These and other initiatives targeted specifically at pregnant women, such as improving the attendance and quality of antenatal and postnatal services, as well as access to HIV testing and treatment, have the potential to reduce deaths. Parliament should support them by closely monitoring their implementation and impact.
Public death traps
Research by public and maternal health experts in South Africa, including Human Rights Watch’s research on maternal healthcare, shows that a major problem contributing to South Africa’s poor maternal health outcomes is the low quality of care that patients receive, particularly in public health facilities, as Fezeka’s case shows. Compounding it is the failure to hold health workers accountable.
After Fezeka died, Nonkulelo said, a doctor had ordered that her body be sent to the casualty ward, explaining to a nurse that if they did not do so, the hospital and the nurse would be in trouble because Fezeka had been taken to the wrong room. Commenting on this, Nonkulelo said: “They were trying to cover up their mess.”
She said the hospital did not do enough to save her daughter and she was unhappy that the doctor did not explain to her the cause of death. I asked Nonkulelo whether she had lodged a complaint with the hospital and she said: “Other people told me that I should have complained.”
But there may be help for women who have been failed by the health system. The portfolio committee on health is considering the latest Health Amendment Bill, which seeks to establish an independent office of compliance with health standards. It will be an overarching institution that monitors the quality of healthcare, including the management of patients’ complaints, and ensures compliance with ethical standards in the public and private sectors.
This institutional reform is necessary to increase accountability in the healthcare system. However, in the Bill the authority is not independent of political interference. There are also other gaps, such as the need to clearly define the powers of the ombudsman vis-à-vis other existing mechanisms to handle patient complaints.
Parliament has an opportunity to transform the health system to make it more accountable to women like Nonkulelo and Fezeka. A truly independent office of compliance could make a real difference.
Agnes Odhiambo is a researcher with Human Rights Watch and the author of the report Stop Making Excuses: Accountability for Maternal Healthcare in South Africa
*Not their real names