Section A: Delivery - hst.org.za Health Barometers/4... · LP MP NC NW WC 75. Section A: Delivery. 4 elivery D . Nienke van Schaik. This chapter covers several aspects of maternal
Post on 12-Oct-2019
1 Views
Preview:
Transcript
Delivery in facility under 18 years rate by NHI district, 2013/14
Percentage
OR Tambo: DC15
uMzinyathi: DC24
G Sibande: DC30
Amajuba: DC25
Pixley ka Seme: DC7
uMgungundlovu: DC22
Vhembe: DC34
Eden: DC4
T Mofutsanyana: DC19
Dr K Kaunda: DC40
Tshwane: TSH
5 10
12.2
7.8
5.4
9.1
10.0
9.8
8.4
9.9
9.4
6.1
7.9SA average: 7.8
Target: 6.9ProvincesECFSGPKZNLPMPNCNWWC
Delivery in facility under 18 years rate by province, 2013/14
Percentage [Source: DHIS]
NC
EC
KZN
MP
LP
FS
NW
WC
GP
5 10
10.1
7.1
5.7
9.3
7.9
9.1
10.2
7.0
6.3SA average: 7.8
Target: 6.9 ProvincesECFSGPKZNLPMPNCNWWC
75
Section A: Delivery
4 Delivery Nienke van Schaik
This chapter covers several aspects of maternal health related to delivery as well as indicators of obstetric and intra-partum care. The following indicators are presented: delivery rate in facility under 18 years, delivery by Caesarean section rate, stillbirth rate in facility, inpatient early neonatal death rate, and maternal mortality in facility ratio.
The indicators represent what is happening at public health facilities in South Africa, as only a small number of private facilities provide data to be incorporated into the District Health Information Software (DHIS).
In 2013/14, the DHIS recorded 943 848 deliveries (3 547 less than in 2012/13), 230 479 Caesarean sections, 937 082 live births and 20 558 stillbirths.
4.1 Delivery rate in facility under 18 years
The delivery rate in facility under 18 years indicator measures the percentage of all deliveries that occur in women younger than 18 years. The numerator is the number of deliveries in women under 18 years of age, while the denominator represents all deliveries that have been recorded at health facilities in South Africa.
This outcome indicator is used as a proxy to track success in the prevention of teenage pregnancies. It also assists in tracking the improvements in maternal health as outlined in Millennium Development Goal 5b.
The delivery rate in facility under 18 years in South Africa was on the decline but showed a marginal increase from 7.7% in 2012/13 to 7.8% in 2013/14. Overall there were 74 070 women under the age of 18 who gave birth in South Africa in 2013/14. This was 1 166 more than in 2012/13.
Provincially, the highest delivery rate in facility under 18 years for the past year was in the Northern Cape (NC) (10.2%), followed by the Eastern Cape (EC) (10.1%) (see Figure 1). The lowest was in Gauteng (GP) (5.7%) even though there was an increase of 0.9 percentage points from 4.8% in the previous year. The rate declined in EC, Free State (FS), North West (NW) and Western Cape (WC). It was stable in KwaZulu-Natal (KZN) and Northern Cape (NC), and increased marginally in Limpopo (LP) and Mpumalanga (MP).
Figure 1: Delivery in facility under 18 years rate by province, 2013/14
DC6
DC7
DC8
DC10
DC5
DC36
DC39
DC1
DC16
DC13
DC19DC18
DC30
DC4
DC2
DC38
DC32
DC45
DC14
DC34
DC12
DC35
DC20
DC33
DC37
DC31
DC3
DC9
DC26
DC40
DC27
DC47
DC15
DC23
DC44
DC43
DC22
DC24
DC28
TSH
MAN
DC25
TSH
DC42
DC48 EKUJHB
Gauteng
LegendProvince
District
DELFCU18_20134.9 - 6.1
6.2 - 7.4
7.5 - 8.9
9.0 - 10.7
10.8 - 12.9
76
Section A: Delivery
The delivery rate in facility under 18 years at district level (see Figure 2) ranged from 4.9% in Ekurhuleni (GP) to 12.9% in Alfred Nzo (EC) which also had the highest rate in 2012/13. This district also has the second lowest couple year protection rate at 20.6%. Four of the five districts with the highest delivery rate in facility under 18 years are in the EC. The percentage of the population aged 10 to 17 years is higher than average in these districts, which may partially explain the higher percentage of delivery rates in young women.
Eight of the 11 NHI pilot districts had delivery rates in facility under 18 years higher than the national average. The rates varied from 5.4% in Tshwane (GP) to 12.2% in OR Tambo (EC).
Map 1: Delivery in facility under 18 years rate by district, 2013/14
Delivery in facility under 18 years rate by district, 2013/14
Percentage [Source: DHIS]
A Nzo: DC44Joe Gqabi: DC14
JT Gaetsewe: DC45OR Tambo: DC15Amathole: DC12
ZF Mgcawu: DC8uMkhanyakude: DC27
iLembe: DC29C Hani: DC13
Ugu: DC21Zululand: DC26
uMzinyathi: DC24Harry Gwala: DC43RS Mompati: DC39
Ehlanzeni: DC32G Sibande: DC30
Amajuba: DC25Pixley ka Seme: DC7
uThukela: DC23uMgungundlovu: DC22
Namakwa: DC6Frances Baard: DC9
West Coast: DC1Vhembe: DC34Overberg: DC3Mopani: DC33
eThekwini: ETHuThungulu: DC28
Eden: DC4Cacadu: DC10
T Mofutsanyana: DC19Cape Winelands: DC2
Sekhukhune: DC47Waterberg: DC36
Central Karoo: DC5Capricorn: DC35
NM Molema: DC38Fezile Dabi: DC20
Lejweleputswa: DC18Sedibeng: DC42Mangaung: MANNkangala: DC31
N Mandela Bay: NMAJohannesburg: JHB
Buffalo City: BUFBojanala: DC37
Dr K Kaunda: DC40Xhariep: DC16
West Rand: DC48Cape Town: CPT
Tshwane: TSHEkurhuleni: EKU
5 10
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
6.1
7.9
11.7
10.7
12.4
12.2
12.9
6.7
5.6
6.9
7.8
7.1
6.8 6.9
5.5
4.9
6.5
5.4
10.6
9.1 9.3
10.0
9.8
10.2
11.3
8.0
10.7
10.0
8.0 8.1
8.4
7.4
7.6 7.7
9.9
6.8
9.9
12.2
8.9
9.4
11.5
8.8
6.1
7.2
10.0
6.1
5.5
8.4
7.7
8.2
7.9
7.6
SA average: 7.8
Target: 6.9
ProvincesECFSGPKZNLPMPNCNWWC
77
Section A: Delivery
Figure 2: Delivery in facility under 18 years rate by district, 2013/14
78
Section A: Delivery
An overview of annual trends for the districts, grouped by province (see Figure 3), shows that there were downward trends in some provinces but that there was still a fair amount of fluctuation. Johannesburg (GP) was the district with the lowest rate in the previous year at 4.0% but this increased by 2.5 percentage points to 6.5% in 2013/14. Joe Gqabi (EC) and iLembe (KZN) also showed increases of 1.5 and 1.4 percentage points respectively. The largest declines were noted in Xhariep (FS) where the rate declined by 3.8 percentage points (probably linked to small numbers), Cape Winelands (WC) by 1.8 percentage points and Central Karoo (WC) by 1.4 percentage points.
The uptake of the sub-dermal contraceptive implant by teenagers may play a role in changing trends. The impact of the Integrated School Health Programme (ISHP), which promotes contraception use among youth and also seeks to address teenage pregnancy through supporting peer education and health promotion in schools, should be assessed.a
At DHB workshops conducted in 2013 and 2014, reasons mentioned for a high delivery rate in facility under 18 years included:
✦ a failure or lack of education through school health programmes;
✦ cultural issues including that one should have a child before marriage; and
✦ poverty.
The importance of access to family planning and education cannot be over-emphasised in order to further reduce the number of deliveries in women under the age of 18.
a South African National Department of Health. Status of Family Planning in South Africa: RMCH Fact Sheet 2013. http://www.rmchsa.org/wp-content/uploads/2013/08/Fact-sheet-Status-of-Family-Planning-in-South-Africa.pdf.
Annual trends: Delivery in facility under 18 years rate
Perc
enta
ge
0
5
10
15
EC FS
●●
●●
●
●
●
● ● ●●
●
GP
0
5
10
15
KZN
●
●●
● ● ●● ● ● ● ●
●
LP MP
0
5
10
15
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
NC
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
NW20
02/0
320
03/0
420
04/0
520
05/0
620
06/0
720
07/0
820
08/0
920
09/1
020
10/1
120
11/1
220
12/1
320
13/1
4
●
●
● ●
●●
●●
●
● ● ●
WC
EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC CacaduEC Joe GqabiEC N Mandela BayEC OR TamboFS Fezile DabiFS LejweleputswaFS MangaungFS T MofutsanyanaFS Xhariep
GP EkurhuleniGP JohannesburgGP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN Harry GwalaKZN iLembeKZN UguKZN uMgungundlovuKZN uMkhanyakudeKZN uMzinyathi
KZN uThukelaKZN uThunguluKZN ZululandLP CapricornLP MopaniLP SekhukhuneLP VhembeLP WaterbergMP EhlanzeniMP G SibandeMP NkangalaNC Frances BaardNC JT Gaetsewe
NC NamakwaNC Pixley ka SemeNC ZF MgcawuNW BojanalaNW Dr K KaundaNW NM MolemaNW RS MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast
●
●
●
79
Section A: Delivery
Figure 3: Annual trends: Delivery in facility under 18 years rate
Annual trends: Delivery in facility under 18 years rate by SEQ
Perc
enta
ge
0
5
10
15
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
SEQ 1
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●
●
●
●● ● ● ●
●●
●
SEQ 2
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
SEQ 3
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●
●
●
●
●
●
●
●
●
● ●
SEQ 4
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●
●
●
●
●
●
● ● ●
●
●
SEQ 5
1 A Nzo1 Amathole1 C Hani1 Harry Gwala1 Joe Gqabi1 OR Tambo1 RS Mompati1 Sekhukhune1 uMkhanyakude1 uMzinyathi1 Zululand2 Capricorn2 iLembe
2 JT Gaetsewe2 Mopani2 NM Molema2 Pixley ka Seme2 Ugu2 uThukela2 uThungulu2 Vhembe3 Amajuba3 Bojanala3 Cacadu3 Ehlanzeni3 G Sibande
3 T Mofutsanyana3 uMgungundlovu3 Waterberg3 Xhariep3 ZF Mgcawu4 Buffalo City4 Central Karoo4 Dr K Kaunda4 Eden4 Fezile Dabi4 Frances Baard4 Lejweleputswa4 Namakwa
4 Nkangala4 West Rand5 Cape Town5 Cape Winelands5 Ekurhuleni5 eThekwini5 Johannesburg5 Mangaung5 N Mandela Bay5 Overberg5 Sedibeng5 Tshwane5 West Coast
●
●
●
80
Section A: Delivery
Figure 4: Delivery in facility under 18 years rate by SEQ
81
Section A: Delivery
4.2 Delivery by Caesarean section rate
The delivery by Caesarean section (C-section) rate remains an important indicator of access to essential obstetric care and is one of the key maternal health indicators.
This indicator measures the percentage of deliveries in district hospitals that are done by C-section. The numerator is the number of C-sections conducted in the facility and the denominator is the number of deliveries that took place in that facility over the same time period. It is thus a facility-based and not a population-based indicator.
In the 2013 National Indicator Data Set (NIDS), which came into effect in April 2013, no specific target has been set for the C-section rate. In June 2010, the World Health Organization officially withdrew its previous recommendation of a 15 per cent C-section rate, stating that “There is no empirical evidence for an optimum percentage. What matters most is that all women who need Caesarean Sections receive them”.b
However, the perception in South Africa is that the C-section rate is too high and that this is a matter of concern.c Identifying the common indications for C-sections can lead to better understanding of the high rates of C-section and associations with morbidity and mortality which can lead to improvements in antenatal services and emergency obstetric care. A method for this has been suggested by the National Department of Health (NDoH) in their publication “Saving Mothers: Caesarean Section Monograph 2013”.d Bleeding during and after C-sections remains one the leading causes of maternal deaths due to obstetric haemorrhage. In 2012, 19 of the 230 maternal deaths (8.3%) due to obstetric haemorrhage were as a result of bleeding during C-section, and 62 of the 230 (27.0%) were due to bleeding after C-section.e
Variations in C-section rates lie in variations in thresholds for intervention both at an institutional and practitioner level, as well as variations in the models of care offered.f The variation in the C-section rate by level of care nationally is shown in Table 1 and in Figure 5.
The overall C-section rate for South Africa, based on all public sector facilities and a small number of private hospitals, was 24.4%, a 1.2 percentage point increase from 2012/13. In total there were 943 848 deliveries and 230 479 C-sections.
There were more data from private hospitals in 2013/14 than in 2012/13 with 73.9% of the 8 945 reported deliveries being C-sections. The C-section rate for public sector hospitals alone was 23.9%.
The majority of deliveries (80.5%) took place at hospitals (as compared to main primary health care or other facilities), as did all but 50 C-sections. At primary health care level, including district hospitals, community health centres, midwife obstetric units and clinics, 59.7% of deliveries took place.
Overall the highest absolute number of C-sections was at regional hospitals (84 919), followed by district hospitals (82 840), tertiary hospitals (30 180) and central hospitals (23 662), with the C-section rates being 36.4%, 21.8%, 39.6% and 42.8% respectively.
Table 1: Caesarean section rate by facility type hospitals, main PHC facilities and other facilities
Caesarean Section rateClassification Type C-Section
RateNumber of C-Sections
Total number of deliveries
Proportion of total deliveries %
Hospitals District Hospital 21.8 82 840 379 807 40.2
Regional Hospital 36.4 84 919 233 161 24.7
Tertiary Hospital 39.6 30 180 76 150 8.1
Central Hospital 42.8 23 662 55 337 5.9
Specialised Psychiatric Hospital - - 116 0.0
Specialised TB Hospital 37.3 2 220 5 952 0.6
Private Hospital 73.9 6 608 8 945 0.9
Total 30.3 230 429 759 468 80.5
b Roxby P. Should there be a limit on Caesareans? BBC News, 30 June 2010. http://www.bbc.co.uk/news/10448034
c Health reporter. Caesarean rates in public healthcare facilities concerning: Motsoaledi. TimesLive, 29 October 2013. http://www.timeslive.co.za/politics/2013/10/29/caesarean-rates-in-public-healthcare-facilities-concerning-motsoaledi
d www.doh.gov.za/docs/policy/2013/CAESAREAN_BOOKLET.pdf
e Pattinson R, Fawcus S, Moodley J. Tenth interim report on Confidential Enquiries into Maternal Deaths in South Africa 2011 and 2012. Pretoria: National Department of Health, 2013.
f Knight M, Sullivan EA. Variation in caesarean delivery rates. BMJ. 2010;341:c5255. Epub 2010/10/12.
Prov
0 10 20 30 40 50 60 70 80Indicator Value
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%% of denominator
EC
FS
GP
KZN
LP
MP
NC
NW
WC
SA
32.5
78.5
48.5
40.9
35.8
24.9
29.8
40.8
47.7
22.3
27.7
21.8
63.3
42.8 73.9
54.617.6
25.6
26.0
69.0
14.0
79.0
42.4
19.4
61.4
23.2
56.2
23.2
41.1
72.1
44.10.5
0.0
0.0
0.0
0.1
14.2%40.2%24.7%
14.1%
17.5%
17.1%
11.4%
20.8%
26.0%
10.9%
20.7%
14.2%
30.0%
22.5%
52.0%
50.6%
15.7%
45.2%
57.8%
59.3%
45.1%
25.9%
34.4%
22.1%
30.5%
38.0%
14.5%
13.6%
10.7%
31.0%
29.0%
21.2%
11.4%
10.6%
12.4%
5.2%8.1%5.9%
6.8%
7.2% 7.8%
8.1%
5.7%
7.1%
Caesarean sect rate, by level of care, FY 2014
OrgUnitType (group)Clinic & Special ClinicCommunity Health CentreMidwife Obstetrics UnitOtherDistrict HospitalRegional HospitalProvincial Tertiary HospitalNational Central HospitalSpecialised HospitalsPrivate Hospital
82
Section A: Delivery
Caesarean Section rateClassification Type C-Section
RateNumber of C-Sections
Total number of deliveries
Proportion of total deliveries %
Main PHC facilities Clinic 0.1 35 48 082 5.1
Community Day Centre - - 5 865 0.6
Community Health Centre - 10 128 087 13.6
Total 0.0 45 182 034 19.3Other Midwife Obstetrics Unit 0.0 0.0 1 021 0.1
Special Clinic 0.7 5 768 0.1
PHC Service - - 223 0.0
Province - - 334 0.0
Total 0.2 5 2 346 0.2
Total 24.4 230 479 943 848 100.0
Figure 5: Caesarean section rate by level of care, by province, 2013/14
Prov District
0 20 40 60 80Indicator Value
0K 10K 20K 30K 40K 50K 60K 70KDenominator (number)
0% 20% 40% 60% 80% 100%% of denominator
EC A Nzo: DC44
Amathole: DC12
Buffalo City: BUF
C Hani: DC13
Cacadu: DC10
Joe Gqabi: DC14
N Mandela Bay: NMA
OR Tambo: DC15
FS Fezile Dabi: DC20
Lejweleputswa: DC18
Mangaung: MAN
T Mofutsanyana: DC19
Xhariep: DC16
GP Ekurhuleni: EKU
Johannesburg: JHB
Sedibeng: DC42
Tshwane: TSH
West Rand: DC48
KZN Amajuba: DC25
eThekwini: ETH
Harry Gwala: DC43
iLembe: DC29
Ugu: DC21
uMgungundlovu: DC22
uMkhanyakude: DC27
uMzinyathi: DC24
uThukela: DC23
uThungulu: DC28
Zululand: DC26
LP Capricorn: DC35
Gr Sekhukhune: DC47
Mopani: DC33
Vhembe: DC34
Waterberg: DC36
MP Ehlanzeni: DC32
G Sibande: DC30
Nkangala: DC31
NC Frances Baard: DC9
JT Gaetsewe: DC45
Namakwa: DC6
Pixley ka Seme: DC7
ZF Mgcawu: DC8
NW Bojanala: DC37
Dr K Kaunda: DC40
NM Molema: DC38
RS Mompati: DC39
WC Cape Town: CPT
Cape Winelands: DC2
Central Karoo: DC5
Eden: DC4
Overberg: DC3
West Coast: DC1
14.9
50.9
70.8
23.7
36.7
24.6
76.6
14.0
22.0
35.0
59.0
19.2
41.1
9.5
12,062
13,471
8,629
6,813
9,213
9,136
9,140
12.7%
25.6%
33.6%
92.2%
87.3%
14.8%
68.9%
96.0%
98.9%
15.0%
41.4%
31.1%
16.9%
59.7%
31.2%
28.3%
20.2%
9.4%
51.5
22.8
10.7
63.3
11.6
32.0
42.4
33.2
0.7
0.7
0.3
2.0
7,441
12.4%17.3%
64.9%
51.2%
32.0%
60.3%
96.9%
26.4%
41.0%
31.8%
35.2%
19.8 41.9
51.8
26.7
17.3
41.7
38.6
33.4
40.1
67.1
0.0
27,575
17,81830,789 16,023
15,833
13,183 13,042
11,761
8,737 8,304
6,932
6,681
19.0%
26.3%
24.3%
16.2%
14.3%
38.4%
25.5%
42.3%
44.5%
23.7%
35.0%
17.1%
43.4%
25.5%
13.0%
45.5%
25.7%
51.5
78.5
25.8
28.8
50.836.3
30.3
40.6
21.6
20.6
51.6
69.0
25.4
31.4
31.1
29.1
14,678
10,813
12,140
33,382
7,098
9,387
8,142
7,032
8,621
6,891
7,761
9,481
18.6%
10.6%
15.0%
12.5%
16.6%
96.7%
24.1%
63.0%
41.0%
81.4%
95.9%
41.0%
34.6%
89.2%
85.4%
59.2%
59.3%
21.0%
41.9%
44.6%
46.2%
9.3%
28.5
19.6
27.6
26.0
21.4
0.8
0.0
15,315
14,948
18,277
15,562
7,169
7,986
9,084
9,562
12.4%
23.5%
22.1%
16.6%
53.5%
58.6%
59.7%
56.4%
64.0%
30.6%
11.0%
15.9%
16.2%
32.5%
21.8
35.7
23.6
18.2
22,684
13,032
7,723
9,814
11.7%
29.2%
59.3%
72.8%
47.4%
20.2%
15.4%
12.7%
22.6%
24.9
24.9
21.0
13.4
56.28.7
0.1
39.5%
31.7%
41.2%
11.6%
12.6%
91.1%
68.3%
58.8%
28.3%60.1%
47.9%
24.5
21.7
51.3
23.6 41.0
44.0
21.4 39.1 7,235
7,299 15.2%
15.5%
10.0%
34.1%
25.2%
25.8%
33.5%
17.5%
13.3%
37.3%
42.2%
28.4%
61.5%
21.4%
14.3%
32.5 48.5
83.5
77.3
17.6
22.4
20.4
29.4
27.4
10,405 14,45318,520 19,664
4,965
1,097 100.0%
100.0%
31.2%
10.0%
22.9%
30.4%
58.2%
90.0%
29.4%
43.4%
32.5%
16.5%
15.9%
9.4%
Caesarean sect rate, by level of care, FY 2014
OrgUnitType (group)Clinic & Special ClinicCommunity Health CentreMidwife Obstetrics UnitOtherDistrict HospitalRegional HospitalProvincial Tertiary HospitalNational Central HospitalSpecialised HospitalsPrivate Hospital
83
Section A: Delivery
Figure 6: Caesarean section rate by level of care by district, 2013/14
Caesarean section rate (district hospitals) by NHI district, 2013/14
Percentage
T Mofutsanyana: DC19
Vhembe: DC34
G Sibande: DC30
uMzinyathi: DC24
Tshwane: TSH
Pixley ka Seme: DC7
Dr K Kaunda: DC40
OR Tambo: DC15
Eden: DC4
Amajuba: DC25
uMgungundlovu: DC22
10 20 30 40
22.0
10.7
20.6
31.1
20.6
22.9
18.8
19.8
21.0
21.4
22.6
SA average: 21.8
ProvincesECFSGPKZNLPMPNCNWWC
Caesarean section rate (district hospitals) by province, 2013/14
Percentage [Source: DHIS]
NC
FS
MP
EC
LP
GP
NW
WC
KZN
10 20 30 40
19.4
17.6
22.3
27.7
19.4
18.1
14.0
23.2
25.6
SA average: 21.8
ProvincesECFSGPKZNLPMPNCNWWC
84
Section A: Delivery
At district hospitals, on which the remainder of this section is based, the C-section rate increased from 20.8% in 2012/13 to 21.8% in 2013/14. This rate has increased steadily over the past decade by 5.6% on average each year. Provincially, the highest rate was in KwaZulu-Natal (27.7%) and the lowest was in the Northern Cape (14.0%) (see Figure 7).
The low C-section rate in NC remained largely unchanged over the past 10 years. Overall, the C-section rate at district hospitals increased in all the provinces in 2013/14, with the highest increase in the percentage of C-sections performed being in the North West, with an increase of 3.0 percentage points from 20.2% in 2012/13 to 23.2% in 2013/14. In Dr Kenneth Kaunda (NW) there was a 9.0 percentage point increase from 12.4% in 2012/13 to 21.4% in 2013/14. Over the past 10 years, the largest increase (10.2 percentage points on average) was in the Eastern Cape.
Figure 7: Delivery by Caesarean section rate by province, 2013/14
The province with highest proportion of total deliveries at district hospitals was Mpumalanga at 59.3% and the lowest was in Gauteng at 15.7%. At a district level, the West Coast (WC) and Central Karoo (WC) reported 100% of institutional deliveries at district hospitals. The lowest proportion of deliveries at district hospitals was reported in Johannesburg (4.5%, GP), Amajuba (7.5%, KZN), Ekurhuleni (7.7%, GP) and Frances Baard (12.6%, NC) (see Figure 8).
The highest C-section rate at district hospitals was in Nelson Mandela Bay at 41.1% (see Figure 8). This district has had the highest C-section rate in the country for the third year running. ZF Mgcawu (NC) again reported no C-sections at its two district hospitals that collectively recorded 1 109 deliveries. Xhariep (FS) reported no C-sections in 2012/13 but reported a rate of 2.0% in 2013/14.
In the NHI districts, the highest rate of 31.1% was in uMgungundlovu (KZN) and the lowest of 10.7% was in Thabo Mofutsanyana (FS). The greatest decrease was in West Rand (GP) with a 4.1 percentage point decline to 17.3%. In Cacadu (EC), the rate dropped by 3.1 percentage points to 24.6% and in uMzinyathi (KZN) by 2.5 percentage points to 20.6%.
The 10 hospitals with the highest C-section rates are listed in Table 2.
85
Section A: Delivery
Table 2: District hospitals with the highest delivery by Caesarean section rates, 2013/14
Facility name C-section rate Caesarean sections
(numerator)
Total deliveries (denominator)
Osindisweni Hospital (KZN – eThekwini) 49.2 934 1 900
Pongola Hospital (KZN – Zululand) 48.4 31 64
Khayelitsha Hospital (WC – Cape Town) 45.8 1 696 3 700
Wentworth Hospital (KZN – eThekwini) 43.5 1 025 2 355
Humansdorp Hospital (EC – Buffalo City) 43.3 784 1 811
Uitenhage Hospital (EC – Nelson Mandela Bay) 41.1 1 252 3 043
Murchison Hospital (KZN – Ugu) 39.3 1 138 2 894
Dr JS Moroka Hospital (FS – Mangaung) 38.4 434 1 130
Botshabelo Hospital (FS – Mangaung) 38.2 699 1 831
GJ Crooke’s Hospital (KZN – Ugu) 37.4 1 272 3 405
There were 42 out of 242 district hospitals (17.4%) where no C-sections were done yet deliveries took place. The majority of district hospitals had C-section rates between 10.0% and 29.9% (see Table 3).
Table 3: Delivery by Caesarean section rates at district hospitals, 2013/14
C-section rate Number of district hospitals % of district hospitals0.0 42 17.4
0.1 – 9.9% 19 7.9
10.0 – 19.9% 76 31.4
20.0 – 29.9% 74 30.6
30.0 – 39.9% 25 10.3
over 40.0% 6 2.5
Total 242 100
There were some data quality issues. Some district hospitals which regularly performed C-sections had at least one month of numerator data missing in 2013/14. The C-section rate is thus likely to be slightly higher than reported. Similar issues were observed at higher-level hospitals. Hospital classification concerns included 116 deliveries being reported at a specialised psychiatric hospital. There were 2 220 C-sections reported at one specialised TB hospital, King Dinuzulu Hospital.
Caesarean section rate (district hospitals) by district, 2013/14
Percentage [Source: DHIS]
ZF Mgcawu: DC8Xhariep: DC16
Frances Baard: DC9Joe Gqabi: DC14
T Mofutsanyana: DC19Lejweleputswa: DC18
JT Gaetsewe: DC45C Hani: DC13
Amathole: DC12Ehlanzeni: DC32
West Rand: DC48West Coast: DC1Nkangala: DC31Capricorn: DC35
Vhembe: DC34Mopani: DC33
A Nzo: DC44Sekhukhune: DC47
Ekurhuleni: EKUCape Winelands: DC2
G Sibande: DC30Overberg: DC3
uMzinyathi: DC24Tshwane: TSH
Pixley ka Seme: DC7Dr K Kaunda: DC40
uMkhanyakude: DC27RS Mompati: DC39
OR Tambo: DC15Waterberg: DC36
Central Karoo: DC5Eden: DC4
Fezile Dabi: DC20Amajuba: DC25uThukela: DC23Bojanala: DC37
Buffalo City: BUFNM Molema: DC38
Cacadu: DC10Namakwa: DC6Zululand: DC26
Harry Gwala: DC43Sedibeng: DC42
iLembe: DC29uThungulu: DC28
uMgungundlovu: DC22Mangaung: MANCape Town: CPT
Ugu: DC21Johannesburg: JHB
eThekwini: ETHN Mandela Bay: NMA
10 20 30 40
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHINHI
NHI
23.7
24.6
14.914.0
9.5
22.0
19.2
41.1
2.0
11.610.7
22.8
32.0
26.7
17.3
19.6
36.6
20.6
36.3
31.1
23.0
20.6
22.9
25.4
21.6
28.828.1
25.8
40.6
19.018.818.6
22.2
19.4
19.8
18.2
17.1
13.4
24.9
21.0
0.0
8.7
23.6
24.5
21.7
21.4
32.5
17.6
19.8
20.4
22.622.4
SA average: 21.8
ProvincesECFSGPKZNLPMPNCNWWC
86
Section A: Delivery
Figure 8: Delivery by Caesarean section rate by district, 2013/14
DC6
DC7
DC8
DC10
DC5
DC36
DC39
DC1
DC16
DC13
DC19DC18
DC30
DC4
DC2
DC38
DC32
DC45
DC14
DC34
DC12
DC35
DC20
DC33
DC37
DC31
DC3
DC9
DC26
DC40
DC27
DC47
DC15
DC23
DC44
DC43
DC22
DC24
DC28
TSH
MAN
DC25
TSH
DC42
DC48 EKUJHB
Gauteng
LegendProvince
District
CAESECR_DH_20132 - 13
14 - 20
21 - 24
25 - 31
32 - 41
87
Section A: Delivery
Map 2: Delivery by Caesarean section rate by district, 2013/14
Annual trends: Caesarean section rate (district hospitals)
Perc
enta
ge
0
10
20
30
40
EC FS
● ● ●●
● ●●
●
●
●● ●
GP
0
10
20
30
40
KZN
●●
● ● ●● ●
● ●●
● ●
LP MP
0
10
20
30
40
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
NC
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
NW
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
● ●● ●
● ● ●●
● ●●
WC
EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC CacaduEC Joe GqabiEC N Mandela BayEC OR TamboFS Fezile DabiFS LejweleputswaFS MangaungFS T MofutsanyanaFS Xhariep
GP EkurhuleniGP JohannesburgGP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN Harry GwalaKZN iLembeKZN UguKZN uMgungundlovuKZN uMkhanyakudeKZN uMzinyathi
KZN uThukelaKZN uThunguluKZN ZululandLP CapricornLP MopaniLP SekhukhuneLP VhembeLP WaterbergMP EhlanzeniMP G SibandeMP NkangalaNC Frances BaardNC JT Gaetsewe
NC NamakwaNC Pixley ka SemeNC ZF MgcawuNW BojanalaNW Dr K KaundaNW NM MolemaNW RS MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast
●
●
●
88
Section A: Delivery
Figure 9: Annual trends: Delivery by Caesarean section rate
Annual trends: Caesarean section rate (district hospitals) by SEQ
Perc
enta
ge
0
10
20
30
40
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
SEQ 1
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●
●
●
●
●●
●
●
●
●
●
SEQ 2
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
SEQ 3
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●
●
●
●
●
●
●
●
●
●
●
SEQ 4
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●●
●
●
●●
●
●
●
●
●
●
SEQ 5
1 A Nzo1 Amathole1 C Hani1 Harry Gwala1 Joe Gqabi1 OR Tambo1 RS Mompati1 Sekhukhune1 uMkhanyakude1 uMzinyathi1 Zululand2 Capricorn2 iLembe
2 JT Gaetsewe2 Mopani2 NM Molema2 Pixley ka Seme2 Ugu2 uThukela2 uThungulu2 Vhembe3 Amajuba3 Bojanala3 Cacadu3 Ehlanzeni3 G Sibande
3 T Mofutsanyana3 uMgungundlovu3 Waterberg3 Xhariep3 ZF Mgcawu4 Buffalo City4 Central Karoo4 Dr K Kaunda4 Eden4 Fezile Dabi4 Frances Baard4 Lejweleputswa4 Namakwa
4 Nkangala4 West Rand5 Cape Town5 Cape Winelands5 Ekurhuleni5 eThekwini5 Johannesburg5 Mangaung5 N Mandela Bay5 Overberg5 Sedibeng5 Tshwane5 West Coast
●
●
●
89
Section A: Delivery
Figure 10: Delivery by Caesarean section rate by SEQ
Stillbirth rate in facility by NHI district, 2013/14
per 1 000 births
uMgungundlovu: DC22
Amajuba: DC25
T Mofutsanyana: DC19
Dr K Kaunda: DC40
OR Tambo: DC15
G Sibande: DC30
Pixley ka Seme: DC7
Tshwane: TSH
Eden: DC4
uMzinyathi: DC24
Vhembe: DC34
10 20 30
25.6
27.5
20.3
32.4
18.4
27.9
17.3
23.1
21.8
26.9
18.5SA average: 21.5
Target: 19.7ProvincesECFSGPKZNLPMPNCNWWC
Stillbirth rate in facility by province, 2013/14
per 1 000 births [Source: DHIS]
FS
NC
NW
KZN
MP
LP
EC
GP
WC
10 20 30
20.6
27.4
20.2
23.2
21.1
21.3
26.1
23.5
17.4SA average: 21.5
Target: 19.7 ProvincesECFSGPKZNLPMPNCNWWC
90
Section A: Delivery
At DHB workshops conducted in 2013 and 2014, reasons for unnecessarily high C-section rates or inadequate availability of C-sections included:
✦ poor observation of women in labour and an inability of labour ward staff to interpret cardiotocography (CTG) tracing and the partogram;
✦ doctors delaying in attending to obstetric emergencies;
✦ a preference by doctors to perform C-sections rather than assisted deliveries. The skills to perform assisted deliveries have been lost or are being lost particularly as there is also a lack of advanced midwives who are trained to perform assisted deliveries. Unnecessary C-sections are being performed instead;g
✦ late first ANC bookings resulting in high-risk cases not being identified early;
✦ hospitals are doing more C-sections because Midwife Obstetric Units (MOUs) have a lack of advanced midwives able to perform assisted deliveries and able to assist with obstetric emergencies;h
✦ a high percentage of deliveries in facility under 18 years.
4.3 Stillbirth rate in facility
The stillbirth rate (SBR) is a good indicator of care during the third trimester and intrapartum period. It is therefore one of the key indicators for Maternal, Newborn, Child and Women’s Health (MNCWH) as it is a reflection of foetal, maternal and health system factors.
The stillbirth rate measures the number of babies who are born dead per 1 000 total births. Only the stillbirths that occur in health facilities are reported here, the majority being public health sector facilities along with a limited number of private hospitals and mobile clinics. Deaths outside of these services, such as in the community, are not taken into account.
A stillborn foetus might have been dead (in utero) for some time (macerated) or have died not long prior to delivery (fresh). The indicator does not differentiate between fresh and macerated stillbirths. Stillbirths should only be counted when the foetus is of 26 or more weeks’ gestational age and/or weighs 500g or more.
The national stillbirth rate was 21.5 deaths per 1 000 total births, representing a slight decrease from the 2012/13 rate of 21.8 per 1 000 total births. This was the lowest rate since 2001/02 but remained higher than the NDoH target of 19.7 per 1 000 total births. The rate was lowest in the Western Cape at 17.4 and highest in the Free State where there was an increase of 2.3 percentage points to 27.4 (after a decline from 29.1 to 25.1 in 2012/13). After being relatively stable for a few years at around 24 per 1 000 total births, Mpumalanga showed a decline of 3 percentage points to 21.3 per 1 000 total births. Over the past five years, Northern Cape has been the only province where the stillbirth rate has increased (4.4% average increase per year)
Figure 11: Stillbirth rate in facility by province, 2013/14
g Pattinson R. Reducing direct causes of maternal death. South African Journal of Obstetrics and Gynaecology. 2013;19(3):59-60. http://www.sajog.org.za/index.php/SAJOG/article/view/772/412
h Pattinson R. Reducing direct causes of maternal death. South African Journal of Obstetrics and Gynaecology. 2013;19(3):59-60. http://www.sajog.org.za/index.php/SAJOG/article/view/772/412
DC6
DC7
DC8
DC10
DC5
DC36
DC39
DC1
DC16
DC13
DC19DC18
DC30
DC4
DC2
DC38
DC32
DC45
DC14
DC34
DC12
DC35
DC20
DC33
DC37
DC31
DC3
DC9
DC26
DC40
DC27
DC47
DC15
DC23
DC44
DC43
DC22
DC24
DC28
TSH
MAN
DC25
TSH
DC42
DC48 EKUJHB
Gauteng
LegendProvince
District
SBR_201312 - 15
16 - 19
20 - 22
23 - 26
27 - 32
91
Section A: Delivery
At district level, there is a 2.7-fold difference between the best and the worst performing districts, with West Coast (WC) being the lowest at 11.9 stillbirths per 1 000 births and uMgungundlovu (KZN) being the highest at 32.4 per 1 000 total births (see Figure 12). uMgungundlovu was still seeing an overall increase in the stillbirth rate from a low of 21.9 in 2009/10. The rate in Pixley ka Seme (NC) increased again to 21.8 following a relatively low value of 13.2 in 2012/13. In Central Karoo (WC) the rate decreased to 19.9 per 1 000 total births following a peak of 33.5 per 1 000 total births in 2012/13.
Map 3: Stillbirth in facility rate by district, 2013/14
Stillbirth rate in facility by district, 2013/14
per 1 000 births [Source: DHIS]
uMgungundlovu: DC22Lejweleputswa: DC18
Amajuba: DC25Mangaung: MAN
JT Gaetsewe: DC45T Mofutsanyana: DC19
Frances Baard: DC9ZF Mgcawu: DC8
Dr K Kaunda: DC40RS Mompati: DC39
uThungulu: DC28OR Tambo: DC15Capricorn: DC35Nkangala: DC31
Ugu: DC21Fezile Dabi: DC20
uThukela: DC23Buffalo City: BUF
iLembe: DC29G Sibande: DC30
Sekhukhune: DC47Zululand: DC26eThekwini: ETH
Ekurhuleni: EKUPixley ka Seme: DC7
Bojanala: DC37NM Molema: DC38
Sedibeng: DC42Xhariep: DC16
Waterberg: DC36Namakwa: DC6Tshwane: TSHCacadu: DC10Mopani: DC33
Central Karoo: DC5Johannesburg: JHB
Ehlanzeni: DC32Eden: DC4
Cape Town: CPTuMzinyathi: DC24
Harry Gwala: DC43C Hani: DC13
N Mandela Bay: NMAVhembe: DC34
Amathole: DC12A Nzo: DC44
Joe Gqabi: DC14uMkhanyakude: DC27
West Rand: DC48Cape Winelands: DC2
Overberg: DC3West Coast: DC1
10 20 30
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
23.2
20.1
17.1
17.8
16.7
25.6
16.9
17.7
20.9
30.1
27.5
23.9
27.6
21.4
15.2
21.9
19.5
20.3
24.0
32.4
23.7
18.4
27.9
21.9
16.3
26.8
23.2
18.0
21.9
20.1
17.3
24.9
20.9
22.923.1
24.3
18.9
27.6
20.4
21.8
27.127.4
21.721.6
26.826.9
18.4
11.9
15.112.0
18.5
19.9
SA average: 21.5
Target: 19.7
ProvincesECFSGPKZNLPMPNCNWWC
92
Section A: Delivery
Figure 12: Stillbirth in facility rate by district, 2013/14
Annual trends: Stillbirth rate in facility
per 1
000
birt
hs
10
20
30
40
50
EC FS
●
●
●●
●
● ●
● ●● ● ●
GP
10
20
30
40
50
KZN
● ● ●
●
●● ● ● ● ●
●●
LP MP
10
20
30
40
50
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
NC
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
NW
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
● ●
●
● ●
●●
●● ●
●
●
WC
EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC CacaduEC Joe GqabiEC N Mandela BayEC OR TamboFS Fezile DabiFS LejweleputswaFS MangaungFS T MofutsanyanaFS Xhariep
GP EkurhuleniGP JohannesburgGP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN Harry GwalaKZN iLembeKZN UguKZN uMgungundlovuKZN uMkhanyakudeKZN uMzinyathi
KZN uThukelaKZN uThunguluKZN ZululandLP CapricornLP MopaniLP SekhukhuneLP VhembeLP WaterbergMP EhlanzeniMP G SibandeMP NkangalaNC Frances BaardNC JT Gaetsewe
NC NamakwaNC Pixley ka SemeNC ZF MgcawuNW BojanalaNW Dr K KaundaNW NM MolemaNW RS MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast
●
●
●
93
Section A: Delivery
Many districts still showed fluctuating trends, particularly those with less than 5 000 births per year (see Figure 13). In the NHI districts, the best performing district was Vhembe at 17.3 per 1 000 total births, with uMgungundlovu being 1.8-fold higher at 32.4 per 1 000 total births. The median stillbirth rate was lowest in the socio-economic Quintile 1 districts at 18.0 per 1 000 births in 2013/14.
Figure 13: Annual trends: Stillbirth in facility rate
Annual trends: Stillbirth rate in facility by SEQ
per 1
000
birt
hs
10
20
30
40
50
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
SEQ 1
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●
●
●
●
●●
●
●
●
●
●
SEQ 2
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
SEQ 3
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●
●
●
●
●
●
●
●
●
●
●
SEQ 4
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●
●
●
●
●●
●●
●●
●
SEQ 5
1 A Nzo1 Amathole1 C Hani1 Harry Gwala1 Joe Gqabi1 OR Tambo1 RS Mompati1 Sekhukhune1 uMkhanyakude1 uMzinyathi1 Zululand2 Capricorn2 iLembe
2 JT Gaetsewe2 Mopani2 NM Molema2 Pixley ka Seme2 Ugu2 uThukela2 uThungulu2 Vhembe3 Amajuba3 Bojanala3 Cacadu3 Ehlanzeni3 G Sibande
3 T Mofutsanyana3 uMgungundlovu3 Waterberg3 Xhariep3 ZF Mgcawu4 Buffalo City4 Central Karoo4 Dr K Kaunda4 Eden4 Fezile Dabi4 Frances Baard4 Lejweleputswa4 Namakwa
4 Nkangala4 West Rand5 Cape Town5 Cape Winelands5 Ekurhuleni5 eThekwini5 Johannesburg5 Mangaung5 N Mandela Bay5 Overberg5 Sedibeng5 Tshwane5 West Coast
●
●
●
94
Section A: Delivery
Figure 14: Stillbirth in facility rate by SEQ
95
Section A: Delivery
At DHB workshops conducted in 2013 and 2014, challenges to reducing the stillbirth rate were identified as follows:
Patient-related factors:
✦ cultural practices;
✦ traditional and over-the-counter medication both during pregnancy and those taken to induce labour;
✦ delay in seeking medical attention;
✦ pre-existing maternal conditions (often unrecognised or not disclosed);
✦ poor response to reduced foetal movements;
✦ no antenatal attendance;
✦ late booking: women typically do not book until showing;
✦ lack of health education;
Administrative factors:
✦ insufficient staff allocation to labour wards;
✦ delay in ambulance response time;
✦ lack of equipment such as CTG machines;
Healthcare Worker related factors:
✦ inability to interpret CTG tracing and partogram;
✦ delay in response to poor foetal condition;
✦ doctors delaying in attending to obstetric emergencies.
The stillbirth rate, although slowly declining, was still higher than the target. Ongoing efforts to improve antenatal and intrapartum care are required.
4.4 Inpatient early neonatal death rate in facility
The inpatient early neonatal death rate measures the number of deaths of live born babies that occur within 7 completed days after birth per 1 000 live births. It includes only neonatal deaths when the foetus is of 26 or more weeks’ gestational age and/or weighs 500g or more. The deaths reported in this chapter occur predominantly in public health facilities but include a limited number of private hospitals. Deaths occurring at home are not included.
The inpatient early neonatal mortality rate provides an indication of the quality of antenatal, intrapartum and postnatal care. It is also a significant contributor to the under-five mortality rate (Millennium development Goal 4A: reduce by two thirds, between 1990 and 2015, the under-five mortality rate). It is therefore a key indicator to address in order for South Africa to meet its targets.
The 2013/14 inpatient early neonatal death rate was 10.1 per 1 000 live births, a marginal decrease from 10.2 in 2012/13. This was lower than the NDoH target of 10.9. Provincially, this was lowest in the Western Cape at 4.8 and 2.9-fold higher in the Eastern Cape at 14.1 (see Figure 15). Decreases were seen in the Eastern Cape (2.3 percentage points), Mpumalanga (0.9 percentage points), North West (0.9 percentage points) and the Western Cape (1.4 percentage points). Increases were seen in the other provinces, with the greatest increase (1.7 percentage points) in KwaZulu-Natal.
Inpatient early neonatal death rate by NHI district, 2013/14
per 1 000 live births
Dr K Kaunda: DC40
OR Tambo: DC15
uMgungundlovu: DC22
T Mofutsanyana: DC19
Pixley ka Seme: DC7
uMzinyathi: DC24
G Sibande: DC30
Amajuba: DC25
Tshwane: TSH
Vhembe: DC34
Eden: DC4
5 10 15 20 25
13.3
12.9
8.2
13.2
11.4
9.2
8.0
9.8
11.5
16.2
6.5
SA average: 10.1
Target: 10.9ProvincesECFSGPKZNLPMPNCNWWC
Inpatient early neonatal death rate by province, 2013/14
per 1 000 live births [Source: DHIS]
EC
NC
FS
LP
KZN
NW
GP
MP
WC
5 10 15 20 25
14.1
12.3
9.3
10.4
11.7
8.6
12.8
9.5
4.8SA average: 10.1
Target: 10.9 ProvincesECFSGPKZNLPMPNCNWWC
DC6
DC7
DC8
DC10
DC5
DC36
DC39
DC1
DC16
DC13
DC19DC18
DC30
DC4
DC2
DC38
DC32
DC45
DC14
DC34
DC12
DC35
DC20
DC33
DC37
DC31
DC3
DC9
DC26
DC40
DC27
DC47
DC15
DC23
DC44
DC43
DC22
DC24
DC28
TSH
MAN
DC25
TSH
DC42
DC48 EKUJHB
Gauteng
LegendProvince
District
ENDR_20133.3 - 4.7
4.8 - 8.8
8.9 - 11.8
11.9 - 17.9
18.0 - 25.7
96
Section A: Delivery
Figure 15: Inpatient early neonatal death rate by province, 2013/14
Nelson Mandela Bay had the highest inpatient early neonatal death rate at 25.7 deaths per 1 000 live births (see Figure 16), although this district’s stillbirth rate was among the lowest. This may indicate poor intrapartum and postnatal care. The lowest inpatient early neonatal death rate was in the Cape Winelands (WC). In the NHI districts, there was a 2.5 fold difference between Eden (WC), the best performing district, with 6.5 deaths per 1 000 live births and Dr Kenneth Kaunda (NW) with 16.2 deaths per 1 000 live births.
Map 4: Inpatient early neonatal death rate by district, 2013/14
Inpatient early neonatal death rate by district, 2013/14
per 1 000 live births [Source: DHIS]
N Mandela Bay: NMAZF Mgcawu: DC8Capricorn: DC35
Dr K Kaunda: DC40uThungulu: DC28
Lejweleputswa: DC18Harry Gwala: DC43
OR Tambo: DC15uMgungundlovu: DC22T Mofutsanyana: DC19
Buffalo City: BUFC Hani: DC13
Fezile Dabi: DC20Namakwa: DC6
iLembe: DC29Pixley ka Seme: DC7
uMzinyathi: DC24Mopani: DC33
Frances Baard: DC9Waterberg: DC36Amathole: DC12
Sekhukhune: DC47Mangaung: MANEkurhuleni: EKU
Ugu: DC21Johannesburg: JHBJT Gaetsewe: DC45
eThekwini: ETHG Sibande: DC30
Overberg: DC3A Nzo: DC44
Joe Gqabi: DC14Amajuba: DC25uThukela: DC23
NM Molema: DC38Xhariep: DC16
Ehlanzeni: DC32Tshwane: TSH
RS Mompati: DC39Vhembe: DC34
Sedibeng: DC42Zululand: DC26
Nkangala: DC31West Rand: DC48
Bojanala: DC37Cacadu: DC10
Eden: DC4Central Karoo: DC5
Cape Town: CPTuMkhanyakude: DC27
West Coast: DC1Cape Winelands: DC2
5 10 15 20 25
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
12.8
6.7
10.4
12.5
9.3
13.3
9.5
25.7
8.8
14.8
12.9
12.4
10.2
8.0
7.2
10.2
10.0
8.2
10.1
13.2
9.0
11.4
9.2
7.6
4.0
14.9
11.8
14.4
9.8
11.2
8.0
17.9
10.9
10.3
9.8
7.3
8.7
9.9
12.2
11.5
21.4
11.2
6.8
9.0
8.1
16.2
4.7
3.9 3.3
9.6
6.5 6.5
SA average: 10.1
Target: 10.9
ProvincesECFSGPKZNLPMPNCNWWC
97
Section A: Delivery
Figure 16: Inpatient early neonatal death rate by district, 2013/14
Annual trends: Inpatient early neonatal death rate
per 1
000
live
birt
hs
0
5
10
15
20
25
EC FS
●● ●
●●
●
● ●
● ●
●
●
GP
0
5
10
15
20
25
KZN
●● ●
●
●
● ●
● ● ● ●●
LP MP
0
5
10
15
20
25
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
NC
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
NW
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
● ●
●●
●
●
●
●
●●
●●
WC
EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC CacaduEC Joe GqabiEC N Mandela BayEC OR TamboFS Fezile DabiFS LejweleputswaFS MangaungFS T MofutsanyanaFS Xhariep
GP EkurhuleniGP JohannesburgGP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN Harry GwalaKZN iLembeKZN UguKZN uMgungundlovuKZN uMkhanyakudeKZN uMzinyathi
KZN uThukelaKZN uThunguluKZN ZululandLP CapricornLP MopaniLP SekhukhuneLP VhembeLP WaterbergMP EhlanzeniMP G SibandeMP NkangalaNC Frances BaardNC JT Gaetsewe
NC NamakwaNC Pixley ka SemeNC ZF MgcawuNW BojanalaNW Dr K KaundaNW NM MolemaNW RS MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast
●
●
●
98
Section A: Delivery
In terms of annual trends (see Figure 17), the greatest decreases were seen in OR Tambo (EC) (-7.0 percentage points), Central Karoo (NC) (-6.6 percentage points) and Frances Baard (NC) (-5.4 percentage points). The greatest increases were seen in ZF Mgcawu (NC) (13.4 percentage points), Amajuba (KZN) (6.3 percentage points) and Xhariep (FS) (5.1 percentage points).
Figure 17: Annual trends: Inpatient early neonatal death rate
Annual trends: Inpatient early neonatal death rate by SEQ
per 1
000
live
birt
hs
0
5
10
15
20
25
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
SEQ 1
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●
●
●
●
●
●●
●
●
●
●
SEQ 2
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
SEQ 3
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●●
●
●
●
● ●
●●
●
●
SEQ 4
2002
/03
2003
/04
2004
/05
2005
/06
2006
/07
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
● ●
●
●
●
●●
● ●
●
●
SEQ 5
1 A Nzo1 Amathole1 C Hani1 Harry Gwala1 Joe Gqabi1 OR Tambo1 RS Mompati1 Sekhukhune1 uMkhanyakude1 uMzinyathi1 Zululand2 Capricorn2 iLembe
2 JT Gaetsewe2 Mopani2 NM Molema2 Pixley ka Seme2 Ugu2 uThukela2 uThungulu2 Vhembe3 Amajuba3 Bojanala3 Cacadu3 Ehlanzeni3 G Sibande
3 T Mofutsanyana3 uMgungundlovu3 Waterberg3 Xhariep3 ZF Mgcawu4 Buffalo City4 Central Karoo4 Dr K Kaunda4 Eden4 Fezile Dabi4 Frances Baard4 Lejweleputswa4 Namakwa
4 Nkangala4 West Rand5 Cape Town5 Cape Winelands5 Ekurhuleni5 eThekwini5 Johannesburg5 Mangaung5 N Mandela Bay5 Overberg5 Sedibeng5 Tshwane5 West Coast
●
●
●
99
Section A: Delivery
Figure 18: Inpatient early neonatal death rate by SEQ
100
Section A: Delivery
The early neonatal death rate remained high in certain facilities and districts. This may have been due to inadequate care provided at the facility or may be indicative of poor service delivery at lower levels of care within that district. It may also be indicative of broader issues such as delays in referral to facilities able to provide care to neonates.
At DHB workshops conducted in 2013 and 2014, reasons suggested for poor performance included:
✦ late presentation to facility both for antenatal care and in labour with high-risk cases not identified in time;
✦ poor quality of antenatal care;
✦ lack of essential equipment, e.g. incubators;
✦ cultural influence;
✦ a higher portion of delivery under 18 years as the newborn babies are premature or have a birth weight of less than 2 500g.
While overall the inpatient early neonatal death rate was slowly improving, certain districts and facilities still had very high rates. Districts with rates far above the average were: Nelson Mandela Bay (EC) and ZF Mgcawu (NC). Capricorn (LP), Dr Kenneth Kaunda (NW), uThungulu (KZN) and Lejweleputswa (FS) were above the district average.
Districts with the highest numbers of early neonatal deaths were: Johannesburg (GP), Ekurhuleni (GP), eThekwini (KZN), Nelson Mandela Bay (EC) and Capricorn (LP). A substantial reduction of the early neonatal deaths in these districts will have a big impact on the country’s overall performance for this indicator.
4.5 Maternal mortality ratio in facility
“Maternal death is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. To facilitate the identification of maternal deaths in circumstances in which cause of death attribution is inadequate, a new category has been introduced: Pregnancy-related death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the cause of death.” In other words, any death whilst the woman is pregnant up to seven weeks post-partum is included in the definition. The maternal mortality ratio (MMR) is the number of maternal deaths per 100 000 live births.i
The NIDS stipulates that these deaths should occur while in a health facility in order to calculate the maternal mortality ratio in facility.
According to Millennium Development Goal 5, South Africa should aim to reduce the MMR by three quarters between 1990 and 2015. The reduction of the MMR is a priority area of the Negotiated Service Delivery Agreement (NSDA) and a key component of the Strategic Plan for Maternal, Neonatal, Child and Women’s Health (MNCWH) and Nutrition in South Africa 2011–2016. South Africa has adopted the Campaign on Accelerated Reduction of Maternal and Child Mortality in Africa (CARMMA) strategy, and action components of this strategy mirror key priorities outlined in the Strategic Plan for MNCWH.
The most recent report from the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) reports that bleeding during or after Caesarean section was the cause for almost a third of maternal deaths due to obstetric haemorrhage for 2011 and 2012 combined. Maternal deaths due to bleeding during or after Caesarean section increased in 2012 to 35.3% compared with 27.5% in 2011. Non-pregnancy related infections, obstetric haemorrhage and hypertension contributed 26.0%, 23.8% and 16.5% of the avoidable deaths respectively.j
The MMR can be calculated in various ways. The population-based MMR is estimated from the vital registration system and includes all registered maternal deaths regardless of the place of death.k The facility-based MMR measures maternal deaths occurring in health facilities, primarily in the public sector, and can be calculated from two sources, namely the District Health Information Software (DHIS) and the NCCEMD. Historically, the NCCEMD MMR values have been higher than those in the DHIS in most geographical areas, presumably because the NCCEMD is a well-established system with a strong regulatory framework. However, the values from the two systems are now approximating each other, so much more reliance can now be placed on the DHIS. DHIS data are available monthly, whereas the NCCEMD is published every three years with a time-lag. With DHIS information being available more timeously and with disaggregation to facility level, it may become a better method of monitoring progress, especially as these data have been reaching completeness since 2012/13. Maternal mortality is a relatively rare event and, therefore, year-one-year fluctuations, especially in districts with low numbers of live births or small populations, must be treated with caution until there is a much longer time series of data available.
i World Health Organization. Maternal mortality ratio (per 100 000 live births) http://www.who.int/healthinfo/statistics/indmaternalmortality/en/
j Pattinson R, Fawcus S, Moodley J. Tenth interim report on Confidential Enquiries into Maternal Deaths in South Africa 2011 and 2012. Pretoria: National Department of Health, 2013.
k Bradshaw D, Dorrington R, Laubscher R. Rapid Mortality Surveillance Report 2011. Cape Town: Medical Research Council; 2012.
Maternal mortality in facility ratio by NHI district, 2013/14
per 100 000 live births
Dr K Kaunda: DC40
OR Tambo: DC15
uMgungundlovu: DC22
G Sibande: DC30
T Mofutsanyana: DC19
Vhembe: DC34
Amajuba: DC25
Eden: DC4
uMzinyathi: DC24
Pixley ka Seme: DC7
Tshwane: TSH
100 200 300
229.7
123.3
63.3
208.3
71.6
109.8
111.2
197.1
67.6
257.4
105.4SA average: 133.3 Provinces
ECFSGPKZNLPMPNCNWWC
Maternal mortality in facility ratio by province, 2013/14
per 100 000 live births [Source: DHIS]
NW
EC
LP
MP
KZN
FS
NC
GP
WC
100 200 300
156.2
143.4
104.5
148.4
152.0
149.1
118.9
184.9
68.6SA average: 133.3
ProvincesECFSGPKZNLPMPNCNWWC
101
Section A: Delivery
In 2013/14, there was a marginal increase in the facility MMR from 132.9 to 133.3 per 100 000 live births. There were 1 249 maternal deaths from 937 082 live births. Provincially, the facility MMR in the DHIS for 2013/14 ranged from 68.6 per 100 000 live births in the Western Cape to 184.9 per 100 000 live births in the North West (see Figure 19). Four provinces showed increases in their maternal deaths: Eastern Cape, Free State, North West and the Western Cape. In the Free State, the absolute number of maternal deaths remained stable at 64 but the total number of live births reported was less than that in 2012/13. The remaining five provinces all showed a decrease.
In comparison, the 2010 MMR from the NCCEMD data was 182.8 deaths per 100 000 live births; in 2011 it was 165.6 and in 2012 it was 151.7 deaths per 100 000 live births. Provincially it was reported to be highest in 2012 in Limpopo (185.8) and lowest in the Western Cape (82.0).
Figure 19: Maternal mortality in facility ratio by province, 2013/14
The facility MMR recorded in the DHIS by district (Figure 20) ranged from 35.5 deaths per 100 000 live births in the Cape Winelands (WC) to 353.7 per 100 000 live births in Capricorn (LP). Capricorn also had the highest MMR in 2011/12 and 2012/13, and had the third highest MMR in 2012 according to the NCCEMD data. The MMR increased from 292.2 in 2012/13 to 353.7 deaths per 100 000 live births in 2013/14 in this district. Two districts reported no maternal deaths, namely Central Karoo (WC) and Xhariep (FS), probably due to a combination of a low number of births and their complicated deliveries being transferred to hospitals in other districts.
Four of the 11 NHI districts had facility MMR above the national average, with Dr Kenneth Kaunda (NW) having the highest MMR of the NHI sites and the second highest facility MMR in the country at 257.4 per 100 000 live births. Tshwane (GP) had the lowest MMR of the NHI sites and the sixth lowest in the country.
When comparing absolute numbers of maternal deaths, they were highest in Ekurhuleni (MP), Capricorn (LP) and eThekwini (KZN) (see Table 6).
DC6
DC7
DC8
DC10
DC5
DC36
DC39
DC1
DC16
DC13
DC19DC18
DC30
DC4
DC2
DC38
DC32
DC45
DC14
DC34
DC12
DC35
DC20
DC33
DC37
DC31
DC3
DC9
DC26
DC40
DC27
DC47
DC15
DC23
DC44
DC43
DC22
DC24
DC28
TSH
MAN
DC25
TSH
DC42
DC48 EKUJHB
Gauteng
LegendProvince
District
MATMORTR_201336 - 74
75 - 105
106 - 148
149 - 230
231 - 354
102
Section A: Delivery
Table 6: Highest absolute number of maternal deaths (district level), 2013/14
District Maternal deaths Live births MMREkurhuleni (MP) 102 61 501 165.9
Capricorn (LP) 98 27 706 353.7
eThekwini (KZN) 97 55 604 174.4
OR Tambo (EC) 74 32 220 229.7
Johannesburg (GP) 50 64 988 76.9
Map 5: Maternal mortality in facility ratio by district, 2013/14
Maternal mortality in facility ratio by district, 2013/14
per 100 000 live births [Source: DHIS]
Capricorn: DC35Dr K Kaunda: DC40
OR Tambo: DC15uMgungundlovu: DC22
NM Molema: DC38G Sibande: DC30
iLembe: DC29Lejweleputswa: DC18
uThungulu: DC28Frances Baard: DC9
eThekwini: ETHC Hani: DC13
Ekurhuleni: EKUUgu: DC21
Bojanala: DC37Nkangala: DC31Mangaung: MANBuffalo City: BUF
N Mandela Bay: NMAT Mofutsanyana: DC19
Zululand: DC26A Nzo: DC44
uThukela: DC23Ehlanzeni: DC32Sedibeng: DC42
Cacadu: DC10Waterberg: DC36
Fezile Dabi: DC20Vhembe: DC34
RS Mompati: DC39Amajuba: DC25
Eden: DC4Joe Gqabi: DC14
Mopani: DC33West Rand: DC48
JT Gaetsewe: DC45Amathole: DC12
Harry Gwala: DC43ZF Mgcawu: DC8
Johannesburg: JHBCape Town: CPT
uMzinyathi: DC24Pixley ka Seme: DC7
Overberg: DC3Tshwane: TSH
Sekhukhune: DC47Namakwa: DC6
uMkhanyakude: DC27West Coast: DC1
Cape Winelands: DC2Central Karoo: DC5
Xhariep: DC16
100 200 300
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
NHI
133.3
121.7
86.3
168.5
105.2
229.7
123.2
132.9
0.0
192.2
123.3
117.8
148.4
122.5
94.4
165.9
76.9
63.3
161.0
208.3
123.0
71.6
109.8
123.3
53.6
186.6
194.1
84.0
174.4
95.7
111.2
353.7
121.4
61.8
197.1
156.1
123.0
93.2
61.2
67.6
78.2
186.0
160.5
206.9
110.7
257.4
74.2
38.9 35.5
63.9
105.4
0.0 SA average: 133.3
ProvincesECFSGPKZNLPMPNCNWWC
103
Section A: Delivery
Figure 20: Maternal mortality in facility ratio by district, 2013/14
Annual trends: Maternal mortality in facility ratio
per 1
00 0
00 li
ve b
irths
0
100
200
300
400
500
600EC FS
●●
●● ●
GP
0
100
200
300
400
500
600KZN
● ● ●
●
LP MP
0
100
200
300
400
500
600
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
NC
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
NW
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
● ●
●
WC
EC A NzoEC AmatholeEC Buffalo CityEC C HaniEC CacaduEC Joe GqabiEC N Mandela BayEC OR TamboFS Fezile DabiFS LejweleputswaFS MangaungFS T MofutsanyanaFS Xhariep
GP EkurhuleniGP JohannesburgGP SedibengGP TshwaneGP West RandKZN AmajubaKZN eThekwiniKZN Harry GwalaKZN iLembeKZN UguKZN uMgungundlovuKZN uMkhanyakudeKZN uMzinyathi
KZN uThukelaKZN uThunguluKZN ZululandLP CapricornLP MopaniLP SekhukhuneLP VhembeLP WaterbergMP EhlanzeniMP G SibandeMP NkangalaNC Frances BaardNC JT Gaetsewe
NC NamakwaNC Pixley ka SemeNC ZF MgcawuNW BojanalaNW Dr K KaundaNW NM MolemaNW RS MompatiWC Cape TownWC Cape WinelandsWC Central KarooWC EdenWC OverbergWC West Coast
●
●
●
104
Section A: Delivery
Figure 21: Annual trends: Maternal mortality in facility ratio
Annual trends: Maternal mortality in facility ratio by SEQ
per 1
00 0
00 li
ve b
irths
0
100
200
300
400
500
60020
07/0
820
08/0
920
09/1
020
10/1
120
11/1
220
12/1
320
13/1
4
SEQ 1
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
● ●
●
SEQ 2
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
SEQ 3
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●
●
●
●
SEQ 4
2007
/08
2008
/09
2009
/10
2010
/11
2011
/12
2012
/13
2013
/14
●
●
●
● ●
SEQ 5
1 A Nzo1 Amathole1 C Hani1 Harry Gwala1 Joe Gqabi1 OR Tambo1 RS Mompati1 Sekhukhune1 uMkhanyakude1 uMzinyathi1 Zululand2 Capricorn2 iLembe
2 JT Gaetsewe2 Mopani2 NM Molema2 Pixley ka Seme2 Ugu2 uThukela2 uThungulu2 Vhembe3 Amajuba3 Bojanala3 Cacadu3 Ehlanzeni3 G Sibande
3 T Mofutsanyana3 uMgungundlovu3 Waterberg3 Xhariep3 ZF Mgcawu4 Buffalo City4 Central Karoo4 Dr K Kaunda4 Eden4 Fezile Dabi4 Frances Baard4 Lejweleputswa4 Namakwa
4 Nkangala4 West Rand5 Cape Town5 Cape Winelands5 Ekurhuleni5 eThekwini5 Johannesburg5 Mangaung5 N Mandela Bay5 Overberg5 Sedibeng5 Tshwane5 West Coast
●
●
●
105
Section A: Delivery
Figure 22: Maternal mortality in facility ratio by SEQ
106
Section A: Delivery
There is an association between districts with a high HIV prevalence according to the 2012 Antenatal Sero-prevalence Survey and those with a high MMR in 2013/14, as can be seen in Figure 23. There was no apparent association with TB incidence (all types).
Figure 23: Scatterplot of maternal mortality in facility ratio versus HIV prevalence and TB incidence (all types) by district, 2013/14
When comparing the stillbirth rate and early neonatal death rate, these were also high in districts with a high MMR (see Figure 24).
There is also an association with a high MMR in facilities where a high number of C-sections are done. This applies to all facilities and does not hold true when looking only at district hospitals.
107
Section A: Delivery
Figure 24: Scatterplot of maternal mortality in facility ratio versus SBR and ENDR by district, 2013/14
At DHB workshops conducted in 2013 and 2014, reasons for poor performance included:
✦ bleeding after C-section is not well managed and additional skills are needed;
✦ blood for transfusions is not always readily available;
✦ Emergency Medical Services are not readily available for inter-facility transport of patients;
✦ South Africa is a multicultural environment with many traditional beliefs and traditional healers. Patients use a concoction to induce labour that wears off but contributes to maternal and foetal fatigue;
✦ dishonesty among patients who “lose their maternal record” so that high-risk women not easily identified;
✦ patients with unrecognised chronic conditions;
✦ late or no booking;
✦ insufficient staff allocated to labour wards;
✦ failure of staff to recognise complications;
✦ poor compliance with protocols;
✦ inadequate leadership and supervision;
✦ wards (especially labour wards) supplemented by nursing students who are inexperienced and are left to manage women on their own;
✦ nursing unit heads should be seeing all patients but are not doing so and are not aware of which patients are in labour;
✦ compulsory rotation of staff through various specialities in the facility at regular intervals can be problematic as this results in not having expert and passionate nursing staff working in labour ward;
✦ receiving hospitals often only have junior doctors.
It is clear that action should be taken to address the direct and avoidable causes of obstetric deaths in order to continue to see a decline in the MMR.
top related