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Saving Mothers 2014-2016: Seventh Triennial Report on Confidential Enquiries Into Maternal Deaths in South Africa: Short Report

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Saving Mothers 2014-2016: Seventh Triennial Report on Confidential Enquiries Into Maternal Deaths in South Africa: Short Report Saving Mothers 2014-2016: Seventh triennial report on confidential enquiries into maternal deaths in South Africa: Short report Table of contents Title Page List of abbreviations iii Acknowledgement iv Foreword v Section 1 Introduction 1 Section 2 Confidential enquiries into maternal deaths for 2014-2016: 2.1 Key findings 2 2.2 Strategies for reducing maternal deaths 8 2.3 Assessment of provincial progress in reducing maternal mortality 13 2.4 The necessity of providing safe caesarean deliveries 21 2.5 Maternal age and iMMR per underlying cause 27 Section 3 3.1 A focus on non-facility deaths during pregnancy, childbirth and 30 puerperium in South Africa using vital registration data from 199-2014 3.2 The role of midwives in reducing maternal mortality 48 Abstracts and key recommendations on each common cause of maternal Section 4 56 death Non-pregnancy related infections 57 Deaths due to medical and surgical disease in pregnancy including 59 suicides Maternal deaths from obstetric haemorrhage 62 Maternal deaths due to hypertensive disorders of pregnancy 64 Early pregnancy loss 66 Pregnancy-related sepsis following viable pregnancies 68 Pulmonary embolus and acute collapse (cause unknown) 70 Anaesthetic related maternal deaths 72 Section 5 Conclusions and recommendations 74 Appendices 1. Detailed comparisons between provinces 77 2. Maternal deaths 2014-2016: Fact sheets for provinces and districts 84 3. Detailed maternal death data 2014-2016 97 Page | ii 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 CS Caesarean section Decl. Declined DIC Disseminated Intravascular Coagulation DH District Hospital EC Eastern Cape Ec Ectopic pregnancy Em Embolism EOST Emergency Obstetric Simulation Training ESMOE Essential Steps in Managing Obstetric emergencies FS Free State GP Gauteng HAART Highly active antiretroviral therapy HCP Healthcare Professional HG Hyperemesis Gravidarum HT Hypertension iMMR Institutional Maternal Mortality Ratio KZN KwaZulu-Natal Lim Limpopo MD Pre-existing maternal disorders Misc. Miscarriage MP 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 Obs. he 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 Page | iii Acknowledgements The NCCEMD would like to acknowledge and thank the Minister of Health, Dr Aaron Motsoaledi and Deputy Director-General: Programmes, National Department of Health: Dr Yogan Pillay, for their continued support. 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 deaths. The following experts we co-opted onto the NCCEMD to help with the analysis and interpretation of the data, the NCCEMD thanks them for their very valuable contribution: Proffs. Karen Sliwaand and John Anthony as well as Dr BaviVythilingum in “Deaths due to medical and surgical disease in pregnancy including suicides” Drs Sylvia Cebekhulu and Laura Cornelissen for the “Pregnancy related sepsis following viable pregnancies” NCCEMD Chairperson Prof. Jack Moodley Vice Chairperson Prof. Sue Fawcus Editor Prof. Robert Pattinson Members Dr Makgobane Ramogale-Zungu Dr Sibongile Desiree Mandondo Dr Marthinus Schoon Elgonda Bekker Prof. Christina Lundgren Dr Tonia Labanino Dr Neil Moran Dr George Mohobo Mothupi Prof. Priya Soma Pillay Dr Anthony Macneil Dr Edgar Mhlanga Sharon Slabbert Secretariat Drs Pearl Holele and Manala Makua Marakgodi Ellence Mokaba Joyce Mahuntsi Avhafani Mafunisa Page | iv FOREWORD The Saving Mother’s Reports (SMRs), as many would know are an analysis of data collected on each institutional maternal death provided by health facilities in South Africa. The SMRs are published triennially and disseminated to all hospitals, academic institutions and relevant professional bodies within the country. The analysis is done by members of the National Committee on Confidential Inquiries into Maternal Deaths; a Ministerial Committee consisting of experts in obstetrics, midwifery and anaesthesia with at least one representative from each of the nine provinces in the country. The SMRs are disseminated every three years and takes a tremendous effort by all members of NCCEMD. Therefore all members need to be thanked for their efforts in writing the various chapters in the report. The latest SMR (2014-2016) shows a continued fall in both the numbers and mortality ratios of institutional maternal deaths since the peak in the numbers of deaths in 2009. The reduction in maternal deaths is in the main due to changes the treatment programmes for HIV positive pregnant women. Changes in antiretroviral drug (ARVs) regimen have seen a decrease of almost 47 per cent in the numbers of deaths due to non- pregnancy related infections (mainly HIV deaths) from the numbers in 2011. More specifically changes in drug regimen has seen a fall in deaths from adverse antiretroviral (ARV) drug events from 130 (2011-2014) to 27 (2014-2016). Furthermore, the NCCEMD’s recommendations to focus on reducing deaths in specific categories such as Obstetric Haemorrhage has resulted in a 22 per cent reduction of deaths in this category. Major challenges, however, still remain and in the main these relate to quality of care, inter-facility transport, and knowledge and skills of health professionals; the quality of care is slowly improving but knowledge and skills is sometimes lacking. More effort needs to be put into respectful care and having a sense of being mindful. For the first time the NCCEMD has obtained more reliable information on “Home Deaths” and it appears that our post-partum care needs to be strengthened. Many of the women who died at home or those who return post- delivery in extremis may have been discharged too early. Finally, despite all the challenges faced by the NDOH, the minister of health needs to be thanked for making Women’s Health a priority issue. J MOODLEY Chair National Committee on the Confidential Enquiries into Maternal Deaths January 2018 Page | v SECTION 1: INTRODUCTION The Confidential Enquiries system of recording and analysing maternal deaths has been in operation since 1 October 1997. The first comprehensive report into maternal deaths in South Africa was published in October 1999, and dealt in detail with maternal deaths occurring during 1998. The second to sixth comprehensive reports covered the trienniums 1999-2001, 2002-2004, 2005-2007, 2008-2010 and 2011-2013. These reports all described the magnitude of the problem of maternal deaths, the pattern of disease causing maternal deaths, the avoidable factors, missed opportunities and substandard care related to these deaths and made recommendations concerning ways of decreasing the number of maternal deaths. This report gives the key findings of the 2014-2016 triennium and new information on maternal deaths occurring outside of health facilities. There is an interesting discussion on the role of midwives in preventing maternal deaths. There have been unacceptable delays in publishing the comprehensive report of 2011-2013 and the NCCEMD has decided that the chapter heads will write articles for journals instead of chapters for the report. In this way we hope to have the finding disseminated much quicker than previously. However, to ensure that the data is still available to those that want or need it, the tables that would be used in the chapters are given in the appendix at the end of this report. The definitions of underlying causes used in this report are the same as those used in the 2008-2010 “Saving Mothers” report. Data used in this report consist of the maternal deaths that occurred and were reported to the NCCEMD secretariat and were entered on the MaMMAS database before 15 May 2017. This cut-off date was selected to try and ensure most deaths were reported and entered into the MaMMAS database but still allow for a fairly rapid analysis of the data. Page | 1 SECTION 2.1 KEY FINDINGS 1. Reduction in mortality The number of maternal deaths continues to fall each triennium by 12.8 per cent from 2008- 2010 to 2011-2013 and 12.5 per cent from 2011-2013 to 2014-2016, and an overall reduction of 24 per cent from the peak in 2008-2010, an overall reduction of 1 152 from 2008-2010 to 2014-2016. 339 fewer deaths in 2016 than 2011 and 580 fewer maternal deaths than at the peak in 2009. 2. There has been a slight improvement in quality of care Potentially preventable deaths are defined as those assessed by the assessors as being possibly or probably preventable at the end of their assessment of the case. The iMMR for potentially preventable deaths decreased from 100 per 100 000 live births in 2008-2010, to 92.6 and then to 83.3 in 2011 in 2011-2013 and 2014-2016 respectively. This indicates a slow but steady decline in the number of potentially preventable deaths. Page | 2 3. There has been a reduction in deaths related to HIV infection and obstetric haemorrhage but no change in deaths due to hypertensive diseases in pregnancy There has been a 47 per cent reduction in NPRI and 22 per cent reduction OH and from 2011 to 2016 Increase of 14 per cent in same time in deaths due to hypertensive diseases in pregnancy 4. Provincial tertiary hospitals have the highest iMMR The iMMR in provincial tertiary hospitals is 160 per cent higher than regional and national central hospitals.
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