Addressing Maternal Morbidity and Mortality in KwaZulu-Natal, South Africa: A Multi-Staged Approach
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Firoza Haffejee
and Nokuthula Sibiya
Department of Basic Medical Sciences, Faculty of Health Sciences, Durban University of Technology
•
Worldwide MMR = 210 / 100 000
•
Developed countries = 16 / 100 000
•
Developing countries – very high
Maternal Mortality in South Africa
•
South Africa has a very high maternal mortality rate.
•
Although the maternal mortality rate has dropped in recent years to
138/100 1000
live births
•
Unacceptably high
Global Maternal Mortality Rates per 100 000 live births, 2015
Adapted from: WHO, 2017
South African Provincial Maternal Mortality Rate per 100 thousand live births
Adapted from: Saving Mothers Report, 2014
Reasons for high MMR in South Africa
Reasons for high MMR in South Africa
•
Obstetric haemorrhage
•
Deaths related to HIV infection
•
Hypertensive diseases in pregnancy
•
Eclampsia
•
Pre-eclampsia
•
Sub-Saharan Africa accounted for 6800 (91%) of the estimated 7500
maternal deaths attributed to acquired immunodeficiency syndrome
(
AIDS
) worldwide
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:
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1
4
Middle East & North Africa
240 000
[150 000 – 320 000]
Sub-Saharan Africa
25.8 million
[24.0 million – 28.7 million]
Eastern Europe & Central Asia
1.5 million
[1.3 million – 1.8 million]
South & South-East Asia
5.0 million
[4.5 million – 5.6 million]
Oceania
53 000
[47 000–60 000]
North America and
Western & Central Europe
2.4 million
[1.5 million – 3.5 million]
Caribbean
280 000
[210 000 – 340 000]
Latin America
1.7 million
[1.4 million – 2.0 million]
East Asia
830 000
[590 000–1.2 million]
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Total = 36.9 million [34.3– 41.4 million]
Source
: UNAIDS Global Report
2014
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Uneven distribution across
the 9 provinces
•
KZN – worst affected (red) –
HIV prevalence in
respondents 2 years and
older was
17.4%
•
WC – lowest HIV prevalence
5.1%
Source: Shisana et al HSRC South African National HIV Survey 2012)
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Y
o
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•
remain worst affected
•
acquire HIV much
earlier -at least 5-7
years
•
peaks at a younger
age in women
compared to men
Problems faced
•
Despite widespread availability of free ANC services in South Africa
most
women attend their first antenatal clinic late
in pregnancy
fail to return for any follow up care
•
Although 71% of pregnant women attend formal ANC at least once
only 44% attend ANC four or more times
as expected
•
Inadequate ANC is a risk factor for maternal mortality
•
A total of 37.5% of these maternal deaths were as a result of
avoidable factors related to
•
non attendance at ANC
•
infrequent ANC attendance
AIMS & OBJECTIVES
•
Identify risk factors that lead to adverse pregnancy outcomes
•
To determine the association between socio-economic, lifestyle,
psychosocial & cultural characteristics
Maternal health Outcomes
•
To determine food consumption patterns and nutritional status of
pregnant women
OUR FINDINGS
Participant Demographics
•
89.9%
single
women
•
70.8%
unemployed
•
65% women resided in households where the income was less than
R1 500.00 per month
•
Mean gestational age for 1
st
ANC booking: 13.8 ± 5.12 weeks
•
range: 2-30 weeks
HIV Status
•
44% were HIV positive
•
44 babies were on prevention of mother to child treatment (PMCT)
for HIV
Antenatal Care
•
Late bookings still prevail
•
A large number of women (57%) book their first ante-natal visit after
12 weeks of gestation
•
This was not correlated with any socio - demographic factors or
underlying medical conditions
•
Late booking has previously been shown to be associated with
adverse pregnancy outcomes (Pattinson, 2007)
Antenatal Satisfaction
•
70% were satisfied with services at the clinic
•
56% felt that the waiting time was appropriate
•
Almost all (97%) were satisfied with the number of antenatal visits
Pregnancy Intention
•
Only
35.7% intended to have their pregnancy
•
Single women more likely to have unintended pregnancies (
p
<0.001)
•
Unemployed women were more likely to have unintended
pregnancies (
p
=0.020)
•
No relationship with alcohol consumption, illicit drug use or smoking
vs pregnancy intention
•
Single women are more likely to engage in sexual activity for reasons
other than child bearing
•
Absence of inter-partner communication regarding pregnancy raises
the risk of unintended pregnancies
•
This is reported to delay prenatal care
•
The proportion of single status within the study population was high,
with a total of 82% women being single
•
This is consistent with findings of high single status among women
from peri-urban areas in South Africa
•
75% used contraceptives
•
There was no relationship between pregnancy intention and contraceptive use
•
36.6% reported that they thought they could not get pregnant
•
Only 2% had difficulty in accessing contraception
•
It is likely that contraceptive use was inconsistent
•
19.5% who reported using contraceptives also provided reasons for not using them
•
Condom usage - most popular method of contraceptive 35%
•
followed by the contraceptive injection 24%
•
Contraceptive usage in HIV positive participants was higher: 81%
•
75% in HIV negative participants
Emergency contraception (EC)
•
35% were aware of the availability of EC options
•
Only 18% utilised these services
•
Little difference in awareness between the two HIV status groups
•
HIV negative participants appear to have a slightly higher EC usage
(19%) compared to HIV positive participants (15%)
Nutritional status of pregnant women from
low socio-economic groups
•
Protein consumption 64% of recommended requirement
•
Required for foetal growth and development
•
Micronutrient intake 41%
•
Iron < 50%
•
Required for RBC
•
Low iron increases risk of preterm delivery and low birth weight
•
Calcium 30.8%
•
Skeletal development of foetus
•
Maintenance of maternal bone
•
Folic acid 50%
•
Nerve development
Nutritional status of pregnant women from
low socio-economic groups
•
Vitamin A intake = high in 20% women
•
Retinoic acid syndrome in infants
•
Affects ear canals, brain formation and heart defects
•
In 80% = lower than recommended
•
Malformation of lungs, heart and urinary tract
Nutritional status of pregnant women from
low socio-economic groups
•
Carbohydrate intake = high
•
Sufficient energy levels
•
>50% overweight / obese in first trimester
•
Possible gestational diabetes
•
Pre-eclampsia
Conclusion
•
Late bookings for ANC
•
High numbers of HIV positive women
•
Large number of unintended pregnancies
•
Low use of contraceptives
•
Apparent satisfaction with ANC
•
Low nutritional status
Where to from here?
•
Educational intervention
•
Nutritional intervention
•
There is a need to promote health at individual and community levels
•
More qualitative research required
•
What services are they receiving?
•
Are these sufficient?
•
Why are they satisfied?
firozah@dut.ac.za
This study focuses on reducing maternal morbidity and mortality rates in KwaZulu-Natal, South Africa, which remain unacceptably high. The research by Firoza Haffejee and Nokuthula Sibiya highlights the need for a comprehensive, multi-disciplinary healthcare strategy to tackle the various factors contributing to maternal deaths. Reasons for high maternal mortality rates in South Africa, such as medical disorders, infections, and obstetric complications, are discussed. Globally, Sub-Saharan Africa carries a significant burden of maternal deaths, with a high number attributed to AIDS. The study emphasizes the importance of addressing these complex challenges through a systematic and integrated approach.
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A multi A multi- -staged, multi staged, multi- -disciplinary health care approach in reducing health care approach in reducing maternal morbidity and mortality in maternal morbidity and mortality in a selected district in Kwa a selected district in Kwa- -Zulu Natal, South Africa South Africa disciplinary Zulu Natal, Firoza Haffejee and Nokuthula Sibiya Department of Basic Medical Sciences, Faculty of Health Sciences, Durban University of Technology firozah@dut.ac.za
Worldwide MMR = 210 / 100 000 Developed countries = 16 / 100 000 Developing countries very high
Maternal Mortality in South Africa South Africa has a very high maternal mortality rate. Although the maternal mortality rate has dropped in recent years to 138/100 1000 live births Unacceptably high
Global Maternal Mortality Rates per 100 000 live births, 2015 Adapted from: WHO, 2017
South African Provincial Maternal Mortality Rate per 100 thousand live births Adapted from: Saving Mothers Report, 2014
Reasons for high MMR in South Africa 0.6 2.31.62.1 Medical and surgical disorder 13.3 2.9 Non-pregnancy-related infection 4.1 Ectopic pregnancy 3.6 Pregnancy-related sepsis Obstetric haemorrhage Hypertension Miscarriage 15.8 Unknown Embolism 29.6 Anaesthetic complications Adverse drug reactions Acute collapse - cause unknown Miscellaneous 16.7 HIV 2 5.3 Adapted from Saving Mothers report, 2014
Reasons for high MMR in South Africa Obstetric haemorrhage Deaths related to HIV infection Hypertensive diseases in pregnancy Eclampsia Pre-eclampsia
Sub-Saharan Africa accounted for 6800 (91%) of the estimated 7500 maternal deaths attributed to acquired immunodeficiency syndrome (AIDS) worldwide
Global HIV prevalence estimates : 2014 Global HIV prevalence estimates : 2014 Eastern Europe & Central Asia 1.5 million [1.3 million 1.8 million] IDU North America and Western & Central Europe 2.4 million [1.5 million 3.5 million] MSM, IDU HSex, MSM, IDU East Asia 830 000 MSM, IDU [590 000 1.2 million] Middle East & North Africa 240 000 [150 000 320 000] HSex, IDU South & South-East Asia Caribbean 280 000 [210 000 340 000] HSex, MSM 5.0 million [4.5 million 5.6 million] Hsex, IDU Sub-Saharan Africa 25.8 million [24.0 million 28.7 million] Latin America 1.7 million [1.4 million 2.0 million] HSex, MSM, IDU Oceania 53 000 [47 000 60 000] IDU HSex Total = 36.9 million [34.3 41.4 million] Source: UNAIDS Global Report
Countries with Highest HIV burden Prevalence Incidence
Prevalence of HIV in South Africa Uneven distribution across the 9 provinces KZN worst affected (red) HIV prevalence in respondents 2 years and older was 17.4% WC lowest HIV prevalence 5.1% Source: Shisana et al HSRC South African National HIV Survey 2012)
HIV in South Africa: Age Sex differences 1992 Young women remain worst affected acquire HIV much earlier -at least 5-7 years HIV Prevalence (%) 2005 peaks at a younger age in women compared to men 2012 Age categories in years
Problems faced Despite widespread availability of free ANC services in South Africa most women attend their first antenatal clinic late in pregnancy fail to return for any follow up care Although 71% of pregnant women attend formal ANC at least once only 44% attend ANC four or more times as expected Inadequate ANC is a risk factor for maternal mortality
A total of 37.5% of these maternal deaths were as a result of avoidable factors related to non attendance at ANC infrequent ANC attendance
AIMS & OBJECTIVES Identify risk factors that lead to adverse pregnancy outcomes To determine the association between socio-economic, lifestyle, psychosocial & cultural characteristics Maternal health Outcomes To determine food consumption patterns and nutritional status of pregnant women
OUR FINDINGS Participant Demographics 89.9% single women 70.8% unemployed 65% women resided in households where the income was less than R1 500.00 per month Mean gestational age for 1st ANC booking: 13.8 5.12 weeks range: 2-30 weeks
HIV Status 44% were HIV positive 44 babies were on prevention of mother to child treatment (PMCT) for HIV
Antenatal Care Late bookings still prevail A large number of women (57%) book their first ante-natal visit after 12 weeks of gestation This was not correlated with any socio - demographic factors or underlying medical conditions Late booking has previously been shown to be associated with adverse pregnancy outcomes (Pattinson, 2007)
Antenatal Satisfaction 70% were satisfied with services at the clinic 56% felt that the waiting time was appropriate Almost all (97%) were satisfied with the number of antenatal visits
Pregnancy Intention Only 35.7% intended to have their pregnancy Single women more likely to have unintended pregnancies (p<0.001) Unemployed women were more likely to have unintended pregnancies (p=0.020) No relationship with alcohol consumption, illicit drug use or smoking vs pregnancy intention
Single women are more likely to engage in sexual activity for reasons other than child bearing Absence of inter-partner communication regarding pregnancy raises the risk of unintended pregnancies This is reported to delay prenatal care
The proportion of single status within the study population was high, with a total of 82% women being single This is consistent with findings of high single status among women from peri-urban areas in South Africa
75% used contraceptives There was no relationship between pregnancy intention and contraceptive use 36.6% reported that they thought they could not get pregnant Only 2% had difficulty in accessing contraception It is likely that contraceptive use was inconsistent 19.5% who reported using contraceptives also provided reasons for not using them Condom usage - most popular method of contraceptive 35% followed by the contraceptive injection 24%
Contraceptive usage in HIV positive participants was higher: 81% 75% in HIV negative participants
Emergency contraception (EC) 35% were aware of the availability of EC options Only 18% utilised these services Little difference in awareness between the two HIV status groups HIV negative participants appear to have a slightly higher EC usage (19%) compared to HIV positive participants (15%)
Nutritional status of pregnant women from low socio-economic groups Protein consumption 64% of recommended requirement Required for foetal growth and development Micronutrient intake 41% Iron < 50% Required for RBC Low iron increases risk of preterm delivery and low birth weight Calcium 30.8% Skeletal development of foetus Maintenance of maternal bone Folic acid 50% Nerve development
Nutritional status of pregnant women from low socio-economic groups Vitamin A intake = high in 20% women Retinoic acid syndrome in infants Affects ear canals, brain formation and heart defects In 80% = lower than recommended Malformation of lungs, heart and urinary tract
Nutritional status of pregnant women from low socio-economic groups Carbohydrate intake = high Sufficient energy levels >50% overweight / obese in first trimester Possible gestational diabetes Pre-eclampsia
Conclusion Late bookings for ANC High numbers of HIV positive women Large number of unintended pregnancies Low use of contraceptives Apparent satisfaction with ANC Low nutritional status
Where to from here? Educational intervention Nutritional intervention There is a need to promote health at individual and community levels More qualitative research required What services are they receiving? Are these sufficient? Why are they satisfied?
