The Free State Province is the eighth largest Province and has a mixed urban, peri-urban and rural population. There is one level 3 hospital and it caters for the whole of the Free State and some parts of the Northern Cape.
The Obstetrics and Gynaecology Department at the University of the Free State initiated a maternal mortality project in 19971 and employed a midwife to tour the province to ensure that all health workers knew about the project and the notification of maternal deaths. A very effective network was established that also included the Government Mortuaries. There is a high level of confidence that all the deaths in the state health institutions were collected. The number of deaths outside the health services and in private hospitals is unknown.
The number of births in the province is unknown. The Official 1996 Census figures for the various regions in the province were used to make estimates of the number of deliveries. The number of babies less than 1 year old was adjusted with 35/1000 perinatal losses to determine the number of deliveries in the province. Reasonable information was obtained regarding the number of institutional deliveries in health regions A and B. This was compared to the estimated number of deliveries as calculated by the 1996 census figures. The number of deliveries in Regions A and B (including 10% estimate of home deliveries) correlated by a factor of 0.9607 by which the census-derived figures were adjusted.
The maternal mortality ratio (MMR) was calculated using the total number of pregnancy related deaths/estimated number of deliveries x 100 000. For the two years of the study the MMR was 135/100 000 deliveries1.
The pattern of disease is shown in Table 12b.1.
The avoidable factors, missed opportunities and substandard care are shown in Tables 12b.2-4. What is striking in the data is the number of cases that were not assessable. Patient-orientated factors could not be assessed in 44%, administrative factors in 31% and the management in the emergency event in 29% of cases. This is a clear indication of very poor note keeping.
The major patient-related problems experienced were non- or infrequent attendance at antenatal care and a delay in patients seeking help. There appeared to be few administrative problems. The major areas of substandard care related to health workers were delays in referral or managing patients at the inappropriate level of care (16% of cases), not following standard protocols or making the wrong diagnosis in 32% of cases and problems in monitoring patients in 21% of cases. It must be remembered that these might be a considerable underestimate of the problems, because a significant proportion of maternal deaths could not be assessed due to poor notes or absent files.
A pleasing finding is the low frequency (6%) in which poor transport between institutions was thought to play a role in maternal deaths.