The level of maternal mortality sustained in the Agincourt subdistrict was surprisingly high for a middle-income country like South Africa, as has been noted at national level.14
The level of obstetrical mortality documented corresponded to that of Sweden around 1900;1
while the level of pregnancy-related deaths matched the highest levels recorded in African Demographic and Health Surveys.35
This occurred despite the relatively small proportion of deaths due to maternal causes in women 15 years–49 years, a fraction much lower than in comparable situations elsewhere.35
This is a new pattern which deserves further attention and has implications for mathematical models based on these proportions.
The Agincourt HDSS data include all maternal deaths that occurred in the study area population over the study period, irrespective of the place of death. They include deaths that occurred at home, in hospitals, en route for care, or elsewhere, and therefore the rates obtained from the demographic surveillance differ from those obtained by other methods, in particular from the confidential enquiries. Agincourt estimates also differ from the vital registration estimates, especially for pregnancy-related deaths. This is mainly due to the fact that the information on pregnancy is completed in only a small proportion of deaths of women age 15 years–49 years (only 28% in the vital registration data for 2006–2009). Improving the coverage of the vital registration system, as well as improving the entry of system forms, is crucial for rigorously monitoring the rapidly changing levels of maternal mortality. Studies such as the Agincourt HDSS contribute to understanding the weaknesses of current health information systems in South Africa.
The magnitude and speed of the changes in maternal mortality in Agincourt was outstanding. The first period (up to 1996) follows a standard pattern of mortality decline found in countries undergoing a health transition; the second period (1996–2006) witnessed a three-fold increase in about 10 years, which is unique in the world; the speed of the decline after 2006 seems to be as rapid and as important. These changes appear to be a direct consequence of the dynamics of the HIV/AIDS epidemic, and seem unrelated to the quality of obstetric care. The magnitude of the changes makes it impossible to have a single estimate of MMR, and explains in part the confusion that arose about national estimates of MMR.
Trends in maternal mortality did not decline as might be expected given South Africa’s stated commitment to the MDG5a and the relatively high access to, and quality of, maternal health services. This disappointing pattern seems driven to a large extent by high levels of HIV/AIDS and tuberculosis. Arguably, the trends observed in MMR are no longer an indicator of safe motherhood, but simply a marker of the dynamics of evolving infectious disease epidemics.
The case definition was important in characterizing the level of maternal mortality. In fact, a lack of standardization can produce confusing estimates that range from 91 to 820 per 100,000 at national level based on the same data but applying different case definitions and statistical methods.14
Our study underlines the need to better characterize “obstetrical causes,” and to adhere to a strict and consistent definition in order to monitor and compare trends over time and across different settings.
The basic structure of causes of maternal death observed in Agincourt, which include deaths in the community as well as in health facilities, does not seem to differ from that found in other sources in South Africa, although precise comparisons are difficult due to a lack of standardization and different data sources. Compared with the confidential enquiries into maternal mortality, limited to health facility-deaths, the proportions and ranking of major causes were comparable for hypertensive disorders, hemorrhage, puerperal sepsis, abortion, and ectopic pregnancy.36
However, the proportion attributed to puerperal sepsis could be inflated in Agincourt by the inclusion of other infectious diseases related to HIV/AIDS, and this may explain why the increased mortality from these causes appeared more pronounced in Agincourt than in national data.
The indirect role of HIV/AIDS on the obstetrical causes needs further analysis. Since many of the classic obstetrical causes did not change over the years, one could attribute most of the change (infections and hypertension) to the direct and indirect effects of HIV/AIDS. Some of the increase in miscarriage and abortion could also be due to HIV/AIDS. The inclusion of some AIDS deaths among the deaths due to puerperal infection may be a diagnostic problem when coding causes of death in verbal autopsies. There is a need to examine this category by specific infectious cause, which remains difficult because of the small number of cases and lack of precision of verbal autopsies.
The increase in hypertensive disorders, also found in the confidential enquiries and in vital registration system data, deserves further research. While not due to HIV infection directly, this could be attributed to its treatment. Indeed, recent studies reported that highly active antiretroviral therapy could induce hypertension and potentially increase maternal mortality from pre-eclampsia and eclampsia. Active antiretroviral therapy may also have an effect on mortality from liver disease.37
In the context of a severe HIV epidemic such as that in Southern Africa, levels and trends in maternal mortality, even when restricted to obstetrical causes, no longer appear to be the exclusive indicators of the quality of obstetric care. This perspective is critical when monitoring change and trends in MDG5a and interpreting their significance for policy and programs relating to sexual and reproductive health and safe motherhood.