Maternal Deaths In South Africa Research Articles

Utilisation of Maternal Health Services and its Impact on Maternal Mortality Rate: A Case for KwaZulu-Natal, South Africa

Despite several strategies in place in South Africa and globally to prevent maternal mortality and morbidity, maternal deaths remain high, especially in sub-Saharan Africa and lower to middle-income countries. The aim of the study was to identify the challenges that lead to pregnant women’s delays in seeking antenatal care (ANC) early and to find strategies to prevent such delays, contributing to a reduction of maternal deaths in South Africa. The study was conducted in two phases. Phase one analysed data on maternal deaths collected by the District Health Information System (DHIS) of the KwaZulu-Natal Department of Health from all 11 districts over a 10-year period (2009–2019). The data on maternal deaths revealed that there was a very high maternal mortality rate; between 800 and 1 780 per 100 000 live births. This correlated with very low antenatal visits; between 695–895 per 100 000 live births. In phase two, a literature review was conducted using several computer-assisted databases, bibliographies and websites to identify and source current policies. The literature review presents causes of delay in seeking ANC and strategies to prevent maternal deaths. Recommendations were made to consider strengthening education and awareness related to family planning; women empowerment through community health programmes and change in healthcare providers’ behaviours and attitudes; ensuring availability of maternal health resources; and developing strategies to ensure that the ANC services delivered are in line with the South African Department of Health Guidelines.

COVID‑19 in pregnant women in South Africa: A retrospective review.

The majority of maternal deaths in South Africa (SA) occur as a result of non-pregnancy-related infections (NPRI). Pregnancy is a known risk factor in severe COVID‑19, increasing the burden of NPRI in SA. In this study, we describe the prevalence, profile and clinical outcomes of pregnant women with COVID‑19 admitted to a tertiary facility. To describe the prevalence, profile and clinical outcomes of pregnant women with COVID‑19 admitted to a tertiary facility in Gauteng, SA. We performed a retrospective review of all pregnant women with COVID‑19 admitted to Charlotte Maxeke Johannesburg Academic Hospital between 6 March and 30 August 2020. Data collected included demographics, medical history, obstetric history, clinical findings and laboratory variables. Outcomes assessed were mortality, admission to intensive care unit (ICU), symptomatic v. asymptomatic disease, maternal and fetal outcome and mode of delivery. A total of 204 pregnant women were included in the study. Of these, 33 (16.2%) women were critically ill, with 21 (10.3%) admitted to the ICU and 3 (1.5%) deaths related to COVID‑19. The median gestational age was 37 weeks and median birthweight 2 940 g. Sixty-seven women (33%) were HIV-positive, in keeping with national statistics regarding HIV in pregnancy. Caesarean section was the most common mode of delivery (n=105, 60%). However, no women underwent caesarean section for indications related to COVID‑19. COVID‑19-related mortality in our cohort was higher than that seen internationally, likely due to differences in background maternal mortality rates and difficulty in accessing care.

WITHDRAWN: Early identification of hypertensive disorders of pregnancy (An mhealth feasibility study for resource limited settings)

Hypertensive Disorders of Pregnancy (HDP) account for 18% of potential preventable maternal deaths in South Africa. MHealth studies on early HDP identification in high income countries showed potential value for limited resource settings. This study aimed to test the feasibility of an mHealth solution for early identification of HDP using self home monitoring of blood pressure (BP) and sharing of information on symptoms of preeclampsia in a low middle income country (LMIC). This mixed methods study, enrolled 100 pregnant women (20 to 30 weeks) to selfmonitor and submit daily BP and pulse readings on a smart phone to an mHealth platform observed by a midwife for targeted action. Information was shared on 7 symptoms of preeclampsia using brochures, posters, targeted digital messages and quizzes. Study data was collected through the mHealth platform, key informant interviews, pre pand post knowledge, attitude and practice (KAP) suveys and self and community health worker’s (CHW) reported outcomes. Ten cases had interventions for HDP in the cohort. All mothers with HDP and their babies had satisfactory outcomes. This was facilitated through the BP monitoring on the App and digital platform, increased knowledge of 7 symptoms of preeclampsia and CHW follow up. The study found in conclusion that pregnant women in resource limited settings are able to self home monitor their BP using a mHealth solution for early identification and management of HDP. The study acknowledge challenges for scale up and cost effectiveness but recognise potential.

Persistent maternal tachycardia: A clinical alert for healthcare professionals providing maternity care in South Africa

Cardiac disease is one of the commonest causes of indirect maternal deaths globally. This brief report is a reminder that isolated maternal tachycardia at rest is a clinical alert and warrants a detailed history in relation to cardiac disorders, thorough clinical examination of all organ systems, relevant investigations such as imaging, and expert advice to avoid serious adverse events. We reflect on a belatedly investigated persistent maternal tachycardia resulting in a fatal postpartum collapse due to mitral stenosis. The lost window of opportunity for appropriate investigation and management of the tachycardia provides an insight into many similar maternal deaths in South Africa. Key clinical messages regarding persistent maternal tachycardia are presented for midwives and doctors caring for pregnant women.

The role of Tenascin-C in HIV associated pre-eclampsia.

Pre-eclampsia (PE) accounts for 14.8% of maternal deaths in South Africa. Tenascin C (TN-C) is an anti-inflammatory cytokine expressed in the extracellular matrix and may be dysregulated in the hyperinflammatory PE microenvironment. This study examined serum TN-C in normotensive pregnant (n=36) and pre-eclamptic (n=36) HIV positive and negative women using an immunoassay. TN-C was significantly upregulated in PE vs normotensive pregnant women (p=0.0075) and HIV-positive vs negative pregnant women (p=0.0009). TN-C levels across all groups was statistically different (p<0.0001). This study demonstrates an elevation of TN-C in HIV-associated PE. The potential benefit of TN-C as a biomarker to detect PE development requires investigation.

Delivery outcomes of patients with pre-eclampsia at 27 - 34 weeks' gestation at Tygerberg Hospital, Cape Town, South Africa: A retrospective observational study.

Obstetricians are cognisant of the serious nature of hypertensive disorders in pregnancy. Despite a 17% overall reduction in maternal deaths in South Africa between 2011 and 2016, there was a 14% increase in deaths due to hypertension. Delivery is the only known cure for pre-eclampsia, but the question regarding the safest route of delivery remains difficult to answer. To determine the success rate of induction of labour (IoL) in patients with early-onset pre-eclampsia with severe features (EOPES) before 34 weeks' gestation. Furthermore, the data from the induction group were compared with those of the caesarean delivery (CD) groups where patients were not eligible for IoL. Additional objectives were to identify variables that could influence the success rate, to determine whether any delivery method was associated with increased morbidity, to assess the short-term maternal and neonatal outcomes, and to make recommendations for future decision-making regarding delivery for women with EOPES. In this single-institution retrospective observational study, all cases in which a decision for delivery was made before 34 weeks 0days of gestation (or the infant's birthweight was ≤2000 g with uncertain gestation) at Tygerberg Hospital, Cape Town, between 1 January and 30June 2017 were identified from the electronic birth register. The cohort fitting the inclusion criteria was subdivided into IoL and CD groups. From a total of 3 938 deliveries, 168 patients met the inclusion criteria. IoL was indicated in 55 cases, resulting in 20 vaginal deliveries (VDs) (36%) and 35 CDs (64%). The remaining 113 patients were not candidates for IoL; of these, 89 required emergency CDs and 24 had semi-elective CDs. In the IoL group with abnormal umbilical artery Dopplers (UADs) there was 1 VD, and 4 CDs were performed for fetal compromise. Of cases with an estimated fetal weight (EFW) ≤3rd centile, emergency CD was required in 24 (65%), and 8 (22%) were considered for IoL, in 6 of which CD was required. Of the EOPES population, 36% had successful IoL that culminated in VD. VD was more likely to occur with fetal growth appropriate for gestational age. The likelihood of CD increased if the UAD was abnormal, if the EFW was ≤3rd centile or if eclampsia was present. The decision to induce should be considered carefully in these circumstances.

Implementing antenatal care recommendations, South Africa.

Despite progress in reduction in maternal deaths in South Africa, deaths due to complications of hypertension in pregnancy remain high at 26 deaths per 100 000 live births in 2016. The South African health ministry modified its existing four-visit antenatal care model to align with the World Health Organization’s (WHO) 2016 recommendations for the number and content of antenatal care contacts. Implementation of the eight-contact antenatal care recommendations began in April 2017, after adaptation to the national context and nationwide trainings. In this article, we describe the stages of implementation and the monitoring of key indicators. We share lessons, particularly from the important early stages of nationwide scale-up and an analysis of the early results. We analysed samples of maternity case records in four catchment areas in the first year of the updated care model. The mean number of antenatal care contacts among five monthly samples of 200 women increased steadily from 4.76 (standard deviation, SD: 2.0) in March 2017 to 5.90 (SD: 2.3) in February 2018. The proportion of women with hypertension detected who received appropriate action (provision of medical treatment or referral) also increased from 83.3% (20/24) to 100.0% (35/35) over the same period. South Africa’s experiences with implementation of the updated antenatal care package shows that commitment from all stakeholders is essential for success. Training and readiness are key to identifying and managing women with complications and developing an efficient antenatal care system accessible to all women.

Making the case for an obstetric medicine subspecialty in South Africa

Obstetric medicine is a subspecialty of internal medicine that involves the management of medical conditions that may affect the course of pregnancy. It is an established subspecialty in many parts of the world, with recognised training programmes and an active international society; however, no formal training programme has been developed in South Africa (SA) as yet. Medical problems are responsible for the majority (60%) of maternal deaths in SA and women of childbearing potential are disproportionately affected by medical conditions such as HIV and obesity. Obstetric physicians would play a complementary role in the care of pregnant patients and could contribute to improving maternal health and lowering the maternal mortality rate in SA.

Maternal deaths due to eclampsia in teenagers: Lessons from assessment of maternal deaths in South Africa.

BackgroundEclampsia remains a major cause of maternal mortality, particularly in teenage pregnancies. Healthcare professionals providing antenatal must regard teenagers as a high risk group for the pre-eclampsia-eclampsia syndrome.SettingData extracted from the South African Saving Mothers Report: 2014–2016.AimTo establish the clinical details in teenage maternal deaths owing to eclampsia.MethodRetrospective review of the case records and maternal death assessment forms of teenagers that died due to eclampsia during 2014–2016.ResultsThere were 47 teenagers (aged 14 to 19 years) who died from eclampsia. Of these 18 out of 47 (38%) deaths occurred in the post-partum period. Forty (85.1%) of the patients had antenatal care. Three (6.4%) had post-partum eclampsia, and of the remaining 44 of the 47 (93.6%), the gestational age at first occurrence of a seizure ranged from 25 to 39 weeks. The blood pressures at the time of seizure ranged from systolic of 131 to 210 mmHg and diastolic of 89 to 130 mmHg. The commonest final causes of death were intracerebral haemorrhage associated with severe hypertension and multi-organ failure. Avoidable factors included transport delays, referral to the wrong levels of health care and poor care by health professionals.ConclusionTeenage pregnancy is a risk factor for eclampsia-related death; awareness of borderline elevations of blood pressure levels from baseline values (prehypertension levels) and taking following national guidelines on the management of hypertensive disorders of pregnancy will decrease deaths from eclampsia.

An audit of patients with abruptio placentae in the Pretoria Academic Complex

Background . Obstetric hemorrhage is the third most common cause of maternal death in South Africa. Abruptio placentae (AP) contributed to 12.9% of deaths caused by haemorrhage between 2017 and 2018. Objective. To investigate the risk factors, management and outcomes of pregnancies affected by AP. Methods. We conducted a prospective descriptive study in a one-year period at the Pretoria Academic Complex (PAC). All patients who presented with AP were recruited for the study. The demographics, risk factors, management, complications and outcomes were reported using descriptive statistics. Results. One hundred women with AP presented during the study period, representing an incidence of 1% of pregnancies at PAC. Sixtyone percent of the women had caesarean delivery while 37% had vaginal delivery. A minority of women presented with known risk factors of AP in this setting. Two comparison groups were defined based on the degree of placental separation from the decidua, i.e. &gt;50% and &lt;50%. A woody hard abdomen occurred more frequently in patients with &gt;50% AP (43% v. 57%; p=0.002). More women had postpartum haemorrhage in the &gt;50% group (67% v. 33%; p=0.001). Fifty-eight (58%) live babies and 44 (44%) stillborn babies were delivered. Conclusion. The known risk factors of AP were largely absent in women with AP in this setting. The typical clinical findings of AP were late signs associated with severe placental separation. Early resuscitation and delivery of the fetus can positively influence perinatal and maternal morbidity and mortality

An approach to hypertensive disorders in pregnancy for the primary care physician.

Hypertensive disorders in pregnancy (HDP) are a leading obstetric cause for maternal morbidity and mortality nationally as well as globally. The Saving Mothers is a report published every three years by the National Committee for Confidential Enquiry, which reports the trends in maternal deaths in South Africa. The last three Saving Mothers reports identified many gaps in the management of HDP and interventions to address these gaps were recommended. The recently published national guidelines on the management of HDP have highlighted approaches for the diagnosis, assessment and management of HDP. This article synthesises the national guidelines and provides approaches for the primary care physician working at the primary healthcare or the district hospital level. The algorithms provide easy clinical pathways once the correct assessment has been made.

The role of the complement system in HIV infection and preeclampsia.

The complement system is a key component of the innate immune system that plays a vital role in host defense, maintains homeostasis and acts as a mediator of the adaptive immune response. The complement system could possibly play a role in the pathogenesis of HIV infection and preeclampsia (PE), both of which represent major causes of maternal death in South Africa. The relationship between PE and HIV infection is unclear as PE represents an exaggerated immune response, while HIV infection is associated with a decline in immune activity. Although the complement system works to clear and neutralize HIV, it could also enhance the infectivity of HIV by various other mechanisms. It has been suggested that the dysregulation of the complement system is associated with the development of PE. There is currently a paucity of information on the combined effect of the complement system in HIV-associated PE. This review highlights the role of the complement system in the duality of HIV infection and PE and provides new insights into this relationship whilst also elucidating potential therapeutic targets.

‘It needs a complete overhaul…’ district manager perspectives on the capacity of the health system to support the delivery of emergency obstetric care in an urban South African district

ABSTRACTBackground: A high maternal mortality ratio persists in South Africa despite developments in emergency obstetric care (EmOC), a known effective intervention against direct causes of maternal deaths. Strengthening the health systems is one of the focus areas identified by the National Committee for Confidential Enquiries into Maternal Deaths in South Africa. District managers as immediate overseers of the frontline health system are uniquely positioned to provide insight into the overall health system processes that influence the delivery of EmOC.Objective: We sought to identify health system enablers and barriers to the delivery EmOC from the perspective of district managers. This would potentially unearth aspects of the health system that require strengthening to better support EmOC and improve maternal outcomes.Methods: Face-to-face audio-recorded key informant interviews were conducted with 19 district managers in charge of the delivery of EmOC in one urban district. Interviews were transcribed and coded. Related codes were inductively grouped into emerging themes. Deductive thematic analysis was then applied to categorise emergent themes into the WHO health system building blocks.Results: Themes included a weaknesses in the organisation of health services; a high vacancy and turnover of senior management; poor clinical accountability from EmOC providers; inadequate resources (including infrastructure, staffing, and funding); and the need to improve district health information system indicators.Conclusion: The functioning of the district health system was weak, affecting the delivery of EmOC. Unless staffing is effectively addressed, the health system is unlikely to reduce maternal mortality to the desired level. Coordination of EmOC services by managers needs to be strengthened to limit fragmentation of care and improve the continuity EmOC. Furthermore, a high turnover of senior leadership affects implementation priorities and continuity in the overall strategic direction of EmOC.

Associations between HIV, highly active anti-retroviral therapy, and hypertensive disorders of pregnancy among maternal deaths in South Africa 2011-2013.

To explore potential relationships between HIV and highly active anti-retroviral therapy (HAART), and hypertensive disorders of pregnancy (HDP). A retrospective secondary analysis of maternal-deaths data from the 2011-2013 Saving Mothers Report from South Africa. The incidence of HIV infection amongst individuals who died owing to HDP was determined and comparisons were made based on HIV status and the use of HAART. Among 4452 maternal deaths recorded in the Saving Mothers report, a lower risk of a maternal deaths being due to HDP was observed among women who had HIV infections compared with women who did not have HIV (relative risk [RR] 0.57, 95% confidence interval [CI] 0.51-0.64). Further, reduced odds of death being due to HDP were recorded among women with AIDS not undergoing HAART compared with women with HIV who did not require treatment (RR 0.42, 95% CI 0.3-0.58). Notably, among all women with AIDS, a greater risk of death due to HDP was demonstrated among those who received HAART compared with those who did not (RR 1.15, 95% CI 1.02-1.29). HIV and AIDS were associated with a decreased risk of HDP being the primary cause of death; the use of HAART increased this risk.

Uterine artery Doppler screening as a predictor of pre-eclampsia

Hypertensive disorders represent the second most common cause of maternal death, affecting 5–10% of pregnancies worldwide and accounting for 19% of maternal deaths in South Africa. Pre-eclampsia is believed to develop from inadequate trophoblast invasion of the maternal spiral arteries. Doppler imaging permits non-invasive evaluation of the uteroplacental circulation and is invaluable in the management of high risk pregnancies.A prospective quantitative experimental study tested the hypothesis that uterine artery (UA) spectral Doppler screening is able to identify patients at risk for developing preeclampsia. Convenience sampling allowed for the recruitment of 144 patients (11–14 weeks gestation) who attended the antenatal clinic at Rahima Moosa Mother and Child Hospital between November 2008 and July 2010. A complete record of 121 participants was available for the final analysis.The results of this study revealed that 7 (5.8%) participants developed pre-eclampsia. Race was identified as the most significant independent variable with an odds ratio of 1.5; 26 and 9 to 1 for developing PET in the 1st, 2nd and 3rd trimesters respectively.Uterine Artery Doppler is promising. An ultrasound screening programme in high risk pregnant women would offer clinicians the opportunity to pre-empt the disease before it manifests clinically.

Uterine artery Doppler screening as a predictor of pre-eclampsia

Hypertensive disorders represent the second most common cause of maternal death, affecting 5–10% of pregnancies worldwide and accounting for 19% of maternal deaths in South Africa. Pre-eclampsia is believed to develop from inadequate trophoblast invasion of the maternal spiral arteries. Doppler imaging permits non-invasive evaluation of the uteroplacental circulation and is invaluable in the management of high risk pregnancies.A prospective quantitative experimental study tested the hypothesis that uterine artery (UA) spectral Doppler screening is able to identify patients at risk for developing pre-eclampsia.Convenience sampling allowed for the recruitment of 144 patients (11–14 weeks gestation) who attended the antenatal clinic at Rahima Moosa Mother and Child Hospital between November 2008 and July 2010. A complete record of 121 participants was available for the final analysis.The results of this study revealed that 7 (5.8%) participants developed pre-eclampsia. Race was identified as the most significant independent variable with an odds ratio of 1.5; 26 and 9 to 1 for developing PET in the 1st, 2nd and 3rd trimesters respectively.Uterine Artery Doppler is promising. An ultrasound screening programme in high risk pregnant women would offer clinicians the opportunity to pre-empt the disease before it manifests clinically.

Point-of-Care Diagnostics for Improving Maternal Health in South Africa

Improving maternal health is a global priority, particularly in high HIV-endemic, resource-limited settings. Failure to use health care facilities due to poor access is one of the main causes of maternal deaths in South Africa. “Point-of-care” (POC) diagnostics are an innovative healthcare approach to improve healthcare access and health outcomes in remote and resource-limited settings. In this review, POC testing is defined as a diagnostic test that is carried out near patients and leads to rapid clinical decisions. We review the current and emerging POC diagnostics for maternal health, with a specific focus on the World Health Organization (WHO) quality-ASSURED (Affordability, Sensitivity, Specificity, User friendly, Rapid and robust, Equipment free and Delivered) criteria for an ideal point-of-care test in resource-limited settings. The performance of POC diagnostics, barriers and challenges related to implementing POC diagnostics for maternal health in rural and resource-limited settings are reviewed. Innovative strategies for overcoming these barriers are recommended to achieve substantial progress on improving maternal health outcomes in these settings.

The importance of cardiovascular pathology contributing to maternal death: Confidential Enquiry into Maternal Deaths in South Africa, 2011–2013

SummaryAimsCardiac disease is emerging as an important contributor to maternal deaths in both lower-to-middle and higher-income countries. There has been a steady increase in the overall institutional maternal mortality rate in South Africa over the last decade. The objectives of this study were to determine the cardiovascular causes and contributing factors of maternal death in South Africa, and identify avoidable factors, and thus improve the quality of care provided.MethodsData collected via the South African National Confidential Enquiry into Maternal Deaths (NCCEMD) for the period 2011–2013 for cardiovascular disease (CVD) reported as the primary pathology was analysed. Only data for maternal deaths within 42 days post-delivery were recorded, as per statutory requirement. One hundred and sixty-nine cases were reported for this period, with 118 complete hospital case files available for assessment and data analysis.ResultsPeripartum cardiomyopathy (PPCM) (34%) and complications of rheumatic heart disease (RHD) (25.3%) were the most important causes of maternal death. Hypertensive disorders of pregnancy, HIV disease infection and anaemia were important contributing factors identified in women who died of peripartum cardiomyopathy. Mitral stenosis was the most important contributor to death in RHD cases. Of children born alive, 71.8% were born preterm and 64.5% had low birth weight. Seventy-eight per cent of patients received antenatal care, however only 33.7% had a specialist as an antenatal care provider. Avoidable factors contributing to death included delay in patients seeking help (41.5%), lack of expertise of medical staff managing the case (29.7%), delay in referral to the appropriate level of care (26.3%), and delay in appropriate action (36.4%).ConclusionThe pattern of CVD contributing to maternal death in South Africa was dominated by PPCM and complications of RHD, which could, to a large extent, have been avoided. It is likely that there were many CVD deaths that were not reported, such as late maternal mortality (up to one year postpartum). Infrastructural changes, use of appropriate referral algorithm and training of primary, secondary and tertiary staff in CVD complicating pregnancy is likely to improve the outcome. The use of simple screening equipment and point-of-care testing for early-onset heart failure should be explored via research projects.

Psychosocial factors associated with early initiation and frequency of antenatal care (ANC) visits in a rural and urban setting in South Africa: a cross-sectional survey.

BackgroundLate booking and infrequent antenatal care (ANC) are common but avoidable patient-related risk factors for maternal deaths in South Africa. The aim of the study was to examine the association of psychosocial factors with early initiation of ANC and adequate frequency of attendance of ANC clinics among women in an urban and rural location in South Africa.MethodsData from a 2006 cross-sectional household survey of 363 women from the rural Western Cape and 466 women from urban Gauteng provinces of South Africa for risk of alcohol-exposed pregnancy were analysed. We examined associations between psychosocial variables (self-esteem, cultural influences, religiosity, social capital, social support, pregnancy desire (wanted versus unwanted pregnancy), partner characteristics and mental health) and both early ANC first visit (before 16 weeks) and adequate frequency of ANC visits (4 or more visits) for respondents’ last pregnancy.ResultsOverall prevalence among urban women of early ANC initiation was 46 % and 84 % for adequate ANC frequency. Overall prevalence among rural women of early ANC initiation was 45 % and 78 % for adequate ANC frequency. After adjusting for clustering, psychosocial factors associated with early ANC initiation in the urban site were being employed (OR 1.6; 95 % CI 1.0–2.5) and wanted pregnancy (OR 1.8; 95 % CI 1.1–3.0). For the rural site, early ANC initiation was significantly associated with being married (OR 1.93; 95 % CI 1.0–3.6) but inversely associated with high religiosity (OR 0.5; 95 % CI 0.3–0.8). Adequate frequency of ANC attendance in the rural site was associated with wanted pregnancy (OR 4.2; 95 % CI 1.9–9.3) and the father of the child being present in the respondent’s life (OR 3.0; 95 % CI 1.0–9.0) but inversely associated with having a previous miscarriage (OR 0.4; 95 % CI 0.2–0.8). There were no significant associations between adequate ANC attendance and the psychosocial factors in the urban site.ConclusionThe majority of women from both sites attended ANC frequently but less than 50 % initiated ANC before the recommended 16 weeks gestational age. Interventions to reduce prevalence of late ANC booking and inadequate ANC attendance should engage religious leaders, address unintended pregnancy through family planning education and involve male partners in women’s reproductive health.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-016-0807-1) contains supplementary material, which is available to authorized users.

An audit of the initial resuscitation of severely ill patients presenting with septic incomplete miscarriages at a tertiary hospital in South Africa.

BackgroundSeptic incomplete miscarriages remain a cause of maternal deaths in South Africa. There was an initial decline in mortality when a strict protocol based approach and the Choice of Termination of Pregnancy Act in South Africa were implemented in this country. However, a recent unpublished audit at the Pretoria Academic Complex (Kalafong and Steve Biko Academic Hospitals) suggested that maternal mortality due to this condition is increasing. The objective of this investigation is to do a retrospective audit with the purpose of identifying the reasons for the deteriorating mortality index attributed to septic incomplete miscarriage at Steve Biko Academic Hospital.MethodsA retrospective audit was performed on all patients who presented to Steve Biko Academic Hospital with a septic incomplete miscarriage from 1st January 2008 to 31st December 2010. Data regarding patient demographics, initial presentation, resuscitation and disease severity was collected from the “maternal near-miss”/SAMM database and the patient’s medical record. The shock index was calculated for each patient retrospectively.ResultsThere were 38 SAMM and 9 maternal deaths during the study period. In the SAMM group 86.8% and in the maternal death group 77.8% had 2 intravenous lines for resuscitation. There was no significant improvement in the mean blood pressure following resuscitation in the SAMM group (p 0.67), nor in the maternal death group (p 0.883). The shock index before resuscitation was similar in the two groups but improved significantly following resuscitation in the SAMM group (p 0.002). Only 31.6% in the SAMM group and 11.1% in the maternal death group had a complete clinical examination, including a speculum examination of the cervix on admission. No antibiotics were administered to 21.1% in the SAMM group and to 33.3% in the maternal death group.ConclusionThe strict protocol management for patients with septic incomplete miscarriage was not adhered to. Physicians should be trained to recognise and react to the seriously ill patient. The use of the shock index in the identification and management of the critically ill pregnant patient needs to be investigated.