Although almost half of all maternal deaths in South Africa are caused by HIV-related complications, there is no evidence yet that the government's antiretroviral drug programme has led to a lower chance of pregnant women infected with the virus dying during pregnancy, childbirth or within 42 days thereafter.

This is according to gynaecologist Eddie Mhlanga, the erstwhile director of maternal health at the department of health and former head of obstetrics and gynaecology at the University of KwaZulu-Natal.

"Antiretroviral drugs [ARVs] have most certainly contributed towards people living longer in general, but we cannot yet say how that has contributed to saving South African women during pregnancy and childbirth because access to the drugs is still problematic," said Mhlanga, who is now working for the Mpumalanga health department.

According to the United Nations Population Fund (UNFPA) as many as 310 in every 100000 pregnant women in South Africa died during pregnancy or childbirth in 2011. The country has been severely criticised for worsening maternal mortality figures in the past two decades – compared with some African countries that have far fewer resources than South Africa but have made more progress. According to UNFPA, Sierra Leone's maternal mortality rate declined by 30% between 1990 and 2010, Mozambique's by 46%, Malawi's by 59% and Eritrea's by 73%. South Africa's rate increased by 21% during the same period.

Last year, a health department report attributed the country's maternal mortality rate to the high HIV infection rate among pregnant women. Studies have shown that HIV-positive women are up to six times more at risk of maternal death than HIV-negative women.

According to the government's latest antenatal survey, one out of every three pregnant women is HIV positive. The health department said HIV is the cause of up to 40% of all maternal deaths. 

Below-standard treatment
But, according to Mhlanga it is the "below-standard treatment" that HIV patients frequently receive because of the accompanying stigma that often leads to their death rather than the virus itself. "Women are regularly recorded to have died of Aids-related illnesses when in fact some health workers provide suboptimal care when HIV has been diagnosed. That is why ARVs alone won't solve this problem," he said. "Several maternal death reviews have shown that women who have HIV are not managed as vigorously as their HIV-negative counterparts. Obviously, substandard treatment has more adverse medical outcomes for HIV-positive women." 

This month the government announced that it will offer all HIV-infected pregnant and breastfeeding women antiretroviral treatment, regardless of the state of their health. Previously, only pregnant women with significantly weakened immune systems qualified for the drugs. Until March, patients had to take three pills twice a day, but the government now supplies HIV-infected pregnant women with a once-a-day tablet.  

The health department's spokesperson, Joe Maila, is adamant that an increase in access to ARVs will lead to a decline in maternal mortality. "We have new, preliminary, unpublished data that suggests that fewer HIV-positive women who give birth in public hospitals are dying. We must therefore not underestimate the role of HIV treatment."

According to Vivian Black from the Wits Reproductive Health and HIV Institute, single-dose pills are likely to lead to more pregnant women accessing ARVs because they're easier to take and distribute, but "ARV access is still problematic". In a study she published in 2009, Black found the major cause of maternal mortality among HIV-infected women was a lack of access to ARVs. "We're doing a follow-up study in the inner city of Johannesburg, where access to ARVs has increased, and we're seeing a difference," she said. "HIV-infected pregnant women, who were previously six times more likely to die, are now only twice as likely to die." 

Mhlanga said, however, that increased ARV access alone will not lead to a significant improvement in the country's maternal death rates. He said negligence, "substandard care" and mismanagement in maternal wards would first need to be addressed. "One may have the best drugs in the world but if there is no proper care during labour and delivery, it is of no use. The patient may have antiretro-viral treatment, but if she is not treated for bleeding after delivery, she will die. Not from HIV but from postpartum haemorrhage." 

Black agreed that many maternal deaths are avoidable. "We need concerted efforts to strengthen the health system and unlock barriers in accessing care if we want to decrease the maternal mortality rate." 

Maila said the department has implemented "interventions to strengthen maternal health services" such as training health workers to better manage "life-threatening situations during pregnancy". 

Marion Stevens, a spokesperson for the reproductive health organisation Wish, believes that HIV often "overrides other systemic issues" that contribute to poor maternal health. "A large proportion of women are reported to have died due to HIV, but we also need to look at issues such as the prevention of unintended pregnancies and unsafe abortions."

The health department says that 28% of maternal deaths are caused by excessive bleeding and 14% by pregnancy-related high blood pressure. Eight out of every 10 deaths caused by haemorrhage are preventable and so are 60% of high blood pressure deaths. "The challenge is in changing the attitudes of public servants. We need to get back to basics by ensuring that nurses and doctors are adequately skilled to deal with problems," said Mhlanga. 

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Africa commits to maternal healthcare

Niger has more than halved its maternal mortality rate over the past two decades despite being labelled in 2012 by the children's rights organisation Save the Children as the worst place in the world to be a mother. 

Power structures and the behaviour of men in the country's rural villages were identified as obstacles to women accessing reproductive health services. Three years ago "husbands' schools" were launched in 137 villages to increase men's involvement in reproductive health. The schools are an assembly of men who – with the support of traditional leaders – are given information and the space to talk about the importance of family planning, issues specific to their villages that aggravate maternal deaths, how they can help their wives during pregnancy and childbirth, and why this is important. 

In Togo, after launching the African Union plan to reduce maternal mortality in 2010, the country established "committees of men to support the health of mothers and children", made up of leaders from various sectors of society. Through these committees, state policies are expected to filter through to community level.

In Uganda, cultural institutions have signed commitments with the government to help to promote maternal health. 

Embedded cultural values have proved to be a challenge for the Malawian government, however. The use of "traditional birth attendants" is deeply rooted in rural communities, a situation aggravated by the shortage of health facilities. In 2007 the government banned these attendants in an effort to get more women to have their babies in clinics or hospitals. The ban was lifted in 2010 but reinstated this year. – Source: United Nations Population Fund reports of 2012 and 2013