Charlotte and Matlou’s story is that of far too many South African women and the children who have to grow up without their mothers. South Africa is an upper middle-income country that is achieving low-income country success when it comes to maternal health. According to World Health Organisation (WHO) statistics, South Africa shares a position in the top forty worst maternal health countries in the world, with countries such as Ethiopia, Haiti, Liberia and Niger. Far too many mothers are dying before or after giving birth.
The welfare of a country’s mothers has profound development impacts. The Millennium Development Goals (MDGs) include a goal on the reduction in maternal mortality (MDGs 5). A reduction in the deaths of mothers contributes to the achievement of almost all other six MDGs, including the eradication of poverty and hunger (MDG 1), achieving universal primary education (MDG 2) and reducing child mortality (MDG 4). Healthy mothers allow a country to maximise its available human capital and, over the longer term, assist in reducing poverty. Maternal health is also an indicator of the strength of a country’s health system and provides early signals of wider health system problems.
Maternal mortality in South Africa almost doubled between 1990 and 2008. (1990 was the year when the MDGs were set). Data on births in hospitals, however, indicate that the turning point may have been reached in 2010 with maternal deaths in hospitals starting to decline in 2011. This improvement follows the implementation of the policy on the provision of ARV-treatment to all HIV-positive pregnant women with a CD4-count of 350 or lower in 2009/10.
While just more than 40% of maternal deaths in South Africa are caused by non-pregnancy related infections, mainly HIV/AIDs and tuberculosis (TB), 28% of mother’s deaths are due to bleeding (haemorrhaging) and high blood pressure. Data collected in hospitals indicate that 40% of the causes of maternal deaths are preventable, with the majority of deaths due to bleeding and high blood pressure being preventable.
All mothers’ deaths are an equal loss to society. However, it is deaths due to preventable causes that we should be worrying about as they signal the strength of the health system. South Africa is a country where pregnant women have free access to healthcare and well-developed health policies and protocols form the backbone of the system. The maternal mortality rate is the outcome of both the supply and demand for healthcare services.
Common explanations for poor health outcomes tend to focus on the supply of health services but perspectives and experiences of the users of health services also matter. Some women are not accessing the health system or not accessing it early enough and it is important to understand whether this is because they can’t or choose not to. If they are choosing not to, the underlying reasons have to be found and addressed. Some of the factors influencing women’s access to services may be due to the quality or acceptability of services provided. Unfortunately the available data in South Africa does not yet allow us to fully answer these questions.
Poor performance in maternal health asks of policymakers and the researchers who advise them to take a step back and systematically identify why health services may not be of a sufficient quality or quantity or why health system users are not accessing the system. It is our task to keep on digging until we have a more comprehensive understanding of what goes wrong in the health system. And then find the answers. Otherwise we are failing our mothers and their children... miserably.