Obstetric haemorrhage - third report on confidential enquiries into maternal deaths in South Africa 2002-2004

Abstract

Obstetric haemorrhage was the third most common cause of maternal death in South Africa for the triennium 2002 to 2004, accounting for 442 deaths or 13% of the total. Antepartum haemorrhage (APH) accounted for 129, and postpartum haemorrhage (PPH) for 313 of these deaths. The number of APH maternal deaths increased from 100 in 1999-2001, to 129 in 2002-2004. The number of PPH maternal deaths increased from 240 in 1999-2001, to 313 in 2002-2004. Part of these increases could be due to better reporting. As in the previous triennium, maternal age over 35 years was a risk factor for deaths level from APH and PPH. Over 75% of deaths from APH and PPH occurred at either a one or two hospital. The proportion of APH deaths at level 1 hospitals decreased slightly from 36.7% in 1999 -2001 to 26.4% in the current triennium. Of concern, is the high proportion of PPH deaths that continue to occur at level 1 hospitals: 40.9% (1999-2001) and 42.2% in the current triennium. The pattern of causes of APH and PPH in 2002 - 2004 has not changed significantly from the previous triennium. Of the 129 causes of APH related maternal deaths, only 81 were assigned a causal subcategory. Of these, abruptio placentae accounted for the majority of APH deaths. Of the 313 deaths from PPH, there were 4 main groups of primary causes, all of which should be easily preventable by basic referral obstetric care. 67 (21.4%) of PPH deaths were from retained placenta, only a small proportion of which were thought to be morbidly adherent. 74 (23.6%) were due to uterine atony, either from prolonged labour or over distension of the uterus. 84 (26.8%) were due to uterine rupture making this the largest cause of PPH. Of these, 41 (13.1%) were in women with a previous caesarean section (C/S) and of particular concern, 43 (13.7%) occurred in women with no previous C/S. The remaining major cause of PPH was 'other uterine trauma', accounting for 78 (24.9%) of PPH deaths. This group was predominantly due to bleeding during and after C/S, with small numbers due to serious vaginal trauma, and rare complications such as uterine inversion and extra uterine pregnancy. This large number of deaths due to C/S associated bleeding raises concern about technical skills, particularly at level 1 hospitals. APH & PPH were the causes of death most likely to be assessed as 'Clearly Avoidable' by assessors: 76.8% for APH and 83% for PPH. Delay in seeking help by the patient occurred for 17.5% of APH deaths compared to 3.7% in the previous triennium; and for 17.8% of PPH deaths. Delay in transport between institutions, particularly from levels 1 to 2, remained a major problem, occurring in 27.8% of APH deaths, but had decreased slightly for PPH (10.9% of deaths). There were marked increases in problems related to lack of availability of blood, lack of health care facilities and lack of appropriately trained staff for both APH and PPH and this was particularly common at level 1 hospitals. Two thirds to three-quarters of cases had avoidable factors related to health workers at each level of care. For both APH & PPH, problem recognition and substandard management were the most frequently cited problems, occurring at all levels of care and showing no significant improvement from the previous triennium. For PPH, problem with monitoring and reacting to abnormal monitoring were problems which had increased from the previous triennium and occurred at all levels of care. Problems with restoring circulation in bleeding patients remained a serious problem, occurring in 78.9% of women dying from APH, and 82% from PPH. Major improvements in the functioning of the health system and appropriate training of doctors and midwives at all levels of care, are essential if deaths from this preventable cause of maternal mortality (obstetric haemorrhage) are to be reduced.