AFJOG

ORIGINAL RESEARCH African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | Maternal deaths from Obstetric Haemorrhage 2020-2022 Figure 9: Bleeding associated with CD CFR per triennia and province from 2014-2022 0 10 20 30 40 50 60 70 80 Eastern Cape FreeState Gauteng Kwazulu Natal Limpopo Mpumulanga NorthWest Northern Cape WesternCape SouthAfrica CFR per 100,000 CD Province 2014-2016 2017-2019 2020-2022 Health system issues: antenatal care, level of care that woman died and obstetric referrals. Antenatal care was received by 87.7% of women who died from OH. The majority of OH deaths (88%) 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 21 deaths at CHCs, 36 in private hospitals, 15 outside a health facility and 13 in transit to or between facilities The corresponding triennial iMMR for level of care was 5.7 maternal deaths per 100,00 LBs in CHCs, 13.2 in DHs, 22.8 in RHs and 44.7 in TH/NCs (Figure 10). These level of care statistics refer to where the women died, not where they delivered, and it must be noted that many women were referred from district level due to bleeding after vaginal delivery or CD. Figure 10. iMMR for obstetric haemorrhage per level of care from 2020-2022 0.0 10.0 20.0 30.0 40.0 50.0 60.0 CHC Districthospital Regional hospital Natcentral &Tertiary hospital Total CHC Districthospital Regional hospital Natcentral &Tertiary hospital Total CHC Districthospital Regional hospital Natcentral &Tertiary hospital Total CHC Districthospital Regional hospital Natcentral &Tertiary hospital Total 2020 2021 2022 2020-2022 iMMR/100000 live births There were 56.1% of the OH deaths who had been referred, mostly from CHCs (16.3%) and district hospitals (23%) demonstrating the importance of availability of emergency transport and optimizing care before and during referral. Table 4 shows the different causal subcategories of OH deaths per level of care. PPH after vaginal delivery was the most frequent cause of death outside a facility (80% of 15 deaths), at CHCs (57.1% of 21 deaths), and at district hospitals (38.3% of 186 deaths). BLDACD was the most frequent cause of death at regional hospitals (35.5% of 186 deaths), tertiary/national central hospitals (35.1% of 174 deaths), and private hospitals (69.4% of 36 deaths). Table 4: Subcategory of OH cause per level of care OH causal subcatgory Outside CHC District hospital Regional hospital Tertiary /NC hospital Private hospital Total Antepartum haemorrhage 0 8 32 46 40 1 127 Ruptured uterus 3 1 25 32 25 4 90 PPH after vaginal delivery 12 12 64 42 48 6 184 Bleeding at/after Caesarean delivery 0 0 46 66 61 25 198 Total 15 21 167 186 174 36 599 Preventability of maternal deaths due to obstetric haemorrhage Assessors judged the majority (85.5%) of the OH deaths to be possibly or probably avoidable by the health system, slightly less than 89.5% in the previous triennium; and 52.4% were thought to be probably avoidable. Patient related avoidable factors, mostly delay in seeking care, were present for 35.4% of women who died. Administrative avoidable factors occurred for 69.8%, highlighting major problems in human resources, health facility management and training. This included lack of blood (8.5%), delays in inter-institution transport (11.4%), delays initiating clinical care due to overburdened services (12.2%), lack of staff (13.4%) and lack of staff with appropriate skill (18.5%). Health worker/medical related avoidable factors occurred for 41% of assessable deaths at CHC level, 83.2% at DH, 74.4% at RH, 61% at TH/NC and 80% at private hospitals. At CHC and DH, problems were identified with initial assessment and problem recognition. For example, many women were discharged from labour ward to postnatal ward with abnormal vital signs and unrecognized PPH. At all three levels of hospital, substandard care was the most frequent problem. Emergency hysterectomy was performed in 27.4% of all OH deaths (19.4% of deaths from bleeding associated with CD and 10.2% of women dying from PPH after vaginal delivery). KEY FINDINGS OF SUBSTANDARD CARE IDENTIFIED BY FOLDER REVIEW The following overarching themes emerged from folder review and will be presented as general problems, and those specific to different causal subcategories of OH. General 1. Late detection of PPH after vaginal delivery and at / after CD. For PPH after vaginal delivery: the diagnosis was frequently made too late in labour ward only after changes in vital signs had occurred and women had already lost more than 1000mls blood; or the diagnosis was made in the postnatal ward after discharged from labour ward with abnormal vital signs. At Caesarean delivery: excessive bleeding was frequently not noticed because the surgery was done too quickly, and the abdomen closed without careful intraoperative inspection prior to closing the abdominal wall; or abnormal vital signs in the recovery area were not acted upon; or the patients were sent too early to the postnatal ward because of insufficient midwives to staff the recovery area. 2. Poor prevention, detection, and management of anaemia. Routine surveillance of haemoglobin was not done at each antenatal visit or in labour; and the only antenatal treatment administered was oral iron with minimal use of parenteral iron 3. Problems with inter-institution referrals. This was most frequently observed from district hospitals, and was due to long distances, lack of ambulances and non-availability of paramedics to accompany bleeding patients who required ongoing resuscitation. African Journal of Obstetrics and Gynaecology | Volume 3 | Issue 1 | 2025 | 09