Chapter 12c. Gauteng Province

Gauteng Province is the second most populous province according to Census 96, but also geographically the smallest. It is regarded as the economic powerhouse of South Africa, and is the most densely populated province. The province is divided into 5 regions as shown in Table 12c.1. The province has three medical schools and provides tertiary medical services for Mpumalanga, Northern Province and North West Province. Thirteen of the deaths reported came from other provinces. The tertiary hospitals are in the Central Wits and Pretoria Regions. East Rand, Vaal and West Rand refer to Central Wits and other provinces, notably Mpumalanga and North West refer to the Pretoria Region. The MMR was calculated as 67.4 per 100000 live births (excluding referrals from other Provinces).

Avoidable factors, missed opportunities and substandard care are shown in Tables 12c.3-5.

Problem areas identified by the Gauteng Assessors were the following:

  1. Sub-standard care identified from the case reports of the Gauteng Province maternal deaths included:
  1. Poor initial patient assessment and problem identification/diagnosis formulation were responsible for 66% (25/38) and 74% (28/38) of cases respectively, who were managed at a level 2 (regional hospital) facility. The equivalent percentages at level 3 hospitals were 12% (9/77) and 13% (10/77) respectively.
  2. An inappropriate management protocol (because the diagnosis was incorrect) was found more frequently amongst pregnant women managed in a level 2 facility (42%) compared to those dying at a level 3 facility (6%). A standard of acceptable management protocol was not followed (where the diagnosis was correct) in 39% of the level 2 women compared to 12% of the level 3 managed women.
  3. Monitoring of these very ill women was either not done, done infrequently or incompletely, or abnormal monitoring results were not reacted to in 32% (35/110) of maternal deaths in the province.
  4. Problems with resuscitation were identified in 27% (21/77) of maternal deaths where a resuscitation attempt took place and was recorded. These problems of basic resuscitation were particularly relevant to cases of hypovolaemic shock in abortion, postpartum haemorrhage and uterine rupture. In a further 22 cases, no information was available on the resuscitation attempt.
  1. Problems of defining what cost-effective investigation is and care of a pregnant woman with AIDS.
  2. Assessors experienced difficulties in assessing the influence of busy labour wards, queues for emergency caesarean section, and staffing shortages, particularly due to absenteeism, on patient care.
  3. Lack of health care facilities was found to have contributed to the maternal death in 25% of assessable cases (25/101), mainly a lack of adequate numbers of intensive care beds (12 cases), poor laboratory facilities (4 cases) and lack of, or defective equipment (2 cases each).
  4. Deaths related to abortion were the third commonest cause of maternal death in Gauteng, and relate mainly to the lack of second trimester termination of pregnancy services in Pretoria.
  5. Problems of anaesthetic-related maternal deaths while under regional anaesthesia.
  6. Difficulties with gaining access to medical notes of cross provincial border referrals, e.g. from Mpumalanga to Gauteng, with the woman dying in Gauteng. Similarly, lack of medical notes on maternal deaths occurring in the private and military sectors.
  7. Referral and transport problems were identified for the critically ill patient presenting at a primary health care facility. There were problems bypassing the secondary facility, and hence wasting precious time, to get the patient to a tertiary facility.

The solutions put forward by the Province are as follows:

  1. SUB-STANDARD CARE:

  1. ASSESSMENT and DIAGNOSIS: Fire-drills on the management of severe pre-eclampsia, eclampsia, antepartum- and postpartum haemorrhage, abortion, ectopic pregnancy and the recognition of sepsis are needed at every level of care, but particularly at regional hospital level. There needs to be feedback to all the medical schools about problems with initial assessment of ill patients, problem recognition and management protocols. The National Committee for Confidential Enquiries into Maternal Deaths should notify the Health Professions Council, who as the co-ordinators of the accreditation process (continuing professional development), can lay emphasis, give more points or make compulsory, certain medical education topics (such as those mentioned above).

  2. MANAGENT PROTOCOLS: As above

  3. MONITORING PROBLEMS relate to point 3 below, where if the standard staffing norm is not met, indicates that health care workers are overwhelmed with patients and cannot render an adequate level of care. If the standard staffing norm is met, health care workers are not doing their required job.

  4. RESUSCITATION PROBLEMS: This was fed back to the relevant institutions by the provincial MCWH directorate. The provincial MCWH directorate to investigate sponsoring for resuscitation courses.

  1. AIDS: Expert opinion in the province is being sought by the provincial MCWH directorate to determine treatment guidelines for pregnant women with AIDS.

  2. STAFFING: The National Committee for Confidential Enquiries into Maternal Deaths needs to ask the National Department of Health for basic normal standards for staffing, beds, and facilities as per patient load. If this standard is not met in a particular health institution, the health facility should be closed down. This is particularly relevant to regional hospitals.

  3. ICU BEDS: Need admission criteria to tertiary and ICU facilities.

  4. ABORTION-RELATED DEATHS: A separate report documenting the abortion-related deaths particularly in the Pretoria region has been presented to the Gauteng Health Department with a proposal that urgent budgetary adjustment, facility identification and staffing needed to bring such services onto immediate line.

  5. ANAESTHESIA: This was fed back to the relevant institutions by the provincial MCWH directorate with a proposal for an anaesthetic workshop. Academic departments and Independent Practitioner Associations will be approached for support by the provincial MCWH directorate. Continuing professional development (CPD) points can be used as motivation for practitioners to attend the workshops.

  6. PATIENT NOTES: This was referred to the National Committee for resolution. The national and provincial Departments of Health must enforce that medical & nursing notes always accompany patients when transferred between health care facilities.

  7. TRANSPORT: This was referred to the provincial MCWH directorate for a solution at the regional level. High level discussions took place between the provincial Department of Health and the ambulance service directorate.

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