Maternal morbidity and Mortality

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Maternal Morbidity and Mortality

Maternal Mortality in South Africa

  • Defined as death of a woman while pregnant or within 42 days of termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, excluding accidental or incidental causes.
  • Institutional maternal mortality ratio (iMMR) for the triennium 2020–2022 was 111.7 per 100 000 live births (LBs), compared with 98.0 in 2017–2019 
  • In 2022, there were 1 062 maternal deaths in South African public facilities and 883 254 LBs, yielding an iMMR of 109.6 per 100 000 LBs 
  • South African iMMR remains ~50 times higher than high-income countries (e.g. UK: 7.3 per 100 000 LBs in 2021).

Leading Causes of Maternal Death (2020–2022)

  1. Non-pregnancy-related infections (NPRI): 35.2 per 100 000 LBs 
  2. Medical and surgical disorders (M&S): 34.7 per 100 000 LBs 
  3. Hypertensive disorders of pregnancy (HDP): 34.5 per 100 000 LBs 
  4. Obstetric haemorrhage (OH): 33.8 per 100 000 LBs 
  5. Embolism (pulmonary, cardiac): 12.8 per 100 000 LBs 
  6. Miscarriage and ectopic pregnancy: 10.1 per 100 000 LBs 
  7. Pregnancy-related sepsis: 9.0 per 100 000 LBs 
  • Haemorrhage and anaesthetic complications are independent risk factors for maternal mortality in Africa
  • iMMR rose by 30% in 2020 and 47% in 2021 during the COVID-19 pandemic, returning to pre-pandemic levels in 2022 .
  • From 2011–2013 to 2020–2022, iMMR fell across most provinces until 2017–2019 but increased again in 2020–2022 except in Limpopo.
  • Only Gauteng showed a decrease in iMMR in 2020–2022; Eastern Cape, Free State, North West and Northern Cape experienced increases; KwaZulu‑Natal, Limpopo, Mpumalanga and Western Cape remained stable.

Caesarean Delivery and Mortality

  • Caesarean delivery (CD) rate was 32.3% in 2022 (up from 28% in 2020–2022).
  • CD case-fatality rate was 122.3 per 100 000 CDs, down from 155.9 per 100 000 CDs in 2017–2019.
  • Bleeding at caesarean (BLDACD) accounted for 41 deaths (CFR 14.4 per 100 000 CDs).

Preventability

  • 58% of maternal deaths in 2020–2022 were assessed as potentially preventable, most commonly in OH and HDP categories.
  • Avoidable factors include delayed recognition of clinical deterioration, lack of skilled personnel, substandard care and poor resource allocation.

5 H’s And 5 C’s Framework for Reducing Maternal Mortality

5 H’s

  • HIV and TB: Early screening, antiretroviral therapy, integrated TB care.
  • Haemorrhage: ESMOE protocols, active management of third stage, E‑MOTIVE bundle.
  • Hypertension: Early detection, magnesium sulphate, antihypertensive therapy.
  • Monitoring and Evaluation: Routine maternal near-miss audits, MaMMAs database utilisation.
  • Audit Cycle: Confidential enquiries, death review meetings, feedback loops.

5 C’s

  • Care: Quality improvement, ESMOE‑EOST training, clinical governance.
  • Coverage: 24/7 access to emergency obstetric care, functioning referral and transport.
  • Caesarean safety: Skilled providers, adherence to SA maternity guidelines, audit of CD indications.
  • Contraception: Universal access to postpartum and antenatal family planning counselling.
  • Community: Engagement via MomConnect, ward-based outreach teams, community health committees.

Health System Building Blocks

  1. Health workforce: ESMOE‑EOST modules for all cadres; mentorship by experienced staff.
  2. Facility readiness: Maternity waiting areas, adequate supply of blood products, anaesthetic and surgical equipment.
  3. Emergency transport: Reliable 24/7 EMS and referral networks.

Abbreviations

  • LB: live birth
  • iMMR: institutional maternal mortality ratio
  • NPRI: non-pregnancy-related infections
  • M&S: medical and surgical disorders
  • HDP: hypertensive disorders of pregnancy
  • OH: obstetric haemorrhage
  • CD: caesarean delivery
  • CFR: case-fatality rate
  • ESMOE: Essential Steps in the Management of Obstetric Emergencies
  • EOST: Emergency Obstetric Simulation Training
  • MaMMAs: Maternal Morbidity and Mortality Audit System

Links

References:

  1. National Department of Health. Saving Mothers: Executive Summary 2020–2022. Pretoria: NDoH; 2023.
  2. Moodley J, Pattinson R. Improvements in maternal mortality in South Africa. S Afr Med J. 2018;108(3 Suppl 1):S4–S8.
  3. World Health Organization. Trends in maternal mortality 2000–2023. Geneva: WHO; 2024.
  4. Sobhy, S., Zamora, J., Dharmarajah, K., Arroyo-Manzano, D., Wilson, M., Navaratnarajah, R., … & Thangaratinam, S. (2016). Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis. The Lancet Global Health, 4(5), e320-e327. https://doi.org/10.1016/s2214-109x(16)30003–
  5. FRCA Mind Maps. (2024). Retrieved June 5, 2024, from https://www.frcamindmaps.org/

Summaries:
Obstetric cardiac disease
Maternal Mortality
MBRRACE

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© 2025 Francois Uys. All Rights Reserved.

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