21 years of confidential enquiries into maternal deaths in South Africa : reflections on maternal death assessments

Abstract

Since 1999, seven triennial reports have been submitted by the South African National Committee for the Confidential Enquires into Maternal Deaths (NCCEMD) to the Minister of Health along with recommendations on methods to reduce maternal mortality. The committee, via an extensive network of provincial assessors, has documented the rise and fall of maternal deaths with the institutional Maternal Mortality Ratio (iMMR) reaching a peak of 189/100000 live births in 2009 and dropping below 100/100000 live births in 2019 for the fi rst time since the start of the enquiry. All provinces have shown a decline in the iMMR, with the Free State, KwaZulu-Natal, Mpumalanga, North West and Northern Cape halving their iMMR from their peaks. The enquiry documented the dramatic rise in deaths due to non-pregnancy related infections until 2008-2010 and a sharp decline from 2011-2013 deaths due in deaths. Consistently more than 90% of the women who died in this category were HIV positive, and the sharp decline is associated with the widespread availability and use of antiretroviral therapy. A decline in hypertensive disorders of pregnancy deaths from 2005-2007 after an early rise in 2002-2004 was observed and an increase obstetric haemorrhage deaths mostly due to bleeding during and after caesarean delivery, followed by a decrease from 2014-2016 once the problem had been identifi ed and addressed. Unfortunately, there has been a steady rise in early pregnancy deaths and deaths due to pre-existing medical and surgical conditions. Interventions contributing to the downward trends include the introduction of safe antiretroviral therapy regimens, the district clinical specialist teams (DCST), the scale-up of Essential Steps in Managing Obstetric Emergencies (ESMOE) training, BANC plus, the Safe Caesarean delivery programme, and the Hypertensive disorders of pregnancy (HDP) guidelines. The proportion of all deaths that were potentially preventable has declined steadily indicating a steady continual improvement in the quality of care, but the types of missed opportunities and sub-standard care have remained constant. The confidential enquiry into maternal deaths (CEMD) system in South Africa has been very useful in describing the causes of maternal death, both pathological and health system failures, and for suggesting effective interventions which were adopted in the National Department of Health’s Strategic Plans.