AFJOG

ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | Maternal deaths from Obstetric Haemorrhage 2020-2022 Major causal subcategories of OH deaths There are 16 major causal subcategory groupings of OH in the MaMMAS database that are illustrated in Figure 5. To simplify the analysis, these were grouped into 4 broad causal subgroupings of OH death as shown in Table 2 and include: 1. Bleeding associated with caesarean delivery (BLDACD, 33.1%, iMMR 6.6 MDs per 100,000 live births), mostly detected after CD. 2. Postpartum haemorrhage (PPH) following vaginal delivery (30.7%, iMMR 6.1 MDs per 100,000 live births), from uterine atony, genital tract trauma, retained placenta and unspecified PPH. 3. Antepartum haemorrhage (21.2%, iMMR 4.2 MDs per 100,000 live births) mostly from abruptio placentae but also from placenta praevia 4. Ruptured uterus (15.0%, iMMR 3 MDs per 100,000 live births) equally from a scarred and unscarred uterus. OH from BLDACD and PPH after vaginal delivery are the two largest causal subcategories. Compared to 2017-2019, the iMMR from PPH after vaginal delivery has decreased slightly, and remained similar for BLDACD, but iMMR for APH and ruptured uterus have increased slightly. Reviewing the last five triennia from 2008-2022, there had been a sequential decrease in iMMR for APH, and ruptured uterus which was not sustained in 2020-2022. PPH after vaginal delivery has shown gradual decline, and BLDACD MMR increased in 2011-2013 and 2014-2016 before declining in 2017-2019 and 2020-2022, as seen in Figure 6. Table 2. Causal subcategories of OH 2020-2022, compared with 2017-2019. Haemorrhage 2020- 2022 Number Haemorrhage % Haemorrhage % Haemorrhage 2017-2019 Antepartum Haemorrhage 127 21.2 17.6% Ruptured uterus 90 15.0 11.2% PPH after vaginal delivery 184 30.7 34.0% Bleeding at/ after Caesarean delivery 198 33.1 37.1% Total 599 100 100% Figure 6: iMMR for the broad subcategories of obstetric haemorhage per triennium 2008-2022 0 5 10 15 20 25 30 APH Ruptureduterus PPH after vaginal delivery BLDACD All OH iMMR/100000 live births Broad Subcategories of Obsteric haemorrhage 2008-2010 2011-2013 2014-2016 2017-2019 2020-2022 For all provinces, the two subcategories BLDACD and PPH after vaginal delivery, were the most common groupings, with APH third, except in the Western Cape, where it was the fourth commonest reason (Figures 7 and 8). Figure 7: Obstetric haemorrhage maternal deaths per causal subgroup per province 0 10 20 30 40 50 60 Eastern Cape FreeState Gauteng Kwa-Zulu Natal Limpopo Mpumalanga NorthWest Northern Cape WesternCape Number of maternal deaths per causal OH subgroups Province APH Ruptureduterus PPH after vaginal delivery BLDACD Figure 8: iMMR obstetric haemorrhage causal subcategories per province 0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 Eastern Cape FreeState Gauteng Kwa-Zulu Natal Limpopo Mpumalanga NorthWest Northern Cape WesternCape Total iMMR/100 000 live births Province APH Ruptureduterus PPH after vaginal delivery BLDACD Deaths from bleeding at/after caesarean delivery During 2020-2022, 889,497 caesarean deliveries (CDs) were performed, yielding a national CD rate of 28.8% (ranging from 21.2% in Mpumalanga to 35% Kwazulu- Natal). There were 198 deaths from BLDACD, 20 from morbidly adherent placenta, 34 from bleeding during CD and 119 from bleeding after CD. The case fatality rate (CFR) from BLDACD in 2020-2022 was 22.3 BLDACD deaths per 100,000 CDs, which is similar to 2017-2019 (23.6), thus it remained lower than in the 2014-2016 and 2011-2013 triennia. Of note in 2020-2022, is the wide discrepancy in BLDACD CFR between provinces with the highest rates in Mpumalanga (46.5 BLDACD deaths per 100,000 CDs) and Limpopo (38.1), with the lowest rates in the Western Cape (10.0) and KwaZulu-Natal (12.1).Table 3 and Figure 9. Table 3. BLDACD deaths and BLDACD CFRs per province 2020-2022 Province CD 2020- 2022 N CD Rate 2020- 2022 % BLDACD death 2020- 2022 N BLDACD CFR 2020-22 per 100,000 CD BLDACD CFR 2017-19 per 100,000 CD BLDACD CFR 2014-16 per 100,000 CD Eastern Cape 100672 30.4 14 13.9 28.9 25.2 Free State 45894 30.6 11 24 29.8 21.4 Gauteng 207695 29.5 57 27.4 24.1 24.6 Kwazulu Natal 232152 35 28 12.1 11.5 18.5 Limpopo 94513 23.1 36 38.1 52.5 70.8 Mpumalanga 58057 21.2 27 46.5 36.1 76.1 North West 43800 23.3 13 29.7 22.5 38.4 Northern Cape 15586 22.8 2 12.8 28.7 44.6 Western Cape 91123 29.8 10 11 6.9 15.6 South Africa 889497 28.8 198 22.3 23.6 31.7 African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 08