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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.108 n.11 Cape Town Nov. 2018 



The continuing process of learning lessons from maternal deaths: 'Red flags'



In this CME, maternal mortality associated with chronic hypertension,[1] cardiac disease[2] and organophosphate poisoning[3] is discussed to highlight lessons learnt. Maternal mortality rates remain high in South Africa (SA), despite reductions in the number of deaths from non-pregnancy-related infections as a result of the widespread use of antiretroviral therapy by HIV-infected women. This success shows the achievement of focused attention on an epidemic, and the National Department of Health is to be congratulated on this aspect. However, similar successes in the reduction of maternal mortality have not been achieved with regard to deaths due to direct obstetric causes, such as hypertensive disorders of pregnancy, mainly pre-eclampsia and eclampsia. The reason may be that the entire health system is not functioning well - it should identify pregnant women at risk of pre-eclampsia, triage patients at risk, timeously refer patients to health facilities staffed by specialists, immediately treat patients (judicious lowering of severe hypertension, use of magnesium sulphate for the prevention of convulsions, timeous delivery without causing harm to the mother and baby) and follow national clinical guidelines strictly.

About 20% of women with chronic hypertension develop pre-eclampsia during pregnancy. Ideally, they should receive pre-pregnancy planning advice so that antihypertensive agents, which have the potential to cause congenital abnormalities, can be discontinued and alternative antihypertensives used. In addition, preventive interventions, such as the administration of folic acid, low-dose aspirin and calcium supplementation, could be discussed. However, it is known that of the poorest women, only 22% had a planned pregnancy in 2012. Women with chronic hypertension also have other comorbid conditions, such as diabetes and obesity, and therefore require appropriate information sharing, counselling regarding pregnancy outcomes and stabilisation of high blood pressure, if appropriate, prior to the intended pregnancy.

Similar to patients with chronic hypertension, women with suspected or known cardiac disease should be risk assessed before or early in pregnancy by a combined obstetric and cardiology team. It is essential that women with cardiac disease are managed by a multidisciplinary team. A large proportion of pregnant women who die from cardiac disease are young, which highlights the need for contraceptive/family planning advice at cardiac clinics in the immediate post-delivery period and at every contact with the health service.

There are worrying trends in maternal deaths associated with suicide; the Saving Mothers Report 2014 - 2016 [4] highlights these trends. Cebekhulu and Pattinson[3] describe lessons learnt from a case report on organophosphate poisoning. Similar cases of maternal deaths from suicide, using a variety of toxins freely available over the counter, have been reported to the National Committee on Confidential Enquiries into Maternal Deaths during 2017 and 2018.

What are the solutions to reduce the number of women dying during pregnancy and in the immediate postpartum period? How can we prevent the preventable?

  • Improve the quality of education of the general population so that women can take responsibility for their own health and spread information regarding health in the community.

  • Ensure access to contraceptive and family services. Women require easy, non-judgemental access from an early age to prevent unplanned pregnancies. In the immediate postpartum period, women should be offered long-term contraceptive methods; a woman who falls pregnant within 18 months of a previous pregnancy is more likely to develop complications. Access to termination of pregnancy should be strengthened for those who require it.

  • A healthy lifestyle and appropriate nutrition may halt the increasing incidence of obesity and diabetes in the SA population.

The abovementioned steps are some of the solutions that the National Department of Health needs to take to reduce maternal mortality in SA.


J Moodley

National Committee on Confidential Enquiries into Maternal Deaths, and Women's Health and HIV Research Group, Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.



1. Moodley J, Ngene NC. Assessment of maternal deaths due to chronic hypertension: Lessons to learn - a 'red flag' for maternal and fetal complications. S Afr Med J 2018;108(11):896-900.        [ Links ]

2. Soma-Pillay P, Anthony J, Mandondo SD. Cardiac disease in pregnancy: When to raise the 'red flag. S Afr Med J 2018;108(11):901-906.        [ Links ]

3. Cebekhulu SN, Pattinson RS. Organophosphate poisoning in pregnancy: Is it a cry for help? S Afr Med J 2018;108(11):907-909.        [ Links ]

4. National Committee on Confidential Enquiries into Maternal Deaths. Saving Mothers 2014 - 2016: Seventh Triennial Report on Confidential Enquiries into Maternal Deaths in South Africa: Executive Summary. Pretoria: National Department of Health, 2018.         [ Links ]

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