15 October 1999
For the first time in South Africa we can confidently say we know how many women are dying of maternal deaths or maternal mortality (the terms used to describe the deaths of women during pregnancy, childbirth and soon after childbirth). Now we even know for certain the causes of these deaths. This report focuses mainly on the findings related to the causes of maternal deaths.
In many developing countries maternal mortality is responsible for 20-25 percent of deaths among women of reproductive age. South Africa is no exception. Although there are still more deaths amongst Africans than White women. The recently completed South African Demographic and Health Survey shows a very high maternal mortality rate. For each 100 000 babies born alive each year 150 mothers die. Clearly this is a cause for concern, as many of these deaths are preventable.
The prevention of deaths related to pregnancy is a priority of our government. This commitment to the health of women is borne out by numerous government programmes including putting this Confidential Enquiry in place.
Why a Confidential Enquiry? - The main objective of the Confidential Enquiry into maternal deaths is to highlight weaknesses particularly within the health care system, and to understand better the underlying causes of these deaths so that we can respond directly to the problem and develop appropriate interventions. Previously it was not possible to determine to what extent our society was failing women when it came to child bearing, nor was it possible to identify what exactly was causing pregnancy-related deaths, or which deaths we could have been prevented.
The "Saving Mothers" report that we launch today, is the product of this Confidential Enquiry and goes some way to answering these questions. It is based on data from 676 women who died in South Africa from 1 January and 31 December 1998.
What then is causing our women to die during pregnancy? - Five major causes of death have been highlighted by this investigation:
Complications caused by hypertension (23.2%)
HIV/AIDS (14.5%)
Excessive bleeding during child birth i.e. obstetric haemorrhage (13.3%)
Infections that occur during pregnancy i.e. pregnancy related sepsis (11 9%),
and;
Other existing medical conditions (10.4%), mainly heart disease.
Indeed the Ministry and Department of Health are ensuring that guidelines, training and necessary facilities are available to prevent deaths due to these causes.
The Enquiry has shown us which women are at greater risk of dying from pregnancy or child bearing. It found that older women, especially women 30 years and older died more often than younger women. It also reports that women during their first pregnancy and women who had 5 or more pregnancies are at greatest risk. Other research has shown that physiologically a woman's body is most vulnerable in the very early and later stages of the reproductive period of her life. Deaths found more frequently amongst African women are indicative of the importance of social and economic conditions in promoting the health of women in general and pregnant women in particular.
These findings, ladies and gentlemen, confirm what we have suspected and what we will continue to emphasise in our health information messages not only to women but men too as this is not only a problem for women.
In almost half of all the maternal deaths reported there was an opportunity to prevent the death but that opportunity was missed. These are opportunities that health workers, communities and women themselves could have used very effectively, if we were paying sufficient attention to the plight of women.
Some women are not attending antenatal care, or delay seeking help, resulting in the most tragic of outcomes. Women must start attending antenatal care as soon as they are aware of their pregnancy, and we urge everyone to support women in making it possible for them to go to seek health care at the earliest opportunity.
We are concerned that women are dying from complications related to terminating pregnancies. The Enquiry found that 30% of women had attempted to self terminate their pregnancy without going to appropriate health care facilities. In response to this observation we have recently commissioned a study to investigate further why women continue to have unsafe even back street abortions when we have now made termination of pregnancy freely available precisely to avoid such complications. Once again we urge all South Africans to be aware of the challenges and pressures women face and support them in making the correct choices to improve their health and well-being.
Now turning to the health service we are disturbed to note that some women are not receiving the quality care we expect them to receive. Sometimes their conditions are not properly or promptly identified (12.4%), and sometimes there are unnecessary delays for women to be referred to appropriate facilities (16.2%). We have also noted that in some instances standard care practices are not being followed (16.2%).
We are attending to these problems in various ways and want to ensure that patients know their rights. I shall be taking firm measures where staff negligence is the main contributing factor for a maternal death.
Unfortunately ladies and gentlemen we are still facing problems related to inadequate resources and facilities - critical ingredients for providing good quality care. This Enquiry noted insufficient facilities in intensive care units (ICU) tertiary hospitals, which would contribute to our mothers dying (15.6% of cases). This finding is consistent with other studies, which also found that a lack of ICU beds was connected with the death of mothers.
Not having and using partograms, (the instrument used to properly assess how well labour is progressing), is also a major factor in women dying as a result of infection and excessive blood loss. The use of the partogram allows for early identification of prolonged or complicated labour and timely intervention. We intend to ensure that this monitoring tool is used, especially for women at greatest risk of complications during labour.
Another problem highlighted by the Enquiry is insufficient blood transfusion facilities. This often results in a shortage of blood to transfuse to women who may require it. In fact almost 12% of maternal deaths in 1998 were directly related to this problem. We are currently reviewing our laboratory services and seeing how to strengthen our blood transfusion services.
The Primary Health Care package, which outlines what must be available at each level of care, will go some way in ensuring that at each level where a women goes into labour, there is a basic infrastructure, and that emergencies can be managed speedily and appropriately.
In conclusion "Saving mothers" highlights some strengths but also concerns for aspects of our health care delivery system. The high rate of deaths of South African mothers during pregnancy and child birth is clearly not due to a lack of knowledge on how to manage severely ill pregnant women. Our challenge now is to focus our energies on every possible strategy and mechanism to prevent any death of women in pregnancy.
We are pleased to say that the Ministry of Health, Department of Health and other stakeholders are already implementing numerous strategies - training health workers, strengthening staff support, refining health messages, providing more clinics, ensuring that the quality of the care we provide is improved and redistributing our financial and human resources. These measures amongst others, we believe will ensure that preventable deaths no longer occur.
I would like to thank the National Committee on Confidential Enquiries into Maternal Deaths of South Africa for this report, the recommendations and most importantly for pro-actively following up on each maternal death to seek out and correct identified problems. This report marks the beginning of an extremely concerted effort and battle to promote the health of women
Finally, I would like to urge all South Africans to take responsibility for the death of women and enable them to live in environments, which are safe, free of abuse, and where the right of motherhood and childbearing can be exercised safely and freely.