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Saving Mothers 2017 Annual Report) Contents Section Page Contents i Abbreviations ii Acknowledgements ii Foreword iii Summary and recommendations iv 1 Overview 2017 1.1. Introduction 1 1.2. Maternal deaths 2017: Comparison between DHIS and NCCEMD data 1 1.3. Maternal deaths, mortality ratios and trends 3 1.4. Underlying causes for 2017 and timing of emergency event and death 5 1.5. Comparison of underlying causes from 2011-2017 7 1.6. Comparison of underlying causes between provinces 9 1.7. Safe Caesarean delivery 14 1.8. Levels of care and mortality 15 1.9. Potentially preventable deaths 21 1.10. Avoidable factors, underlying causes and levels of care 25 1.11 Mortality ratios and level of care per province 30 1.12. Summary of findings 33 1.13. Conclusions and recommendations 34 1.14 Suggested recommendations per province 35 Appendices 1. Comparison of maternal deaths in DHIS and MaMMAS per district 39 2. Detail of underlying causes 2017 40 3. iMMR per district and province 2017 42 4. iMMR of provinces and districts ranked from highest to lowest 44 5. Number of health care professional avoidable factors per level of care 46 2 Progress report on reducing deaths associated with caesarean section 47 Appendices 1. Caesarean delivery and BLDACD CFR per province and district 58 2. Ranking of Caesarean delivery CFR per province 60 3. Ranking of CD CFR per district 61 4. Ranking of BLDACD CFR per province 62 5. Ranking of BLDACD CFR per district 63 6. Proportion of maternal deaths with CD due to BLDACD, per province and district 64 3 Managing Hypertensive Diseases in Pregnancy (HDP) 65 4 Monitoring and Evaluation of Basic Antenatal Care Plus implementation in 82 South Africa 5 Saving Mothers Report 2017: Report on key decisions taken by the National 90 Health Council; 6-7 December 2018 i List of abbreviations Abbreviation Meaning AA Anaesthetic related death AC Acute collapse AIDS Acquired Immune Deficiency Syndrome AF Avoidable Factors APH Antepartum haemorrhage ARV Antiretroviral drugs BLDACD Bleeding associated with caesarean section CEMD Confidential enquiries into maternal deaths CFR Case Fatality Rate CHC Community Health Centre C Primary health care clinic CD Caesarean Delivery Decl. Declined DIC Disseminated Intravascular Coagulation DH District Hospital EC Eastern Cape Ec Ectopic pregnancy Em Embolism EMS Emergency Medical Services EOST Emergency Obstetric Simulation Training ESMOE Essential Steps in Managing Obstetric emergencies FS Free State Gau Gauteng HAART Highly active antiretroviral therapy HCP Health Care Professional HG Hyperemesis Gravidarum HDP Hypertensive Disorders of Pregnancy iMMR Institutional Maternal Mortality Ratio KZN KwaZulu-Natal Lim Limpopo MD Pre-existing maternal disorders Misc. Miscarriage Mpu Mpumalanga MMR Maternal Mortality Ratio NC Northern Cape NCCEMD National Committee for the Confidential Enquiries into Maternal Deaths Neg. Negative NPRI Non-pregnancy related infections NNDR Neonatal death rate NW North West Province OH Obstetric Haemorrhage PCP Pneumocystis carinii pneumonia Pos. Positive PPH Postpartum haemorrhage PRS Pregnancy related sepsis PNMR Perinatal Mortality Rate RH Regional Hospital TH Tertiary Hospital TB Tuberculosis Unk. Unknown WC Western Cape Acknowledgements The NCCEMD would like to thank all the provincial assessors and the MCWH coordinators of all provinces and the National Department of Health’s MCWH Youth and Nutrition cluster for their hard work and cooperation in collecting and entering the data on maternal death ii Foreword In South Africa, the institutional maternal mortality ratio (iMMR) is approximately 134 deaths per 100 000 live births. This figure has declined considerably from a peak number of deaths recorded in 2009 when the iMMR was 188 per 100 000 live births. The National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD), the Ministerial committee which began reporting on deaths since 1998 estimated that approximately 60% of these deaths were potentially preventable. South Africa is one of a few countries in which maternal deaths are reviewed at an institutional health facility in a structured formation and the information (maternal death notification form) which includes demographic data, clinical data, avoidable factors and lessons learnt are sent to independent provincial assessors for further none biased assessment. The information is finally collated and detailed Saving Mothers report are published every 3 years. In between annual reports are provided with basic demographic information and a highlight a specific issue which has been identified. In addition these reports, identify lessons learnt and target ways to prevent other deaths. In this 2017 Annual Report highlights some positives and negatives. Deaths from non- pregnancy related infections fell considerably from a peak in 2009 by over 40% and was mainly due to the introduction of ARVs irrespective of the CD cell count; the rate of decrease in deaths from this cause seems to be levelling off. A considerable amount of effort has been put into decreasing deaths from Obstetric Hemorrhage and there has been a decline in 2017 albeit about a 2% decline. However a cause for concern has been a slight increase in preventable deaths from hypertensive disorders of pregnancy. It is hoped that there will concerted effort in decreasing these deaths by instituting guidelines for all levels of health care. The 2017 Annual report provides in detail interventions to be strengthened in 2019. These include the 5 Cs viz. C - Improve access to all forms of contraception particularly to those < 18years and those >35 years C - Strengthen access to and improve quality of antenatal care in particular history taking off previous history of preeclampsia, family history of hypertension and taking action on diagnostic findings such as slight elevations in blood pressure levels C - improve communication with communities regarding early booking for antenatal care and involve general practitioners, pharmacists to refer women who are found to be pregnant on urine pregnancy testing . C - Improve safe CD package including safe anesthesia package in all provinces C - “Quality of care“ improve attitudes of all health care professionals; train nurses and doctors on use of clinical protocols; strengthen use of DCSTs by exploring the best site in which they are placed (district office /regional hospital). Finally I would like to thank the Minister and all the provincial MECs for supporting the NCCEMD and producing a joint report to save mothers and babies lives in South Africa J MOODLEY Chair National Committee on the Confidential Enquiries into Maternal Deaths (Section 5 has the National Health Councils decisions on the Saving Mothers 2017 Annual Report) iii Summary and recommendations The HIV epidemic can be likened to a spring tide, the water or in this case HIV infections dominated everything; but as the tide changed (and as we have got on top of the HIV epidemic) the shore under water was revealed with rocks that were not visible before. Similarly with the receding deaths associated with HIV reducing we are left with new “rocks” and challenges. This is well illustrated in figure 1 below which looks at the proportions of potentially preventable deaths and their underlying causes. Figure 1. Distribution of potential preventable deaths 2008- 2017 35,0 30,0 25,0 20,0 NPRI OH Percent 15,0 HT M&S 10,0 5,0 0,0 2008-2010 2011-2013 2014-2016 2017 NPRI – Non-pregnancy related infections; OH – Obstetric Haemorrhage; HDP – Hypertensive disorders of pregnancy; M&S – Pre-existing medical and surgical conditions In 2008-2010 non-pregnancy related infections dominated the percentage potentially preventable maternal deaths, but it’s proportion has been greatly reduced making obstetric haemorrhage (OH) the most common potentially preventable death but this is now being challenged by hypertensive disorders in pregnancy (HT) as the challenges in dealing with OH are being solved. The priorities in ending preventable maternal deaths have changed as the low hanging fruit has been plucked and now HDP is of greatest concern. Further reductions in maternal deaths will require system wide interventions which are difficult to achieve. The main finding of the 2017 Saving Mothers Annual report are: • The decline in iMMR is plateauing • ARV programmes have been effective but need vigilance; sharp decline NPRI no longer happening; there is a need to explore reasons for this. • It is encouraging that there is an overall decrease in obstetric haemorrhage deaths but has not occurred in all provinces and still needs attention • Focus on reducing hypertension deaths needs to be highlighted with an action plan • Higher proportion avoidable deaths in district hospitals(DH) point to need for mentorship at this level and the improvement of emergency transport from this level to RH or PTH where the deaths tend to occur after referral. Non Pneumatic anti shock garments (NASG) and involvement of EMS is important for this. • There has been a 41.5% reduction in the iMMR of Provincial Tertiary Hospitals. The reason for this is not immediately clear, but there was a 2% increase in births and a 2% reduction in iv maternal deaths. Perhaps the enquiry into the functioning of the PTHs had an effect on their better functioning. • Lack of appropriately trained doctors and nurses continues to be the most frequently cited avoidable factor • Problems with inter-facility transport of ill patients has been reduced, but there is still a large problem with women getting from home to a health facility. Innovative ways of ensuring transport at all times from townships and rural areas need to be investigated. Community involvement is very important in this aspect, as are maternity waiting areas. • Concentration of high CFRs for CD and BLDACD in certain provinces illustrates serious inequities in maternal health care provision. It appears that these are also the provinces with the greatest reported incidents of “lack of appropriately trained staff” this needs to be explored further. It is known that some of the provinces with poorest outcomes have unacceptable deficiencies in numbers of specialists.
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