Saving Mothers 2008-2010: Fifth report on the confidential enquiries into maternal deaths in South Africa

The report covers the maternal deaths that were reported to the NCCEMD secretariat by 15th April 2011, and that occurred in the triennium 2008-2010. The same definitions used in previous Saving Mothers reports were used in this report.

Key findings

• More maternal deaths were reported in 2008-2010 (4867) than in any of the previous years. The distribution of deaths between the provinces has remained the same.
• The institutional Maternal Mortality Ratio (MMR) has increased to
• 176.22/100000 live births from 151.77/100000 live births in 2005-2007 and the Institutional MMR increased at every level of care.
• The pattern of disease has remained similar to 2005-2007 report. In 2008-2010, the “big 5” underlying causes of maternal death were non pregnancy related infections (NPRI ): (40.5%, mainly deaths due to HIV infection complicated by Tuberculosis (TB), Pneumocystis Carinii Pneumonia (PCP) and other pneumonias), complications of hypertension in pregnancy (14.0%), obstetric haemorrhage (14.1%), pregnancy related sepsis (9.1%, includes septic miscarriage and puerperal sepsis) and medical and surgical disorders (8.8%). These five account for 86.5% of maternal deaths.
• The top three causes of maternal death NPRI, obstetric haemorrhage and hypertension) accounted for almost 70% of all deaths.
• HIV infection is the most common contributory condition. Almost 4 out of 5 women who died in pregnancy, childbirth or the puerperium were tested for HIV infection throughout South Africa. Of those tested 70% were HIV infected.
• Two thirds of the women with AIDS had respiratory complications namely TB (26.9%), PCP pneumonia (13.3%) and other non-specified pneumonia (26.7%). The second largest group of underlying causes in women with AIDS was meningitis (12.9%).
• The majority of HIV infected women who died were diagnosed in the antenatal period (52%), whereas the majority of these women (61%) died postnatally, giving a chance to health care workers to initiate treatment.
• Complications of antiretroviral therapy, although fairly rare, increased significantly in 2010 when compared with 2008 and 2009. Liver complications and Stevens-Johnson syndrome were the most common complications · Anaemia was a common contributory condition of maternal death. 42.9% of women who died and had their haemoglobin measured were anaemic.
• The reduction in deaths due to complications of hypertension in pregnancy reported in the 2005 -2007 report seems to have slowed down.
• The pattern of missed opportunities, avoidable factors and sub-optimal care has remained the same as in previous reports.
• Obstetric haemorrhage continues to be the most common avoidable cause of maternal death and appears to be increasing. Bleeding during and after caesarean section is the largest category and accounts for 26.2% of deaths due to obstetric haemorrhage. The majority of the haemorrhage during and after caesarean section occurs in district and regional hospitals.
• Complications of anaesthesia remain the most clearly avoidable deaths in this report.
• Maternal deaths due to obstetric haemorrhage and hypertension were thought to be possibly and probably preventable in 81% and 61% of cases respectively.
• Resuscitation was sub-optimal in 22% of cases where it was attempted and the cases had sufficient information to assess.
• Maternal deaths due to NPRI, obstetric haemorrhage and hypertension were the three biggest contributors to preventable maternal deaths, accounting for two-thirds of avoidable deaths · Preventing maternal deaths due to NPRI, obstetric haemorrhage and hypertension should have the highest priority

Key recommendations
The 2008-2010 report has clearly identified three conditions that contribute to the majority of preventable maternal deaths,  namely non-pregnancy related infections, obstetric haemorrhage and complications of hypertension in pregnancy. These conditions comprise 66.7% of the possibly and probably preventable maternal deaths.