Maternal Mortality Review Lessons learned in South Africa

1. Maternal Mortality Review Lessons learned in South Africa RE MHLANGA Nelson R Mandela School of Medicine University of KwaZulu-Natal, DURBAN South Africa

2. MATERNAL DEATHS – GLOBAL TRAGEDY • Over 600 000 women die each year in the line of national duty for survival • Very few concerns are raised • Not a voice in protest can be heard concerning these deaths • Tsunami, Katrina • In South Africa, over 1500 women die because they happened to be pregnant

3. Maternal deaths – lessons from review WHY INVESTIGATE? Why do women continue to die? • CEDAW, Safe Motherhood Initiative • World Summit Goals, ICPD, Beijing POA • Free health care – pregnancy, children < 6 yrs • UN Convention on the Rights of the Child Magnitude of maternal mortality unknown Associated factors unknown, not investigated • Need for monitoring and evaluation of interventions

4. Maternal deaths – lessons from review • Task team • Pilot project over six months • Maternal death notification form – user friendly • Orientation and advocacy for maternal death notification • Collating data and producing report • Making recommendations • Monitoring implementation

5. MDR - lessons • Community mobilisation - political buy-in • Identification of cases, notification and report • Development of guidelines • Oversee process • Strengthening of health system - capacity • Monitoring of implementation of recommendations • Partnerships – signing from the same page • Feedback to policy makers - strengthen buy-in

6. The maternal mortality surveillance cycle Identify cases Collect information Implement Evaluate and refine Recommendations for action Analyse the results

8. Key principle: Confidentiality • No names • Confidentiality assured • No blame • Not used for litigation or punitive action • Staff are reassured.

9. Maternal deaths – lessons • Looking at wrongs and mistakes • Human resources • Budget for increase in challenges • Challenges change in time • HIV and malnutrition change things • Recommendations, not a wish-list • Strategy for implementation • Indicators for monitoring implementation

10. Looking at wrongs and mistakes Facility • Meeting of the team – no blame • Check with guidelines or protocols of Mx • Filling of maternal death notification form Provincial • Completeness of information • Assessment National • Quality, causes and avoidable factors

11. Maternal Deaths – lessons GUIDELINES: HYPERTENSIVE DISORDERS • Antenatal diagnosis and management • Timely delivery • Management of emergencies – eclampsia, assoc. abruptio placentae • Mag. sulphate regime • High care • Follow-up

12. Reducing Maternal Deaths HAEMORRHAGE • Antenatal prevention of anaemia • Identification for active management of 3rd stage of labour • Skilled intervention – midwives, doctors, specialists • Community management of postpartum haemorrhage – abdominal aorta compression by lay people • Institutional - condom/balloon method, advanced surgical intervention, selective embolisation, sub/total hysterectomy • Blood supply, transport • Guidelines and protocols

13. Challenges change in time • HIV and complications • Impact on staff and inevitability of death • Increase work load • Brain drain or looting • Need for midlevel workers

14. Primary obstetric cause of reported maternal deaths: 1998-2001 Numbers

15. Levels of care where maternal deaths due to accidents of anaesthesia occurred: 1998-2001

16. BUDGET and HUMAN RESOURCES • HIV added needs for material, financial and human resources • Training and retraining • Accommodation • Time • Revitalization of staff, assessors • Preparedness and transparency

17. Maternal deaths – lessons from review • Unexpected outcomes • Commitment to address the associated factors • Perinatal health • Increased funding for women’s health – change in approach to women’s health • Millennium Development Goals • Stigma of HIV invades health workers and professionals • Care to count • Behind numbers are faces and shattered lives

18. Let us commit ourselves To women care, safety and concern One death is one death too many Let us find out what went wrong And correct the mistakes we have made We must do what we have to do EVERY MOTHER AND CHILD COUNTS It is all about moving people’s hearts Commitment starts with me

19. THANK YOU

20. An unarmed army In the face of tragedy, we decided to look away In the hour of need, we chose to seal our ears The wind blew, and the petals flew And the seed was not to be The army marched on an empty stomach An army unarmed, an army forced They stumble and tumble by the hundreds Hardware of war we shall buy While the army we shall starve Whose war is it; whose struggle It is national duty, it is national responsibility A person is a person through others A person is a person through her mother

21. Do we not owe the army Recognition Do we not owe the army Means of transport Do we not owe the army Loyalty and support Let us join hands Each of us contribute to the greater good Of women and children. If we seek to save ourselves only We shall all but perish I am sorry I was not there to respond to your cry I was not there to stop the abuse, the blood, the pain But, I shall always remember you As I look into the mirror and see myself I am because you were, because you are.

22. Pass it on …. “If you live for yourself You’ll live in vain, (But if you) live for others You’ll live again…” Bob Marley