South Africa's maternal mortality rate is on the road to recovery

South Africa is fighting an uphill battle to bring down its maternal mortality rate after a significant spike in deaths during the height of the country’s HIV pandemic.

The rate of deaths rose dramatically after 1998, almost doubling to 302 per 100,000 live births by 2009 with the trend line still rising. Since then, the rate has declined by about one-third, but has still not returned to the 1998 level of 150 deaths per 100,000 live births.

South Africa is also not close to meeting its Millennium Development Goal target of 38 deaths per 100,000 live births. This sets it apart from other developing countries, such as India and Brazil, that are within reach as the 2015 deadline draws to a close.

However, other countries have not had the severe HIV epidemic seen in sub-Saharan Africa and have had a significant fall in maternal deaths. Directly comparing South Africa with them is unfair.

The reasons for the recent trends in South Africa are not hard to identify. Since the start of the new millennium, South Africa has had to contend with an HIV epidemic and a set of confused policies to address it.

Positive trend line, but still a long way to go

The good news is that the maternal mortality rate has been coming down steadily since 2009 and is likely to fall below the 1998 level very soon.

Between 2000 and 2010, there was considerable development of new antiretroviral drugs such as emtricitabine, efavirenz and tenofovir – which have been combined into one tablet that could treat the HIV infection. The cost of these drugs also began declining. But the real turnaround began in 2009 with the appointment of Aaron Motsoaledi as South Africa’s health minister.

Dramatic changes in the government’s approach to HIV soon became apparent. Health policies aimed at dealing with HIV became clear and coherent. An HIV screening and treatment programme was scaled-up and considerably expanded. This resulted in a concerted nationwide effort to get people screened for HIV and treated, if necessary.

Data from 2011 and 2012 demonstrated a significant fall in maternal deaths due to infections not related to pregnancy, indicating the success of the HIV screening and treatment programme. Enormous strides have been made in first curbing the rise and now reducing deaths related to HIV infection.

The Department of Health is to be congratulated on this achievement – but there is still a very long way to go.

HIV’s long shadow

The bad news is that South Africa remains way off meeting its Millennium Development Goal target.

When maternal deaths were at their highest, more than two-thirds of all mothers who died were HIV-infected. The most common cause of maternal deaths was infections not related to pregnancy such as tuberculosis (TB) and pneumonia. More than 90% of these women were infected with HIV.

Being HIV-infected increases the chances of a woman dying due to other pregnancy complications such as haemorrhage (bleeding) or hypertension (high blood pressure) by five to ten-fold.

HIV infection rates in women attending antenatal care peaked at about 30% in 2005. It has remained fairly constant.

Efforts to prevent HIV infection were concentrated on reducing the mother’s transmission of HIV to her child, and various publicity campaigns. The prevention of the transmission of the virus from the mother to the child has been very effective.

However, the campaigns to prevent the spread of HIV infection among adults have been less successful. So what set of policies does South Africa need to reduce the number of mothers dying from HIV?

Set of policies has worked

After the 2009 election, Motsoaledi signed a Negotiated Service Delivery Agreement with President Jacob Zuma. Two of the outcomes were to increase life expectancy and to reduce the deaths of pregnant women and children.

The maternal mortality rate by that stage had doubled to a rate of 302 deaths per 100,000 live births. The trend was still increasing. The target set for Motsoaledi was to reverse the increasing trend of maternal deaths and reduce the rate to 252 per 100,000 live births by 2014. These were targets considerably higher than the Millennium Development Goal, but realistic considering the HIV epidemic.

Since 2012, the Health Data Advisory and Coordinating Committee has produced Rapid Mortality Surveillance reports. The latest report (2014) has recently been released, and deals with the period from 2000 until 2013. It gives the maternal mortality rate at 197 deaths per 100,000 live births for 2011.

Establishing the rate has been difficult and there are many estimates of it from different organisations. However, all estimates indicate a sharp and rapid decline from about 2009.

What should South Africa be doing now?

HIV infection, particularly the deathly combination of HIV and tuberculosis, is still the most common underlying factor in the deaths of mothers. Added to this is that health issues such as haemorrhage and hypertension in pregnant women are becoming increasingly present.

Tackling these problems will require changes to the health system to enable it to be more effective and responsive to all the people in South Africa, especially those in underserviced areas.

Robert Pattinson receives funding from SAMRC, UKAid, European Union, CDC, UNICEF and WHO. He is a member of the National Committee for the Confidential Enquiries into Maternal Deaths.