Maternal Mortality Maternal Mortality Review Review Lessons learned in Lessons learned in South AfricaSouth Africa
RE MHLANGARE MHLANGA
Nelson R Mandela School of Nelson R Mandela School of MedicineMedicine
University of KwaZulu-Natal, University of KwaZulu-Natal, DURBANDURBAN
South AfricaSouth Africa
MATERNAL DEATHS – GLOBAL MATERNAL DEATHS – GLOBAL TRAGEDYTRAGEDY
Over 600 000 women die each year in Over 600 000 women die each year in the line of national duty for survivalthe line of national duty for survival
Very few concerns are raisedVery few concerns are raised Not a voice in protest can be heard Not a voice in protest can be heard
concerning these deathsconcerning these deaths Tsunami, KatrinaTsunami, Katrina In South Africa, over 1500 women die In South Africa, over 1500 women die
because they happened to be pregnantbecause they happened to be pregnant
Maternal deaths – lessons from reviewMaternal deaths – lessons from review
WHY INVESTIGATE?WHY INVESTIGATE?
Why do women continue to die?Why do women continue to die? CEDAW, Safe Motherhood InitiativeCEDAW, Safe Motherhood Initiative World Summit Goals, ICPD, Beijing POAWorld Summit Goals, ICPD, Beijing POA Free health care – pregnancy, children < 6 Free health care – pregnancy, children < 6
yrsyrs UN Convention on the Rights of the ChildUN Convention on the Rights of the Child
Magnitude of maternal mortality unknownMagnitude of maternal mortality unknown
Associated factors unknown, not investigatedAssociated factors unknown, not investigated Need for monitoring and evaluation of Need for monitoring and evaluation of
interventions interventions
Maternal deaths – lessons from reviewMaternal deaths – lessons from review
Task teamTask team Pilot project over six monthsPilot project over six months Maternal death notification form – user Maternal death notification form – user
friendlyfriendly Orientation and advocacy for maternal Orientation and advocacy for maternal
death notificationdeath notification Collating data and producing reportCollating data and producing report Making recommendationsMaking recommendations Monitoring implementationMonitoring implementation
MDR - lessonsMDR - lessons
Community mobilisation - political buy-inCommunity mobilisation - political buy-in Identification of cases, notification and Identification of cases, notification and
reportreport Development of guidelinesDevelopment of guidelines Oversee processOversee process Strengthening of health system - capacityStrengthening of health system - capacity Monitoring of implementation of Monitoring of implementation of
recommendationsrecommendations Partnerships – signing from the same pagePartnerships – signing from the same page Feedback to policy makers - strengthen buy-Feedback to policy makers - strengthen buy-
inin
The maternal The maternal mortality surveillance mortality surveillance cyclecycle
Identify cases
Recommendations for action
Collect information
Analyse the results
ImplementEvaluate and refine
Key principle: ConfidentialityKey principle: Confidentiality
No namesNo names
Confidentiality assuredConfidentiality assured
No blameNo blame
Not used for litigation or punitive actionNot used for litigation or punitive action
Staff are reassured.Staff are reassured.
Maternal deaths – lessonsMaternal deaths – lessons
Looking at wrongs and mistakesLooking at wrongs and mistakes Human resourcesHuman resources Budget for increase in challengesBudget for increase in challenges Challenges change in timeChallenges change in time HIV and malnutrition change thingsHIV and malnutrition change things Recommendations, not a wish-listRecommendations, not a wish-list Strategy for implementationStrategy for implementation Indicators for monitoring Indicators for monitoring
implementationimplementation
Looking at wrongs and Looking at wrongs and mistakesmistakes
Facility Facility Meeting of the team – no blameMeeting of the team – no blame Check with guidelines or protocols of MxCheck with guidelines or protocols of Mx Filling of maternal death notification formFilling of maternal death notification form
ProvincialProvincial Completeness of informationCompleteness of information AssessmentAssessment
NationalNational Quality, causes and avoidable factorsQuality, causes and avoidable factors
Maternal Deaths – lessons Maternal Deaths – lessons
GUIDELINES: HYPERTENSIVE DISORDERSGUIDELINES: HYPERTENSIVE DISORDERS Antenatal diagnosis and managementAntenatal diagnosis and management Timely deliveryTimely delivery Management of emergencies – eclampsia, Management of emergencies – eclampsia,
assoc. abruptio placentaeassoc. abruptio placentae Mag. sulphate regimeMag. sulphate regime High careHigh care Follow-upFollow-up
Reducing Maternal DeathsReducing Maternal Deaths
HAEMORRHAGEHAEMORRHAGE Antenatal Antenatal prevention of anaemiaprevention of anaemia Identification for active management of 3Identification for active management of 3rdrd stage stage
of labourof labour Skilled intervention – midwives, doctors, Skilled intervention – midwives, doctors,
specialistsspecialists Community management of postpartum Community management of postpartum
haemorrhage – haemorrhage – abdominal aorta compressionabdominal aorta compression by by lay peoplelay people
Institutional - Institutional - condom/balloon methodcondom/balloon method, advanced , advanced surgical intervention, selective embolisation, surgical intervention, selective embolisation, sub/total hysterectomysub/total hysterectomy
Blood supply, transportBlood supply, transport Guidelines and protocolsGuidelines and protocols
Challenges change in timeChallenges change in time
HIV and complicationsHIV and complications Impact on staff and inevitability of Impact on staff and inevitability of
deathdeath Increase work loadIncrease work load Brain drain or lootingBrain drain or looting Need for midlevel workersNeed for midlevel workers
Primary obstetric cause of reported maternal deaths: 1998-2001 Numbers
0
50
100
150
200
250
300
350
HT PPH APH EPL PRS AA AC NPRI (AIDS) MD Unk
1998
1999
2000
2001
Levels of care where maternal deaths due to accidents of anaesthesia occurred: 1998-2001
0
10
20
30
40
50
60
70
80
1998 1999 2000 2001
Level 1 Level 2 Level 3
BUDGET and HUMAN RESOURCESBUDGET and HUMAN RESOURCES
• HIV added needs for material, financial HIV added needs for material, financial and human resourcesand human resources
• Training and retrainingTraining and retraining• Accommodation Accommodation • Time Time • Revitalization of staff, assessorsRevitalization of staff, assessors• Preparedness and transparencyPreparedness and transparency
Maternal deaths – lessons from reviewMaternal deaths – lessons from review
• Unexpected outcomesUnexpected outcomes• Commitment to address the associated Commitment to address the associated
factorsfactors• Perinatal healthPerinatal health• Increased funding for women’s health – Increased funding for women’s health –
change in approach to women’s healthchange in approach to women’s health• Millennium Development GoalsMillennium Development Goals• Stigma of HIV invades health workers and Stigma of HIV invades health workers and
professionalsprofessionals• Care to countCare to count• Behind numbers are faces and shattered Behind numbers are faces and shattered
liveslives
Let us commit ourselvesLet us commit ourselvesTo women care, safety and concernTo women care, safety and concern
One death is one death too manyOne death is one death too manyLet us find out what went wrongLet us find out what went wrong
And correct the mistakes we have madeAnd correct the mistakes we have made
We must do what we have to doWe must do what we have to doEVERY MOTHER AND CHILD COUNTSEVERY MOTHER AND CHILD COUNTS
It is all about moving people’s heartsIt is all about moving people’s heartsCommitment starts with meCommitment starts with me
THANK YOUTHANK YOU
An unarmed armyAn unarmed army
In the face of tragedy, we decided to look awayIn the face of tragedy, we decided to look awayIn the hour of need, we chose to seal our earsIn the hour of need, we chose to seal our earsThe wind blew, and the petals flewThe wind blew, and the petals flewAnd the seed was not to beAnd the seed was not to be
The army marched on an empty stomachThe army marched on an empty stomachAn army unarmed, an army forcedAn army unarmed, an army forcedThey stumble and tumble by the hundredsThey stumble and tumble by the hundredsHardware of war we shall buyHardware of war we shall buyWhile the army we shall starveWhile the army we shall starve
Whose war is it; whose struggleWhose war is it; whose struggleIt is national duty, it is national responsibilityIt is national duty, it is national responsibilityA person is a person through othersA person is a person through othersA person is a person through her motherA person is a person through her mother
Do we not owe the armyDo we not owe the armyRecognitionRecognitionDo we not owe the armyDo we not owe the armyMeans of transportMeans of transportDo we not owe the armyDo we not owe the armyLoyalty and supportLoyalty and support
Let us join handsLet us join handsEach of us contribute to the greater goodEach of us contribute to the greater goodOf women and children.Of women and children.If we seek to save ourselves onlyIf we seek to save ourselves onlyWe shall all but perishWe shall all but perish
I am sorry I was not there to respond to your cryI am sorry I was not there to respond to your cryI was not there to stop the abuse, the blood, the painI was not there to stop the abuse, the blood, the painBut, I shall always remember youBut, I shall always remember youAs I look into the mirror and see myselfAs I look into the mirror and see myselfI am because you were, because you are.I am because you were, because you are.
Pass it on ….Pass it on ….
““If you live for yourselfIf you live for yourself
You’ll live in vain,You’ll live in vain,
(But if you) live for others(But if you) live for others
You’ll live again…”You’ll live again…”
Bob MarleyBob Marley