/ 26 July 2009

Giving birth in SA gets riskier

Deaths of pregnant women have soared by 20%, but more than a third of them could have been prevented.

Deaths of pregnant women have soared by 20%, but more than a third of them could have been prevented.

Among healthcare providers, poor assessment of health problems and failure to follow standard health protocols are the most frequent causes of these deaths.

These are major findings in a report by the government-appointed National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD). The department of health silently posted the report on its website this month without any public notification.

The report is based on maternal deaths in all health institutions from 2005 to 2007 that were reported to the NCCEMD. ”Maternal deaths” are defined as ”deaths of women while pregnant or within 42 days of termination of pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes”.

In this period 4 077 maternal deaths were reported, up 20% from the 3 406 deaths reported during 2002 to 2004. The majority of these occurred in public health institutions but the report does not specify how many.

The report states that the 4 077 deaths may be an underestimate as most maternal deaths occurring outside of health institutions are not reported to the committee.

In rural areas maternal deaths occurring in health institutions vary between 20% and 66%, the report estimates. Of the 4 077 maternal deaths reported, 38,4% of them were ”clearly avoidable”, the report says. Four out of five of these deaths were because of complications of hypertension, pregnancy-related sepsis and non-pregnancy-related infections.

The top five causes of maternal deaths were non pregnancy-related infections, complications of hypertension, obstetric haemorrhage, pregnancy-related sepsis and pre-existing maternal disease. HIV infections were the biggest killer, accounting for 43,7% of maternal deaths. ”The ways to prevent these deaths are known,” the report says. ”Specific protocols have been developed — Despite this, the most important avoidable factor is still substandard care.”

The lack of appropriately trained staff contributed to 9% of assessable maternal deaths and was a factor in 22,4% of anaesthetic-related deaths and 17,5% of obstetric haemorrhage cases. Incorrect diagnoses, delays in referring patients and infrequent monitoring of patients by health workers were common problems.

These occurred most frequently in community health centres and district hospitals and least in provincial tertiary and national central hospitals. The report contains no data on staff-related problems in private health institutions.

Other major problems include the lack of patient transport and of ICU facilities — factors in more than 8% of maternal deaths. A lack of blood for transfusion was reported in 19% of cases. Patient-related avoidable factors such as delays in seeking help and lack of attendance at antenatal clinics were recorded in 46% of cases.

The report also underlines the mounting impact of HIV/Aids on maternal deaths. Seventy-nine percent of maternal deaths tested between 2005 and 2007 were HIV positive and Aids-related illnesses accounted for 43,7% of maternal deaths reported during this period.

Marion Stevens of the Health Systems Trust, a health research and activist NGO, says the intersection between HIV/Aids and maternal deaths is a major cause for concern. ”While we have seen improvements in the prevention of mother to child transmissions, treatment is poorly conceptualised. At present pregnancy is an incentive to get HIV/Aids treatment. We need to better integrate HIV/Aids, sexual and reproductive health services.”

She added that it was unlikely that South Africa would meet the Millennium Development Goal to reduce maternal deaths by 75% by 2015.

The NCCEDM calls for the continuous scaling of ARV therapy and HIV testing and counselling.

It stresses the urgent need for emergency transport facilities to be made available for all pregnant women. Delays in seeking medical help were recorded in nearly a third of cases of maternal deaths, with the most common reason being the lack of transport between the woman’s home and a healthcare institution.

The report further recommends training for all health professionals in maternity units and the provision of comprehensive care to pregnant women, including screening for HIV, malaria, anaemia and cardiac disease.

Jagidesa Moodley, chairperson of the NCCEMD, declined to comment on the report. The department of health had not responded to questions at the time of going to press.