How to save more mothers from dying during childbirth
South Africa’s sharp decline in maternal mortality was reversed during the worst two years of COVID-19. (Photo: Annie Spratt/Unsplash)COVID-19 temporarily reversed South Africa’s hard-won reduction in maternal mortality, but the death rate has now stabilised, and hopes are high that the downward trend will resume. However, if experts are right, we’re missing some crucial interventions that would further prevent what are avoidable deaths. Chris Bateman talks to some of the leading lights in the field.
If fewer mothers in South Africa are to die during childbirth, then primary healthcare workers must identify and refer high-risk pregnancies upwards far sooner, improve their “fire-drill” skills when deliveries go wrong, and educate their patients. District clinical specialists need to monitor and evaluate rural clinics and district hospitals for these interventions more regularly while concurrently upskilling nurses, junior doctors, and community healthcare workers (CHW’s) – and empowering women with information about pregnancy and co-morbidities like hypertension.
That’s the advice of Professor Jack Moodley, former chairperson of the National Committee on Confidential Enquiries into Maternal Deaths in SA (NCCEMD), and editor of ten Saving Mothers’ reports. Since 1999, seven of these triennial reports have been submitted by the South African National Committee for the Confidential Enquiries into Maternal Deaths (NCCEMD) to the Minister of Health along with recommendations on methods to reduce maternal mortality. The enquiry identifies challenges in the health system and makes recommendations for improvement.
Rise and fall
The committee, via an extensive network of provincial assessors, has documented the rise and fall of maternal deaths with the institutional Maternal Mortality Ratio (iMMR) reaching a peak of 189/100000 live births in 2009 and dropping below 100/100000 live births in 2019 for the first time since the start of the enquiry.
Moodley’s advice is backed by another maternal health veteran, Professor Justus Hofmeyr, of the Effective Care Research Unit at Wits University, who singled out quality of labour care as crucial. To this remedial list, he added the promotion of long-acting contraception uptake, (unintended pregnancies account for most maternal deaths), and improving early diagnosis and treatment of postpartum haemorrhage. Hofmeyr cited a finding that two thirds of full-term pregnancies in South Africa are unintended and one research study between 2015 and 2019 showing that sixty five percent of pregnancies in Southern Africa were unintended, with 36 percent ending in abortion.
According to Professor Sue Fawcus, current Editor of the Saving Mothers reports and Emeritus professor in the Department of Obstetrics and Gynaecology at the University of Cape Town, South Africa’s sharp decline in maternal mortality was reversed during the worst two years of Covid but stabilised in 2022. She and her team have “high hopes” that it will resume the downward trend. Their 2023 report is expected to be published in November.
She said access to antiretroviral medicines from 2010 for all HIV positive women was a major contributor to the reduction, as well as the ESMOE programme (Essential Steps in Managing Obstetric Emergencies), training and protocols. ESMOE is a skills-and drills programme developed in 2008 to train all maternity staff in South African conditions to combat the high rate of maternal deaths.
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National Department of Health spokesperson, Foster Mohale, cited as contributors to reduced maternal mortality a host of overarching national policies, including the Campaign on Accelerated Reduction of Maternal Mortality in Africa (CARMMA) strategy from 2012, the strengthening of the ESMOE programme, the prevention of mother to child transmission 2016 guidelines with improved HIV testing and antiretroviral therapy for all pregnant women, the Basic Antenatal Care Plus programme in 2017, updated maternity care guidelines in 2016, the safe Caesarean Section programme which accredited facilities as safe sites, the updated Management of Hypertension Disorders pregnancy guidelines (2019), the SA Maternal Perinatal and Neonatal health policy (2021), and the strengthening of HIV viral load monitoring and changes to antiretroviral treatment regimens for pregnant women.
According to Dr Sylvia Cebekhulu: NCCEMD Acting Chairperson, South Africa is one of the few countries in the world that has an assessment of individual deaths and implements the recommendations. However, the COVID-19 pandemic, “came when we least expected it, and South African women were not spared – its aftermath is still evident. We also lost a sizeable number of healthcare workers. It had both direct and indirect effects on our health system,” she said.
Compared to a 2019 baseline, maternal deaths increased by 30% in 2020 and 47% in 2021 but decreased to pre-pandemic levels in 2022, at just above 100 maternal deaths per 100 000 live births. The pandemic set back progress towards achieving the Sustainable Development Goal of a maternal mortality rate of below 70 per 100 000 live births by 2030, “but now we’re back on track, and hopefully great lessons are learned for the future”, Cebekhulu added.
In absolute terms, there were 1 234, 1 507, and 1 062 maternal deaths in 2020, 2021 and 2022 respectively, giving a three-year total of 3 803, which is greater than the 3 347 deaths reported in the previous three-year period (2017 to 2019).
Pivotal people
Moodley, who still helps collate maternal mortality data in KwaZulu-Natal where he consults at the University of KZN’s medical school in Durban, said the pivotal people in reducing maternal deaths were community health workers, district health specialists and family physicians. Family physicians could help reduce maternal mortality by, for example, identifying women who are at high risk of pregnancy complications.
Writing in the latest South African Journal of Science, Professor Bob Mash, head of the Division of Family Medicine and Primary Care at Stellenbosch University, said family physicians were one of the most underutilised solutions to many of the problems facing district level service delivery. Unlike other specialties that are limited to a particular organ or disease, family physicians are the only specialists qualified to treat most ailments and provide comprehensive healthcare for people of all ages — from newborns to seniors. The specialty was created in 2007, but only some two hundred doctors are registered, and training posts are limited with human resource policy documents, “misunderstanding the role of family physicians”, according to Mash.
Only a third of Family Medicine graduates had been retained in the public sector, while 10% had emigrated and 11% had stopped practicing medicine. Mash emphasised that the SA Academy of Family Physicians recommends a mid-term goal of one family physician at every district hospital, community health centre or sub district – requiring four hundred family physicians, (which would take more than 20 years at the current training rate.)
Hofmeyr agreed that family physicians would make a substantial difference but adds that a general strengthening of health services “such as transport, facilities, equipment and staff,” is needed to reduce maternal and infant deaths. He cited the lack of functional ambulances, paramedics, poverty-limited timeous private transport options, and properly equipped and appropriately staffed clinics and district hospitals. This, when combined with a healthcare workers ability and willingness to probe risk factors during any stage of pregnancy prior to birth – and enhancing their emergency obstetric skills during birth – would contribute to further lowering maternal mortality.
Continuous training
Moodley said a lot of research has led to recommendations and guidelines, “but we haven’t assessed whether they take place”. One of the things “left undone” is the strengthening of community interaction, particularly when it comes to women’s health.
“There’s been no discussion with communities in respect to family planning, contraception, and termination of pregnancies. Those things don’t seem to be conveyed to the community at large. Although we have community health workers, we don’t really assess the work they do and the messages they’re getting across,” he added.
He said it was a “two-way street”, and that the paucity of community feedback to healthcare workers made prioritising needs difficult. Imbizos (pre-arranged gatherings) during outreach clinics were particularly effective tool in initiating this dialogue.
Moodley said South Africa had excellent policies and guidelines on severe pre-eclampsia and eclampsia and, “although this advice is not given timeously, people are aware of what to do. The issue is not that we don’t do it, the problem is a lack of repetition. Doctors and nurses need to practice these things. We recommend doing fire drills for emergencies. What steps do you take? Can you assess quickly? Does the mother need intubation or not? Who should you call, what must you do?”
These were among the vital life-saving questions a birthing attendant should be able to answer – immediately.
“Our educational system needs to somehow ensure that interns and registrars have continuous training on those things, so it becomes drilled into them. People forget these things. GP’s and people in private practice should do this, even if they don’t see that many emergencies. What happens when they are doing sessions in hospitals or when they are on call?” he asked.
At a lower level of care, he said, healthcare professionals sometimes failed to clinically identify patients at risk of birth complications.
“For example, hypertension – if you have it chronically, you’re much more likely to get pre-eclampsia. Even if the patient tells them, they’re unlikely to refer them to a higher level of care,” Moodley said.
He singled out pregnant adolescents (19 years old and below) and women 35 years and older (more likely to be obese), as among the groups at the highest risk of birth complications.
“The other point is hospitals are busy. Seeing the problem is one thing, but having the time to provide the information to the patient is the bigger issue. We should spend more time talking to patients and more especially, communities – that’s a function of the community health workers,” he added.
Mohale said the five leading causes of maternal deaths were non-pregnancy related HIV-related infections, (NPRI’s), obstetric haemorrhage, hypertensive disorders of pregnancy, puerperal (postpartum) sepsis and medical and surgical conditions. (You can see Mohale’s full response to Spotlight here.)
“While poor health worker knowledge and skills contribute to maternal deaths, many other factors are at play,” he said.
NPRI’s were the most recent leading cause of deaths, primarily through late presentation and/or non-adherence to antiretroviral therapy, according to Mohale. He said non-attendance of antenatal care, delays in seeking healthcare by patients, (aggravated by health systems transportation issues), led to delays in diagnosis and care.
Of the 3 673 maternal deaths in the past three recorded years, 812 mothers had not attended antenatal care, while antenatal care attendance was ‘not known’ in an additional 277 cases, according to figures provided by Mohale.
He said updated National Department of Health Maternity Care guidelines were launched online in February this year (2024) with plans underway to create online training modules for healthcare workers. Printed versions would be distributed to far flung health districts with poor or no network connectivity.
All maternity facilities were obligated to ensure ESMOE training, including regular ‘fire drills,’ especially at primary care level where the rarity of conditions made doing emergency drills essential to maintain skills, Mohale concluded.