In recognition of the need to reduce maternal mortality in South Africa, deaths during pregnancy, childbirth and the puerperium were made notifiable events on 1 October 1997, in terms of the National Policy Health Act, Number 116 of 1990. The Minister of Health appointed a National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD). The NCCEMD is responsible for the confidential enquiry into maternal mortality in South Africa and in so doing has developed a reporting system for maternal deaths.
The task of the NCCEMD is
"To make recommendations, based on the confidential study of maternal deaths to the Department of Health such that the implementation of the recommendations will result in a decrease in the maternal mortality"
The NCCEMD decided that to have a major impact the key recommendations must involve conditions that make a major contribution to maternal deaths and their implementation must be feasible in the South African context within three years. The impact should be measurable for the next comprehensive report. "Feasible" in the context of this report means they are affordable and practical.
The recommendations are specific so that the progress of their implementation may be measured by health authorities.
The International Classification of Diseases, Injuries and Causes of Death - 10th Revision defines a maternal death as "the death of a woman 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".
The maternal death notification process requires that all deaths of women that occur in pregnancy or within 42 days of being pregnant be reported. These deaths are then subdivided into direct, indirect and fortuitous deaths. The NCCEMD does not report on late deaths that is deaths occurring between 42 days and one year after abortion or delivery that are due to direct or indirect maternal causes. Only direct and indirect deaths are counted for statistical purposes.
Fortuitous deaths are included in the recording of maternal deaths in South Africa, to identify the magnitude of the problem of violence against women and to identify the number of suicides in pregnancy.
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Definitions of maternal deaths |
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| Maternal deaths | 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 |
| Direct | Deaths resulting from obstetric complications of the pregnancy state (pregnancy, labour and puerperium), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above. |
| Indirect | Deaths resulting from previous existing disease, or disease that developed during pregnancy and which were not due to direct obstetric causes, but which were aggravated by the physiological effects of pregnancy. |
| Fortuitous | Deaths from unrelated causes which happen to occur in pregnancy or the puerperium. |
| Unknown | Deaths during pregnancy or the puerperium where an underlying cause was not identified. |
After each maternal death in a facility, a defined process is followed. First, the facility completes a Maternal Death Notification Form (MDNF) which is sent to the provincial office within 7 days of the maternal death. The Province forwards all documentation to a Provincial Assessor, who in turn informs the NCCEMD that a death has occurred. The NCCEMD issues a unique file number for the case. The Provincial Assessor is responsible for completion of the MDNF. The assessor must provide information on the primary, final and contributory causes of death and must also establish whether there were avoidable factors, missed opportunities or any other aspects of substandard care present in the maternal death. The Assessor must complete and return all documentation to the Province within 30 days. All documentation is then forwarded to the NCCEMD for collations and analysis. The NCCEMD uses this data to compile reports on maternal deaths in South Africa. Once the report is accepted, all data is destroyed, and work begins on the next report. Detailed reports will come out every three years, hereafter. Details of the process and method of assessment are given in Appendix 3.
The data provided in this report represents all maternal cases reported to the National Office through the Confidential Enquiry into Maternal Deaths process described above during the period from 1st January to 31st December 1998.
The number of deliveries is not known for the whole of South Africa. The Maternal Mortality Ratio (MMR) used in this report is based on the number of reported maternal deaths and deliveries. A MMR could only be estimated for Gauteng Province and the Western Cape using this method. Reliable data was also obtained from the Free State and an MMR was calculated for that Province as well. The method of estimating the number of deliveries in the Free State is given in Chapter 12b. Extrapolation of the total number of deliveries for South Africa was attempted, but proved inaccurate. Census 96 still has not made available information on the age categories for women. Hence using age specific fertility rates was not possible. Information was available from Census 91.
Estimation of number of deliveries for each age category and for Provinces was performed. This data was compared with observed data for Provinces where it was available (Gauteng and Western Cape). There was a more than 25% discrepancy between observed and estimated deliveries. For further details on the MMR see Chapter 2.
The estimated MMR for the country as a whole has been calculated in the Demographic and Health Survey (SADHS) Report. Here the MMR was estimated at 150/100 000 live births.
An attempt has been made to estimate where the risk of maternal death per age category is highest. Deaths occurring in early pregnancy have been incorporated into the estimate of the MMR.