The turn of the century brought with it many changes. For starter’s the dreaded Y2K which had everyone worried that all power and computers are going to shut down on the 1 January 2000. This necessitated the largest upgrade of computer systems globally at that time, and still ensures that the year is now written in full as opposed to the last two digits which the norm at the end of the last century.
However of more significance globally, was the United Nations Millennium Declaration, in 2000. This gave birth to the eight Millennium Development Goals (MGD’s), designed to uplift quality of life, health, food security and environment globally. MDG 5A Maternal Mortality Ratio (MMR) Target was to reduce maternal deaths by three quarters between 1990 and 2015. South Africa missed this target to decrease child and maternal deaths with current MMR of 140.
The world Health Organisation, defines maternal death of a woman as, “while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of the pregnancies, from any cause related to; aggravated by the pregnancy or its management, but not from accidental and incidental causes”. A further distinction is made between direct causes, when death is attributed to the pregnancy and indirect causes where the pregnancy fatally aggravates a pre-existing condition.
It is said, that a reduction in the MMR will significantly contribute towards achieving almost all other MDGs such as, poverty eradication and hunger; achieving universal primary education and reducing child mortality. Healthy mothers’ allow a country to maximise it’s available human capital which in the longer term, will assist in reducing poverty. Maternal Health is also a key indicator of the strength of a country’s health system; providing early warning signals of wider health systems problems.
Maternal health care is a priority reproductive health issue, hence the National Department of Health has made maternal deaths a notifiable condition by establishing of the National Committee on Confidential Enquiry into Maternal Deaths (NCCEMD).
The Welfare of the country’s mothers’ has profound development impact. Reducing MDG5, contributes to the achievement of almost all the other six MDG’s, such as, poverty eradication and hunger; achieving universal primary education and reducing child mortality. Healthy mothers’ allow a country to maximise it’s available human capital which in the longer term, will assist in reducing poverty. Maternal Health is also a key indicator of the strength of a country’s health system; providing early warning signals of wider health systems problems.
To date, however, the growing litigation, arising from maternal deaths due to healthcare worker negligence has seen Provincial departments cash-strapped but more significantly, more children have to grow up without their mother’s. Recently the KZN Department of Health, settled R 25million claim to 2 mothers for children but it is believed that the department is facing claims over R 1 billion as per the National Department of Health. My focus however, is maternal deaths like recent RK Khans hospital tragedy and others reported by the NCCEMD.
As an upper middle-income economy, South Africa is achieving low-income success due to among other factors; poor record keeping; lack of real-time assessment resulting from outdated data and no benchmarking. Skills challenges and medical negligence claims that threaten the future and is worrying. SAs caesarean section is at 20%, yet the WHO recommends < 5%.
The KZN MMR of 274 (2014/2015) is nearly double the National figure. This is concerning since maternal death is mostly preventable.
If the Skilled Birth Attendants (SBA) target of 100% had already been achieved then why is the MMR still remain five times above the targeted 38/100000 live births. She question how “skilled” are SBA’s this is an important area that need evaluation.
The top five causes of maternal deaths are haemorrhage, pregnancy-related infections, hypertension, anaesthesia and HIV.
Maternal deaths are preventable with adequate nutrition proper healthcare, access to family planning, and the presence of a SBA during delivery or emergency obstetric care. Therefore access to SBAs with necessary training and medicines to administer interventions are pivotal, however, high numbers of SBA alone, may not necessarily translate into quality healthcare.
The role and skills of the SBA when contrasted with the traditional birth attendant, independent of the formal health system. Usually with no formal training, being a community based healthcare provider, which is why many believe that traditional birth attendants must be incorporated into a formalised structures aiming to provide minimum standards and skills transfer.
National Health Minister stated that “dismal obstetrics and gynae training was contributing to highly preventable maternal deaths”, necessitating the need for a skills audit and further training, with a view in the medium term to implement the WHO initiative of ‘Treat, Train and Retain’. For the long term, there must be accelerated production of health professionals oriented to practice in low-resource environments.
The view that; ‘every death counts’, hence healthcare workers are the “doers”, requiring relevant skilling in order to save both mothers and babies. The task of evaluating the critical role played by SBA’s must be carried with the aim to improve maternal mortality outcomes.
SBA training, remuneration and the adoption of the Skilled Birth Index( SBI) for example to measure performance and improve MMR outcomes, must be prioritised.
Generalisation given cultural, legal and ideological acceptability and sustainability strategies is difficult, but a vital consideration to adopt evidence based standards and provider competence benchmarks.
In conclusion, investments in quality of care must be prioritised and the skilled birth attendant reclassification is imperative given the high MMR, using applied assessment tools as indicator sets to measure quality aspects of SBA concept, classification and roles in different levels of health facilities for conformity of application, as NHI is rolled-out, with a focus on special Maternal and Child Health Hospitals to achieve the broader objective of reducing Maternal Mortality.