The past 20 years have seen a significant drop in maternal mortality rates from 342 deaths to 211 per 100,000 worldwide. But every day more than 800 women around the world die from complications of pregnancy and childbirth, up to 42 days after giving birth. Most of these deaths are preventable. For every maternal death, another 20 women suffer serious injuries, infections and pregnancy-related disabilities. Professors Salome Maswime and Lawrence Chauke explain the state of maternal health in South Africa and how to improve it.
How South Africa compares to other countries
In low-income countries, the maternal mortality rate in 2017 was 462/100,000 compared to 11/100,000 in high-income countries. In Western Europe, rates are as low as five deaths per 100,000 births. Sub-Saharan Africa has 533 deaths per 100,000 births.
The risk of a woman dying from pregnancy-related complications was one in 5,400 in high-income countries, compared to one in 45 in low-income countries.
In West and Central Africa, the maternal mortality rate is 674 per 100,000. In South Sudan it is 1,150 and in Chad 1,140.
South Africa has one of the lowest rates in Africa (113/100,000) but much higher than the UK (7/100,000). The rate in South Africa has risen from 150 deaths per 100,000 births in 1998 to 113 per 100,000 in 2019, according to the South African Demographic and Health Survey and confidential national surveys of maternal deaths.
Maternal mortality factors in South Africa
The three leading causes of maternal death in South Africa are HIV-related infections, obstetric haemorrhages and hypertensive disorders of pregnancy.
Pre-existing medical conditions also account for a high proportion of pregnancy-related complications in South Africa. Most deaths are still considered preventable.
A significant number of South African women attend at least four antenatal clinics (76%) and deliver in health facilities (96%) under the care of a skilled birth attendant (97%). Ideally, these numbers should translate into a much lower maternal mortality rate. This means that there are still gaps and there is still work to be done.
The biggest challenge remains late booking. Only 47% of women booked during the first trimester in 2016. Between 2017 and 2019, 72% of women who died had attended antenatal care. But only half had booked before 20 weeks.
Delays in seeking prenatal care have been associated with a higher likelihood of having adverse pregnancy outcomes.
A very high percentage (90%) of South Africans live within 7 km of a health facility and 67% live within 2 km of a health facility. Despite this proximity, women struggle to get quick transport to health facilities. The situation is even worse for rural women due to poor road infrastructure and emergency referral systems.
Health facilities provide different levels of care. Most deaths occur in district hospitals in South Africa, where specialist services, intensive care or effective emergency medical services may not be readily available. Patients with complications do not reach higher levels of care in a timely manner.
Even when they have access to higher levels of care, women face a possible shortage of specialized medical and nursing staff, in addition to overcrowding.
A report from 2017 to 2019 found that 80% of women who died had received substandard care in district hospitals. This figure was 60% for community health centers and regional hospitals. Poor quality of care is therefore a major problem within the country’s health system. The same report identified overcrowding, lack of resources, including shortage of nursing and medical staff among the main drivers of poor quality of care.
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Disrespectful maternal care is also a problem. Abuse in South African maternity wards was described as “one of the world’s greatest disgraces” in 2015. It included verbal and physical abuse, non-consensual care, non-confidential care, neglect and abandonment. In some facilities, women said they expected to be yelled at, beaten and neglected.
Maternal mortality is an indicator of access to care and quality of care. It is also indirectly linked to socio-economic factors. Women who have access to education, adequate housing and employment opportunities are more likely to have good health outcomes than those who do not.
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Sociodemographic variables like “race” have also been linked to how women are treated.
Health workers’ attitudes towards patients impact women’s care-seeking behavior and health workers’ provision of care (even delaying and refusing care).
What can be done to improve the results?
The first step is to meet the need for contraception to avoid unwanted and unplanned pregnancies. In 2012, it was estimated that 215 million women worldwide had an unmet need for contraception.
Health education and promotion at the community level would encourage women to attend antenatal clinics and deliver in a health facility under the care of trained personnel.
Maternal care must be respectful and dignified.
Efficient transportation and emergency medical services are needed to ensure women receive timely and appropriate care.
Stronger health systems would improve access to high quality obstetric care. Women survive complications of pregnancy and childbirth in functioning health systems with effective referral systems. There is an urgent need for a responsive health system that takes into account demographic and disease trends.
There is also an urgent need to address the imbalance between demand and supply of health services; improve the social and economic status of women in society as well as the quality of maternal and reproductive health services, to win the battle against maternal deaths.