The profile of maternal deaths in a district hospital : a five-year review of maternal deaths at Northdale Hospital (2006-2010).

Abstract

Background The estimated global number of maternal deaths has decreased from 536000 in 2005 to 358000 deaths in 2008. Sub Saharan Africa contributed with 57% of maternal deaths in 2008. Although there is a general decrease in maternal deaths, available data shows that most countries, including South Africa, will not meet their Millennium Development Goal 5 A target by 2015. The South African target is a maternal mortality ratio of 38 deaths per 100000. Based on various sources, South African maternal mortality ratio is on the increase. The United Nations interagency estimates placed South African maternal mortality ratio at 410 in 2008 from 260 in 1990. It is therefore necessary that health facilities, the government and the community at large make an effort to reduce avoidable maternal deaths. Aims The main aim of the study was to clinically and demographically profile maternal deaths at Northdale Hospital, assess the quality of care provided to maternal death patients and make recommendations to the hospital clinical management. Secondary objectives included the determination of the following: the prevalence of Human Immunodeficiency Virus infection among maternal deaths, and the commonest primary and final causes of deaths. Methods This cross-sectional survey retrospectively reviewed maternal deaths patients’ records at Northdale Hospital, a district hospital in South Africa. All 61 pregnancy-related deaths that were reported from January 2006 to December 2010 fulfilled the criteria of maternal deaths and were included in the study. Demographic and clinical characteristics of patients were extracted from patients’ charts using a structured pre-designed data sheet. Descriptive statistics were computed and analysed using IBM SPSS software. Medical records of all 61 deaths were assessed by three assessors who determined the causes of death and evaluated the quality of care received by each patient. Results A decrease in number of maternal deaths and maternal mortality ratio has been noticed during the study period. The average maternal mortality ratio for the study period was 204 per 100000 live births: ranging from 219 to 168. The majority of participants were of African origin aged between 20 to 34 years; with a mean age of 28 ± 6.4 years. Of the 61 maternal deaths reviewed, only 33 patients (54.1%) had attended antenatal clinic. Of these patients who had antenatal care, 57.6% booked at 20th week of gestation or earlier. The median number of antenatal visits was 4 visits. Of the 28 patients who died in the postpartum period, seven delivered at home and six had a caesarean section. Of those patients who had a caesarean section, three died within 24 hours, as a result of anaesthetic complications. Only 73.8% of all maternal deaths and 93.9% of those who attended antenatal care were tested for Human Immunodeficiency Virus. Of the 39 patients who tested positive for Human Immunodeficiency Virus infection, only 17 (43.6%) patients had their Cluster of Differentiation 4 cell count results; 10 patients were on antiretroviral triple therapy and four were on antiretroviral dual therapy. Half of the patients died within 41 hours of admission to the hospital. The five most common primary causes of maternal deaths at Northdale Hospital were non-pregnancy related sepsis (54.1%), miscarriage (14.8%), acute collapse (8.2%), pregnancy related sepsis (6.6%), and anaesthetic complications (4.9%). Antepartum haemorrhage, postpartum haemorrhage, pre-existing maternal conditions, hypertension, embolism and an unknown cause contributed 1.6% each. Almost half of maternal deaths were assessed as avoidable. Equally, almost half of maternal deaths received care that was assessed as substandard. Of these 30 patients who received substandard care, a different approach to the management would have made no difference for eight patients (13.1%) whose deaths were unavoidable anyway. A multidisciplinary approach to patients’ management, availability of blood/blood products and resuscitation medicines, and good communication with consultants at the regional hospital are some of the strengths on which Northdale Hospital should capitalise. Some of the problems that contributed to substandard care include: difficulties in referring patients to the regional hospital, inability of staff to manage emergencies correctly, inconsistent patients’ monitoring, and poor communication with the casualty department and the private sector. Conclusion The study has confirmed that the profile of maternal deaths at facility level may paint a totally different picture to what is found at the national level. While there is an increase at the national level, the number of maternal deaths and the maternal mortality ratio are on the decrease at Northdale Hospital, this decrease should be treated with caution as this may just be a yearly fluctuation. Non-pregnancy related sepsis remains the leading cause at both national and district hospital (Northdale Hospital) levels; the other four major causes of maternal deaths are somewhat different. The fact that almost half of the patients received substandard care and almost half of the deaths were assessed as avoidable is an issue of concern. The hospital should capitalise on its strength and build a basis for improvement in patient care. Recommendations The Primary Health Care coordinator should sensitise the community to improve their health seeking behaviour. The establishment of a mothers’ waiting lodge and acquisition of an ambulance dedicated to pregnant women and stationed at the hospital may reduce the number of home deliveries and delays in women at risk of complications accessing the health facility. The Prevention of Mother-to-Child Transmission programme should be strengthened and contraceptive use by all women but specifically by those tested positive for human immunodeficiency virus should be encouraged. Medical officers should be trained in the management of obstetrical emergencies (especially septic abortion) and resuscitation. Medical Interns should not be left unsupervised when attending to critically ill patients. Family physicians should actively assist the department of Obstetrics and Gynaecology in managing patients with medical conditions. Innovative ways should be found to improve the referral difficulties between Northdale and Grey’s Hospitals.