Mpumalanga is the seventh largest province and is mainly rural in nature. The province is divided into three regions (Highveld, Eastern Highveld and Lowveld) for the purposes of assessing cases. The pattern of disease is shown in Table 12e.1. The province lacks a level 3 hospital, and tertiary referrals are sent to the Pretoria Region of Gauteng Province. If these deaths are included, complications of hypertension are responsible for 31% of all deaths and 40% of direct deaths. This is clearly the most pressing problem in Mpumalanga.
Transport between health institutions was a major problem in the province, occurring in 38% of cases transported. This may be an underestimate as the majority of deaths occurred at level 1 hospitals. Was this because no transport was available for patients, there was no hospital to refer patients to, or the doctors did not think of transferring patients. The latter may be the case as 22% of maternal deaths were thought to have been managed at the wrong institute. However, this may be simplistic and the MCWH unit will need to determine the real causes of this phenomenon.
Missed diagnosis (22%), not following the standard protocol (44%) and poor monitoring of patients (36%) of maternal deaths in the province were the major health worker-related avoidable factors. The reasons behind this is not clear but may be due to a lack of knowledge or a lack of staff.
Difficulties were also experienced in collecting maternal deaths, due to delay in notifying cases, folders getting lost in health institutions, poor completion of the maternal death notification form, sometimes by the most junior member of staff and lack or minimal involvement of the private sector. Despite these problems the province performed well in getting the process instituted throughout all its health districts.
Provincial guidelines and protocols for managing emergency conditions are urgently required. These will need to be disseminated throughout each health institution dealing with pregnant women. Protocols dealing with complications of hypertension will need to be addressed first.
Referral patterns and criteria for referral will need to be negotiated between the districts and regions. An agreement on the priority conditions of pregnant women requiring transport will need to be established with the ambulance services. The lack of a tertiary hospital is a problem, and Witbank Hospital should be considered as the staging post for patients being referred to Gauteng requiring tertiary management.
A skills and human resources audit of each health institution should be considered to gain a greater understanding on the reasons for the poor monitoring.
The District MCWH Co-ordinators should attend maternal and perinatal mortality meetings in their districts and where they do not exist, begin the meetings. This will encourage better reporting of deaths and facilitate feedback to the institutions.