AFJOG

ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | Maternal deaths from Obstetric Haemorrhage 2020-2022 ABSTRACT Introduction: The SA national confidential enquiry into maternal deaths (NCCEMD) produces triennial reports, the most recent being for 2020 to 2022, which showed marked increase in iMMR during the Covid-19 pandemic years (2020-2021). The purpose of this paper was to perform an in-depth analysis of deaths from obstetric haemorrhage (OH) during 2020-2022. Methods: Data on OH deaths were retrieved from the database, MaMMAS, of the NCCEMD. In addition, a secondary analysis was performed by the chapter author from a review of the hard copy files of OH maternal deaths which contained the clinical notes, maternal death notification forms and assessors forms. Descriptive statistical analysis was conducted to analyse all maternal deaths. Results: Maternal deaths (MDs) from OH increased in the 2020-2022 triennium and accounted for 599 maternal deaths (16.4% of total maternal deaths) compared to 544 (15.7%) in 2017-20119. OH was the second most common cause of maternal death with an iMMR of 19.8 deaths per 100,000 live births compared to 19.1 in 2017-2019, with considerable variation between provinces. The higher number of OH deaths in 2020 and 2021 probably reflected an indirect effect of the Covid-19 pandemic which adversely affected the functioning of the health system due to staff shortages, reallocation of duties, overburdened ICUs and emergency transport services. The major causal subcategory groupings of OH deaths were bleeding associated with caesarean delivery (33.1%), postpartum haemorrhage (PPH) following vaginal delivery (30.7%) from uterine atony, genital tract trauma, retained placenta and unspecified PPH, antepartum haemorrhage (21.2%) mostly from abruptio placentae, and ruptured uterus (15.0%), equally from a scarred and unscarred uterus. The majority of OH deaths (88%) had antenatal care and occurred at public hospitals; 27.9% at district hospitals (DH), 31.1% at regional hospitals (RH) and 29% at tertiary hospitals (TH/NC). There were 56.1% of the OH deaths who had been referred, mostly from community health centres (16.3%) and district hospitals (23%) reiterating the significance of emergency transport availability and optimizing care before and during referral. Assessors judged the majority (85.5%) of the OH deaths to be possibly or probably avoidable. Patient /community related factors occurred in 35.4%, and administrative avoidable factors in 69.8%, highlighting major problems in health facility management and training. Health worker/medical related avoidable factors occurred for 41% of assessable deaths at community health centre level, 83.2% at district hospitals, 74.4% at regional hospitals, 61% at tertiary and national central hospitals and 80% at private hospitals. Vignettes are presented to illustrate problems identified; and a list of key recommendations is presented. Conclusion: The promising decrease in obstetric haemorrhage deaths up to 2019 was negatively affected by the Covid-19 pandemic, and OH became the second most common cause of MD, with the majority being potentially preventable. Lack of optimal care by the health system and relevant providers were the most common preventable factors. Important interventions such as E Motive approach, surgical safety at caesarean delivery (CD), blood transfusion protocols and availability and prevention of anaemia should all facilitate improvement in the coming years. INTRODUCTION The eighth triennial Saving Mothers comprehensive report for 2020-2022 presents an overview of maternal mortality, with underlying causes, trends, associated factors and preventability, compared to previous triennia. It is important to note that this report covers the period in which the Covid-19 pandemic, which was declared a public health emergency in South Africa in March 2020, until May 2023 occurred. The purpose of this paper is to perform an in-depth analysis of deaths from obstetric haemorrhage (OH) during 2020-2022. METHODS The method used to compile the triennial report was the same as used for previous reports. 1,2,3 All maternal deaths (MDs) were notified to the provincial maternal, child and women’s health office, assessed by independent assessors, and data entered anonymously into the secure password protected national Maternal Morbidity and Mortality Audit System (MaMMAS) database used by the NCCEMD. The classification of maternal deaths (MDs) used in South Africa is based on the WHO ICD-10 adaptation for maternal deaths whereby maternal deaths are classified by primary obstetric cause, for example (OH), non pregnancy related infections (NPRI) etc. 4,5 The number of live births was obtained from the DHIS database and this is used as the denominator to calculate maternal mortality rates. The term institutional MMR is used (iMMR) to reflect the fact that the MD enquiry is predominantly facility based with under reporting of home deaths and births. Data tables on OH were derived from the MaMMAS database. In addition, a secondary analysis was performed by the chapter author from a review of the hard copy files of OH MDs which contained the clinical notes, maternal death notification and assessors forms. The analysis of deaths is by descriptive statistical methods. The MaMMAS database is confidential, anonymised and contains no patient or provider identifiers. All data was collected retrospectively in line with the NCCEMD process mandated and protected by the National Department of Health (NDOH). The hard copy OH files reviewed for this chapter are the property of the NCCEMD, and chapter authors are pledged to confidentiality whilst reviewing the files which are all kept in a secure location. After publication of the second edition of the comprehensive eighth triennial report all hard copy data are destroyed. Results of analysis of maternal deaths due to obstetric haemorrhage 2020-2022 SR Fawcus 1 , Su-Ritha Wessels 2 1 Professor Emeritus and Senior Research scholar, Department of Obstetrics and Gynaecology, University Cape Town; and NCCEMD, South Africa 2 Medical officer, Robert Mangaliso Sobukwe Hospital, Kimberly, Northen Cape; and NCCEMD, South Africa CORRESPONDENCE: S Fawcus | Email: sue.fawcus@uct.ac.za Maternal deaths from Obstetric Haemorrhage 2020-2022 African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 06