Data collection for the report was incomplete, however, a significant number of deaths were reported and a clear pattern of disease and problems in patient care emerged. The Maternal Mortality Ratio (MMR) could not be accurately calculated but the data obtained by NCCEMD agrees with the estimated MMR of 150/100 000 live births obtained by the Demographic and Health Survey. The "big five" causes of death are complications of hypertensive conditions in pregnancy, AIDS, obstetric haemorrhage, pregnancy-related sepsis and pre-existing medical conditions. The women 30 and older were at greater risk of dying than younger women, and women in their first pregnancy or with 5 or more were also at greater risk. The proportion of the various causes of maternal deaths varied between the levels of care. Obstetric haemorrhage was the most common cause of death at level 1 hospitals, whereas AIDS was at level 2 hospitals and hypertensive diseases at level 3 hospitals. The vast majority of anaesthetic deaths occurred at level 1 hospitals. The pattern of referral within provinces and across Provincial borders demonstrates that Gauteng services a much larger area than its own population. In some Provinces there was an unexpectedly high proportion of deaths at Level 1 institutions, possibly due to a lack of referral criteria or to an inability for whatever reason to refer patients. Non attendance and delayed attendance at the health institutions were the most common patient orientated problems. Poor transport facilities and a lack of intensive care facilities were the major administrative problems. Problems in the care of women occurred in more than half the cases of maternal deaths, the majority occurring at the primary level of care. Poor initial assessment and diagnosis of cases especially at secondary level of care, failure to follow standard protocols at primary and secondary levels and poor monitoring of patients at all levels of care were the common health worker related problems.
Ten key recommendations have been made by the NCCEMD which address some of these problems and each if implemented will result in a reduction of maternal deaths.
In 1952 the Maternal Mortality Ratio (MMR), excluding early pregnancy deaths, was 54/100 000 births for England and Wales. This was the first year of the Confidential Enquiry in Maternal Deaths in England and Wales. In the triennium, 1994-1996 the MMR for the United Kingdom was 12.2/100 000 maternities. It is estimated that the MMR for South Africa is about 150/100 000 live births. Clearly the approximately twelve times higher MMR in South Africa is not due to a global lack of knowledge on how to manage severely ill pregnant women, but due to maternity services in South Africa not implementing available knowledge. There may be many reasons for this, medical education, availability of resources and socio-economic problems immediately spring to mind. The establishment of the Confidential Enquiry into Maternal Deaths in South Africa allows us to determine at what level there is a breakdown in the health system and in turn this will allow for remedial action.
Information for "Saving Mothers" comes from an analyses of data on women who died in South Africa during pregnancy, labour or the puerperium during 1998 and were reported to the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD).
During 1998, a total of 676 maternal deaths were reported. On the 15th May 1999, 74 maternal death notification forms had still not been received, but the primary (underlying) cause of death was given in 17 of these. Data was entered on 585 cases of the 619 cases received by 15th May. (See Appendix, Table A1). The 15th May was set as the cut-off date for data collection and entry to allow for data analysis and production of the "Saving Mothers" report during 1999.
Reporting of maternal deaths functioned well in a number of Provinces, but in some the system did not function well at all. In some areas no or very few maternal deaths were reported during some months. (See Chapter 2, Table 2.1). The poor reporting in some provinces does not allow for a reliable estimation of the Maternal Mortality Ratio (MMR) for the whole country. However, reliable estimates can be obtained for Free State, Gauteng, and the Western Cape. The Demographic and Health Survey estimates a MMR of 150/100 000 live births for the whole country. This is in keeping with the findings of the Confidential Enquiry. (See Chapter 2).
The "big five" causes of maternal death were complications of hypertensive conditions in pregnancy (23.2%), AIDS (14.5%), obstetric haemorrhage (13.3%), pregnancy-related sepsis (11,9), and pre-existing medical conditions, mainly pre-existing cardiac disease (10.4%). The "big five" accounted for 73.3% of all the deaths. (See Appendix, Table A2 for a detailed breakdown of the deaths).
Obstetric haemorrhage includes antepartum and postpartum haemorrhage. Pregnancy-related sepsis includes cases of septic abortion and puerperal sepsis. Early pregnancy deaths due to complications of miscarriage (abortions) and ectopic pregnancies accounted for 7.5% of deaths.
The deaths resulting from AIDS were probably significantly under-reported. The HIV status was unknown in 75.8% of maternal deaths. There were 32 cases of tuberculosis, pneumonia and meningitis and in 25 the HIV status was unknown. It is possible that some of could have been reclassified to AIDS if the HIV status had been known.
Other significant causes of death were acute collapse and embolism (7.3%) and anaesthetic complications (4.8%). No cause of death could be allocated to 3.2% of cases and there were 20 fortuitous deaths.
Direct causes of maternal death were responsible for 63.3% of deaths and indirect causes responsible for 33.6%. When considering direct causes of maternal death alone (see Appendix Table A.3), hypertensive conditions were responsible for more than 1 in 3 cases, haemorrhage more than 1 in 5, and pregnancy related sepsis (including septic abortions) just under 1 in 5 cases. In 138 maternal deaths, hypertension was present, (24.4% of all deaths), haemorrhage was involved in 93 cases (16.5% of all deaths) and sepsis was involved in 67 (11.9% of all deaths). Obstructed labour contributed directly to 20 (3.5%) of deaths, either by being a predisposing factor for haemorrhage or puerperal sepsis. Almost of a third of women (32.4%) who died had an anaesthetic at some point in the process.
The deaths that could not be classified, were mainly deaths that occurred at home and where insufficient information was available to allow for an allocation of cause. There were 20 fortuitous deaths, with motor vehicle accidents being the major contributor.
The older woman especially the woman 30 years and older was demonstrated to be at significantly higher risk than the women under 30 years of age. (See Appendix, Table A4 and 5). Women of during their first pregnancy or who had 5 or more pregnancies were also a greater risk of maternal death. (See Appendix, Table A6 and 7). For a discussion on this see Chapter 2.
Most deaths occurred in African women (92.6%). The remainder 4.4%, 0.9% and 0.7% occurred in Coloured, Whites and Indian races. In 1.4% the race was not recorded.
The average gestational age at delivery or time of death of the women was 32.6 weeks ((7.1 weeks). The gestational age was not recorded in 23.9% of cases. Death occurred before 24 completed weeks in 8.5% of cases, in 19.5% in the antenatal period, in 8.7% in labour and in 61.5% in the postpartum period.
The majority of maternal deaths occurred in the Level 2 hospitals (35.0%), Level 3 having the second highest number (29.6%), followed by Level 1 hospitals (27.3%), home deaths (2.8%), community health centres (2.3%), private hospitals (1.8%) and unknown (2.7%).
Considerable differences in pattern of disease occurred at the various levels. Obstetric haemorrhage was the commonest cause of death in the Level 1 hospitals whereas non-pregnancy related infections was most common in Level 2 hospitals and complications of hypertension in Level 3. Sixty percent of all anaesthetic related deaths occurred at Level 1 hospitals (See Chapter 2, Tables 2.7-9.).
Deaths occurring at the various levels of care and the referral patterns within and outside the Provinces are shown in Chapter 2, Tables 2.10 and 2.11. A total of 40% of maternal deaths were transferred between health institutions. Thirty-eight percent of cases were referred between health institutions within Provinces, with a range of 16% in Mpumalanga to 68% in the Western Cape. Two percent of maternal deaths were referred across Provincial boundaries. Most of these came from Mpumalanga and all these were referrals to Gauteng Province. North West Province also referred to Gauteng Province. See Chapter 2 for a detailed discussion on levels of care and referral patterns.
Table 1.2 summarises the magnitude of the problems in care experienced. Details are found in the Appendix, Tables A9-14. In almost half of the maternal deaths there was a missed opportunity for preventing death related to the behaviour of the woman herself or within her community. The most common factors were not attending antenatal care and delay in seeking help. It is not known what the specific reasons for non-attendance at antenatal clinics or the reason for delay in seeking help were. More attention will need to be placed on establishing these reasons so interventions can be introduced. Self-induced termination of pregnancy occurred in 30% of women dying from complications of abortion.
Problems with the administration were evenly distributed throughout the levels of care. However, delay in transporting patients between institutions was seen in 13.6% of cases requiring transport. The problem varied considerably between Provinces with the lowest being 5% in Gauteng Province and the Western Cape to the highest of 38% in Mpumalanga Province, followed by the Eastern Cape at 33%. (See Chapter 12 for details). The problem of transport is probably even greater than this because the delays in transporting women from their homes to health institutions could not be estimated due to lack of information. A correlation has been found between delay in the transfer of women with acute severe morbidity and their conversion to maternal deaths (Mantel, Pattinson, Macdonald - Maternal mortality and severe acute morbidity in the Pretoria Region (1/2/97-31/1/99). Report to Gauteng Health Department).
A lack of intensive care facilities, beds, equipment and personnel was found to be a factor in 15.6% of cases where mothers died in tertiary institutions. This is also probably an underestimate of the magnitude of the problem because it is not known in how many cases doctors from Level 1 and 2 hospitals wanted to refer patients but were informed that there was no ICU bed available and to try other hospitals. Mantel et al., found an association between the availability of ICU beds and the conversion from severe maternal morbidity to mortality (Mantel, Pattinson, Macdonald - Maternal mortality and severe acute morbidity in the Pretoria Region (1/2/97-31/1/99). Report to Gauteng Health Department). A lack of availability of blood transfusion facilities was found in 11.7% of cases that required urgent blood transfusions.
Lack of personnel was rarely mentioned as an avoidable factor. This may be due to an adequate supply of staff; health workers at the institution not thinking of inadequate staffing because they have become so used to the shortages that it regard it as normal; or lack of information available to the assessor for them to allocate it as an avoidable factor.
While assessing the cases the assessors were requested to also look at the standard of routine care (See Appendix, Table A10). They were asked to assess the care of the women before and apart from the event that ultimately led to her demise occurred. Obviously there was more information in women during their antenatal period than intrapartum and postpartum. This may be a biased sample and the care may not reflect that which occurred in women who did not die. However, the major problems that were identified were poor problem identification (12.4%), delayed or lack of referral of problems (16.2%) and not following standard protocols (16.2%) all at the primary level of care. Similar problems occurred at primary and secondary levels of care during the intrapartum period. During the postpartum period, two problems stood out, namely infrequent, incomplete or prolonged abnormal observations without action (15%) and inappropriate discharge from hospital (14%). This may indicate a general feeling that once the baby has been delivered no problems will be experienced.
Management of the emergency event revealed problems in the care in more than half the cases. This was especially the case at the primary level with there being problems in almost three quarters of cases managed for some part of their care at a level 1 care (Table 1.2). More than half the cases managed at the level 2 care for some part of their care also had problems. Assessing the patient was done poorly in level 1 (53 cases) and level 2 (60 cases) and better at level 3 care (13 cases). Similar data emerged for making a diagnosis or a problem list (52, 64 and 15 cases respectively). The wrong diagnosis was made in 22 cases at level 1, 38 cases at level 2 and 8 cases at level 3. The standard protocol was not followed in 84 cases at level 1, 50 cases at level 2 and 20 cases at level 3. Unfortunately, a reliable denominator could not be established for the levels of care because of the referrals between levels and patients entering level 2 or 3 without passing through level 1 or 2. (Details are shown in the Appendix, Tables A13 and A14).
Problems in the initial assessment of the case i.e. taking a history and examining a case and in problem identification i.e. making a diagnosis or making a list of problems was especially poor at the secondary level of care. The major problems in the management related to not following the standard protocols for the management of the conditions (39% of cases) and wrong diagnosis (13% of cases). It is not known whether this is due to ignorance or "laziness" on the part of the staff. There was a delay in referring patients or they were managed at an inappropriate level of care in 18.4% of cases. This may represent problems in transport, problems in appreciating the severity of the condition or not having an identified referral hospital that will accept the patient. This is discussed in detail in Chapter 2. In more than a quarter of cases, observations after the emergency event were done infrequently or incompletely, or there were prolonged abnormal observations without any action (25.3% of cases). It is not known what the reason for this is. It could be due to the lack of staff, or due to laziness on the part of the staff. Almost a third of cases had an anaesthetic at some point in the course of their management, and in 25.3% of cases having an anaesthetic, it was assessed that there was some form of substandard care.
Unprofessional conduct occurred on a few occasions. The most common problems were not attending patients when called or daily (26 cases) and not performing observations when prescribed (24 cases). (See Appendix, Table A12).
Motivation. From the subject chapters it is clear that many health workers are not following standard protocols. It is not know whether this is due to ignorance or laziness. By ensuring protocols are available and promoted, ignorance should no longer be a factor. (See chapters 3-10)
Motivation. Delay in referral or managing patients at inappropriate institutions is a common avoidable factor. Lack of clear referral criteria, sites where to refer and resistance by the receiving hospital to accept patients are possibly responsible for these avoidable factors. (See chapters 2-12)
Motivation. Poor monitoring of women has been identified as a common avoidable factor. It is not known whether this is due to inadequate staffing and equipment or due to laziness on the part of the staff. Without clear norms it will not be possible to assess where the problem lies. (See chapter 2-12).
Motivation. The majority of deaths due to abortions occur in the second trimester and are often the result of interference by the woman herself or a non registered person. (See chapter 5).
Motivation. Lack of use of the partogram was clearly illustrated as a major avoidable factor in women dying as a result of puerperal sepsis and postpartum haemorrhage. The use of the partogram allows for early identification of prolonged labour and timely intervention. (See chapters 4 and 6).
Motivation. The availability of emergency blood for women with obstetric haemorrhage is life saving. In 11.7% of maternal deaths where a blood transfusion was urgently required, it was not available. The excess of deaths at level 1 hospitals due to obstetric haemorrhage is in part due to the lack of blood. (See chapter 4).
Motivation. Cardiac disease in pregnancy is a major cause of maternal deaths. The woman with a heart lesion has often been mismanaged by the health workers managing the pregnancy. By establishing these clinics, these women should not slip through, and their management could be more expertly performed. (See chapter 10).
Motivation. Anaesthetic accidents are an important preventable cause of maternal deaths, and occur most commonly in the Level 1 hospitals. Lack of training and infrequent use of regional anaesthesia probably contribute to these deaths. (See chapter 7).
Motivation. Women 30 and over and with 5 or more children are at significantly greater risk of dying during pregnancy, labour and the puerperium. (See chapter 2).
Motivation. AIDS is the second most common cause of maternal deaths in South Africa. A clear policy needs to be established on managing AIDS as this has enormous implications for the allocation of scarce resources. Many women with AIDS are managed at tertiary institutions using resources that might be better used on women with a better prognosis. Medical personnel are very reluctant to take such positions and the debate needs to be opened to allow for consensus to be established. (See chapter 9).
The NCCEMD wishes to emphasise the following points:
Public health education can play a major role in preventing maternal deaths. Antenatal education should be part of every health education programme that deals with reproductive health issues.
The reporting of every death that occurs during pregnancy, labour and the puerperium is essential so that an accurate MMR can be obtained and progress in preventing maternal deaths can be ascertained. All health workers are encouraged to report all these deaths. They are reminded that failure to report a maternal death is regarded as professional misconduct by the Health Professions Council.
The Health Professions Council will be requested to give additional Continuing Profession Development (CPD) points to medical practitioners who attend training programmes designed to reduce maternal mortality. Using this positive encouragement it is hoped that the standard of care of all doctors dealing with pregnant women can be improved.