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