Women are dying unnecessarily while in labour because it takes too long for their local clinics to refer them to hospitals or because they lack transport to get them to hospital in time.

This is according to the health department’s Confidential Enquiry into Maternal Deaths in South Africa, which recently released 1998 statistics.

Health Minister Dr Manto Tshabalala-Msimang says that almost half of the maternal deaths in South Africa in 1998 were preventable. “The fact that 150 mothers die in the process of giving birth for each 100 000 babies born alive is an indictment of our new democracy especially since access to primary health care facilities have been greatly improved in South Africa,” Tshabalala-Msimang said. This maternal mortality ratio is the best in Africa, but is 12 times higher than in developed countries.

The report identifies numerous shortcomings in the health care system, many of which concern failures in the referral and transport systems between health institutions.

Mpumalanga, North West and Northern Cape still have no tertiary level hospitals in their provinces and have to refer patients who need full intensive care facilities to other provinces.

But inadequate referral and transport between health institutions was a problem in all provinces, regardless of whether or not they have tertiary level hospitals. As a result, many patients do not receive the required emergency care or are managed at the wrong institution, with sometimes fatal consequences.

Lack of emergency transport is a particular problem in the more rural provinces. Most deliveries in rural provinces occur at hospitals which have no full-time specialist staff. When complications arise, women must be transported to more specialized facilities.

In the Eastern Cape, there is only one referral centre with an intensive care unit for the whole province. Lack of transport between health institutions was identified as a significant problem in a third of the cases of maternal mortality in this province.

Nomsa (not her real name) was a 28-year-old mother of two in the Eastern Cape. Having already had a Caesar, she was at risk for uterine rupture and should immediately have been referred to a hospital for ante-natal care.

But she took traditional medicine to induce labour, which causes uncontrolled contractions and commonly results in uterine rupture. By the time she reached the intensive care unit, after having finally been referred from her local clinic three hours away, Nomsa was comatose. Her ruptured uterus had caused septic shock and renal failure. An emergency hysterectomy was performed. But it was too late. Nomsa died three days later.

The community service medical officer who attended to Nomsa has no idea how long it took for her to reach the intensive care unit. But she does know that the furthest clinic is about 4 hours away and that patients seldom arrive in that time.

“We get phoned and told to expect an emergency referral at 10.00 p.m. and then the patient arrives the next day.” In Mpumalanga, lack of emergency transport between health institutions was identified as a major factor in at least 38% of maternal mortalities last year.

Subsequent to the release of these findings, the Emergency Health service in Mpumalanga has already been improved by the acquisition of 45 new ambulances, of which 30 have already been delivered, according to the Acting Head of the Mpumalanga Department of Health, Dr Golaam Karim.

The Western Cape, which has the best health infrastructure of any province, had the lowest maternal mortality ratio (49.8 per 100 000 live births) in the country. By comparison to other provinces, delays in transporting women between institutions played a relatively minor role in maternal deaths.

Delays in transporting women from one health facility to another were reported as a factor in 14% of all maternal mortalities countrywide. But this figure is probably much larger, as it does not include delays in transporting women from their homes to health institutions.

Patients whose lives are at risk who can be cured should all be managed in hospitals where the required expertise and resources are available. This is still far from being the case in many parts of South Africa.

If the referral and transport systems between hospitals could be made to function properly, there would be a substantial decrease in all deaths, including maternal deaths, in South Africa.

The Department of Health has accepted the recommendations of the report and will start implementing them. “The challenge now is to focus our energies on every possible strategy and mechanism to prevent any death of women in pregnancy,” says Dr Tshabalala-Msimang.

“The protection and promotion of the rights of women in cases where their deaths are avoidable will be monitored with vigilance and action will be taken.” – health-e news service.