Maternal Mortality Review
Lessons learned in South Africa
RE MHLANGA
Nelson R Mandela School of Medicine
University of KwaZulu-Natal, DURBAN
South Africa
MATERNAL DEATHS – GLOBAL TRAGEDY





Over 600 000 women die each year in
the line of national duty for survival
Very few concerns are raised
Not a voice in protest can be heard
concerning these deaths
Tsunami, Katrina
In South Africa, over 1500 women die
because they happened to be
pregnant
Maternal deaths – lessons from review
WHY INVESTIGATE?
Why do women continue to die?
 CEDAW, Safe Motherhood Initiative
 World Summit Goals, ICPD, Beijing POA
 Free health care – pregnancy, children < 6 yrs
 UN Convention on the Rights of the Child
Magnitude of maternal mortality unknown
Associated factors unknown, not investigated
 Need for monitoring and evaluation of
interventions
Maternal deaths – lessons from review







Task team
Pilot project over six months
Maternal death notification form – user
friendly
Orientation and advocacy for maternal
death notification
Collating data and producing report
Making recommendations
Monitoring implementation
MDR - lessons








Community mobilisation - political buy-in
Identification of cases, notification and report
Development of guidelines
Oversee process
Strengthening of health system - capacity
Monitoring of implementation of
recommendations
Partnerships – signing from the same page
Feedback to policy makers - strengthen buy-in
The maternal mortality
surveillance cycle
Identify cases
Implement
Collect information
Evaluate and refine
Recommendations
for action
Analyse the results
Key principle: Confidentiality

No names

Confidentiality assured

No blame

Not used for litigation or punitive action

Staff are reassured.
Maternal deaths – lessons








Looking at wrongs and mistakes
Human resources
Budget for increase in challenges
Challenges change in time
HIV and malnutrition change things
Recommendations, not a wish-list
Strategy for implementation
Indicators for monitoring implementation
Looking at wrongs and mistakes
Facility
 Meeting of the team – no blame
 Check with guidelines or protocols of Mx
 Filling of maternal death notification form
Provincial
 Completeness of information
 Assessment
National
 Quality, causes and avoidable factors
Maternal Deaths – lessons
GUIDELINES: HYPERTENSIVE DISORDERS
 Antenatal diagnosis and management
 Timely delivery
 Management of emergencies – eclampsia, assoc.
abruptio placentae
 Mag. sulphate regime
 High care
 Follow-up
Reducing Maternal Deaths
HAEMORRHAGE







Antenatal prevention of anaemia
Identification for active management of 3rd stage of
labour
Skilled intervention – midwives, doctors, specialists
Community management of postpartum haemorrhage –
abdominal aorta compression by lay people
Institutional - condom/balloon method, advanced surgical
intervention, selective embolisation, sub/total
hysterectomy
Blood supply, transport
Guidelines and protocols
Challenges change in time





HIV and complications
Impact on staff and inevitability of death
Increase work load
Brain drain or looting
Need for midlevel workers
Primary obstetric cause of reported maternal
deaths: 1998-2001
Numbers
350
1998
1999
2000
2001
300
250
200
150
100
50
0
HT
PPH
APH
EPL
PRS
AA
AC
NPRI (AIDS)
MD
Unk
Levels of care where maternal deaths due
to accidents of anaesthesia occurred:
1998-2001
80
70
60
50
40
30
20
10
0
1998
1999
Level 1
2000
Level 2
Level 3
2001
BUDGET and HUMAN RESOURCES
• HIV added needs for material, financial and human
resources
• Training and retraining
• Accommodation
• Time
• Revitalization of staff, assessors
• Preparedness and transparency
Maternal deaths – lessons from review
•
•
•
•
•
•
•
•
Unexpected outcomes
Commitment to address the associated factors
Perinatal health
Increased funding for women’s health – change
in approach to women’s health
Millennium Development Goals
Stigma of HIV invades health workers and
professionals
Care to count
Behind numbers are faces and shattered lives
Let us commit ourselves
To women care, safety and concern
One death is one death too many
Let us find out what went wrong
And correct the mistakes we have made
We must do what we have to do
EVERY MOTHER AND CHILD COUNTS
It is all about moving people’s hearts
Commitment starts with me
THANK YOU
An unarmed army
In the face of tragedy, we decided to look away
In the hour of need, we chose to seal our ears
The wind blew, and the petals flew
And the seed was not to be
The army marched on an empty stomach
An army unarmed, an army forced
They stumble and tumble by the hundreds
Hardware of war we shall buy
While the army we shall starve
Whose war is it; whose struggle
It is national duty, it is national responsibility
A person is a person through others
A person is a person through her mother
Do we not owe the army
Recognition
Do we not owe the army
Means of transport
Do we not owe the army
Loyalty and support
Let us join hands
Each of us contribute to the greater good
Of women and children.
If we seek to save ourselves only
We shall all but perish
I am sorry I was not there to respond to your cry
I was not there to stop the abuse, the blood, the pain
But, I shall always remember you
As I look into the mirror and see myself
I am because you were, because you are.
Pass it on ….
“If you live for yourself
You’ll live in vain,
(But if you) live for others
You’ll live again…”
Bob Marley