By Yogan Pillay and Olive Shisana
Pregnancy and childbirth should be a joyous event, often long anticipated. Everyone involved should therefore ensure that pregnancies are planned and that everything possible should be done to ensure that women are healthy during their pregnancy and are able to have a safe and respectful delivery.
Deaths of women during pregnancy or childbirth therefore should always result in significant introspection, especially on the part of the health system.
South Africa has had high maternal mortality rates for decades. In 1998 it was estimated by the Demographic and Health Survey that of every 100 000 live births, 150 women died in childbirth.
The HIV epidemic, however, contributed to a massive increase in maternal deaths through the next decade and by 2010 it was estimated that 270 women died of every 100 000 live births. It should be noted that these data are estimates and try to reflect on all deaths (both in hospital and those that happen in communities).
The recently published report by Statistics South Africa suggests that the number of women who die in hospital during childbirth has reduced to 88 per 100 000 live births in 2020 from a high of 145 per 100 000 in 2012. This is good news even if these data, which only reflect deaths in public hospitals, do not include deaths that occur outside hospitals.
The report also reflects wide differences between provinces with the Western Cape (44) and Mpumalanga (67) showing the lowest number of deaths per 100 000. Provinces with the highest numbers are: Free State (116); Northern Cape (110) and Eastern Cape (108). These data also reflect not only resources available in the public health sector but also issues related to levels of poverty.
While these data reflect progress between 2012 and 2020. We know that the Covid-19 pandemic had a significant impact on a number of areas of life, including growing unemployment and limited access to health facilities, especially during the lockdown.
Recently published data in the South African Medical Journal shows that the number of pregnant women who died between March and December 2020 increased by 22.7%. Similarly, there has been an increase in teenage pregnancies during the past two years. Between 2018/19 and 2020/21 the percentage of deliveries among 10-14 year olds increased by 15% and that for 15-19-year-olds increased by 11%.
What have we done to reduce maternal deaths in the public sector over the last decade and what more needs to be done?
The major causes of maternal deaths are well known and include HIV associated deaths, deaths from bleeding either during or after delivery and pregnancy-related hypertension. The Department of Health has over the years put in place a range of interventions to address these causes of death. In 1999 the minister of health, in recognition of the high rates of maternal mortality, established a ministerial committee to evaluate each death and make recommendations on interventions – this committee continues to advise the current minister.
The acceleration of access to antiretrovirals since 2008 has contributed to the decrease in HIV associated deaths in pregnant women. Additional training of nurses and doctors working in maternity wards in dealing with obstetric emergencies since 2009 has improved skills and contributed to the decline in deaths.
Finally, based on research conducted in South Africa, and new guidelines from the World Health Organization, South Africa was one of the first countries to require eight antenatal visits from four to better address conditions that arise in the third trimester that contribute to poor maternal outcomes such as pregnancy-associated hypertension.
Whilst data suggests that the Covid-19 pandemic has reversed some of the gains made in the last decade, the declines in maternal deaths from many different data sources clearly show that the policies implemented by the Department of Health are working.
We can reach and surpass the Sustainable Development Goals target for 2030 of no more than 70 deaths per 100 000 live births. We are on the right track but we cannot let our guard down as shown by the impact of Covid-19 and we need to do more in the provinces that are still clearly lagging.
* Yogan Pillay, PhD (extraordinary professor, Stellenbosch University) and Olive Shisana ScD, (honorary professor, University of Cape Town)