MATERNAL DEATH REVIEW AUDIT REPORT MINISTRY OF HEALTH AND SOCIAL WELFARE REPRODUCTIVE HEALTH PROGRAMME

MATERNAL DEATH REVIEW AUDIT REPORT MINISTRY OF HEALTH AND SOCIAL WELFARE REPRODUCTIVE HEALTH PROGRAMME Swaziland 2001 i Report on maternal morta...
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MATERNAL DEATH REVIEW AUDIT REPORT

MINISTRY OF HEALTH AND SOCIAL WELFARE

REPRODUCTIVE HEALTH PROGRAMME Swaziland

2001

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Report on maternal mortality review in the Kingdom of Swaziland 2001

MATERNAL DEATH REVIEW AUDIT REPORT

Dr. Patrick Muia Ndavi WHO Consultant

Ms Dudu Dlamini WHO National Programme Officer

Mrs Prisca Khumalo Reproductive Health Programme Manager Ministry of Health and Social Welfare

September 2001

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Report on maternal mortality review in the Kingdom of Swaziland 2001

TABLE OF CONTENTS ACKNOWLEDGEMENTS…………………………………...iv ABBREVIATIONS………………………………………….…v LIST OF AUDITORS………………………………………….vi EXECUTIVE SUMMARY……………………………………..vii-viii INTRODUCTION……………………………………………….1 Background………………………………………………….……..1 Demographic Situation…………………………….……...1 Safe Motherhood………………………….…….….……...2

RATIONALE………………………………………..…………..3 OBJECTIVES……………………………………………….….4 METHODOLOGY………………………………………………5 STUDY DESIGN………………………………………….………....5 DATA COLLECTION STEPS…………………………….………...5 - 7 DATA ENTRY AND ANALYSIS……………………….……….…7 LIMITATIONS………………………………………….…………...8

RESULTS OF MATERNAL DEATHS REVIEW………..…...9 MAGNITUDE …………………………………………………….…9. CAUSES…………………………………………………...……….…9 - 11 REPRODUCTIVE FACTORS……………………………………....11 AGE DISTRIBUTION……………………………………....11 - 12 GESTATIONAL AGE……………………………………....13 - 14 PARITY OF WOMEN……………………………………....14 - 15 CAUSES OF DEATH BY PARITY………………………...15 - 16 PAST OBSTETRIC HISTORY……………………………..16 - 17 December 2001

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Report on maternal mortality review in the Kingdom of Swaziland 2001 MEDICAL HISTORY……………………………………....17

SOCIO-ECONOMIC FACTORS…………………………………..17 MARITAL STATUS…………………………………….…18 EDUCATION ……………………………………………...18 - 19 OCCUPATION……………………………………………..19 AVOIDABLE FACTORS…………………………………………..20 DELAYS………………………………………………….…21 - 22 COMMUNITY ………….……………………….…25 - 27 HEALTH FACILITY ………………………………27 - 35 SUMMARY OF AVOIDALE FACTORS………………………….35

CONCLUSIONS AND RECOMMENDATIONS………….…36 - 38 ANNEXES AND ANNEXURES………………………………39 - 60 REFERENCES…………………………………………………61

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Report on maternal mortality review in the Kingdom of Swaziland 2001 ACKNOWLEDGEMENTS

We wish to acknowledge the collective efforts and tireless commitment of all those who participated and make this activity a success. First and foremost, we are indebted to the Minister for Health and Social Welfare, the Hon. Dr. Phetsile K. Dlamini who facilitated the initiation and authorized the maternal death review audit in Swaziland; the former Principal Secretary, for the Ministry of Health and Social Welfare, Mr. S.S. Mdziniso and the then Director of health Services, the late Dr. John J. Mbambo who through the MOHSW provided all the resources needed in this activity. Our gratitude also goes to the Central Statistics Office and Ministry of Health for their statistical assistance in this exercise. Our indebtedness also goes to the Regional Health Management Teams (RHMTs), other regional authorities and health workers who collaborated positively and facilitated access to information for this study. Our sincere gratitude also goes to the communities and families of the deceased mothers who despite the sad memories brought by this exercise, fully participated by either making the necessary arrangements for the teams in the community or providing information as respondents. The team is very grateful to the former WHO representative Dr. Therese Lesikel and WHO/AFRO for providing technical support through out the audit.

Dr. John Kunene THE PRINCIPAL SECRETARY MINISTRY OF HEALTH AND SOCIAL WELFARE

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Report on maternal mortality review in the Kingdom of Swaziland 2001 LIST OF ABBREVIATIONS AFB AIDS ANC APH ARC C/S CSO FHP FLAS HIV ICPD ICU IEC MDR MMR MOHSW NGOs OT PET PHU PPH PTB RFM RH RHM RHNA SADAT SMI SRH SWAGAA TBA TFR TOR WHO Who/afro WRA

Acid Fast Bacilli Auto Immune Deficiency Syndrome Antenatal Care Clinic Antepartum Haemorrhage Aids Related Complexes Caesarean Section Central Statistics Office Family Health Programme Family Life Association of Swaziland Human Immune Deficiency Virus International Conference on Population and Development Intensive Care Unit Information Education and Communication Maternal Death Review (audit) Maternal Mortality Ratio Ministry of Health and Social Welfare Non Governmental Organization Operating Theatre Pre-Eclamptic Toxaemia Public Health Unit Post Partum Haemorrhage Pulmonary Tuberculosis Raleigh Fitkin Memorial Hospital Reproductive Health Rural Health Motivator Reproductive Health Needs Assessment Students Against Drug Abuse and Trafficking Safe Motherhood Initiative Sexual and Reproductive Health Swaziland Action Group Against Abuse Traditional Birth Attendant Total Fertility Rate Terms Of Reference World Health Organization WHO/Africa Regional Office Women of Reproductive Age

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Report on maternal mortality review in the Kingdom of Swaziland 2001 LIST OF AUDITORS SHISELWENI REGION Dudu Ndzimandze – team leader Sindy Shongwe Dudu Dlamini WHO driver

LUBOMBO REGION Margaret Lubhedze – team leader Maureen Mndzebele Mirriam Sihlongonyane Pedro Mfumo – driver

MANZINI REGION Alexia Masuku – team leader Ruth Dlamini Thabiso Mavuso Margaret Mamba – driver

HHOHHO REGION Salatia Ndzimandze – team leader Siphiwe Sithole Patricia Mavuso Vusi Sibabndze – driver

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Report on maternal mortality review in the Kingdom of Swaziland 2001 EXECUTIVE SUMMARY The maternal death review (MDR) audit was both institutional and community based covering all maternal deaths that occurred between 1st January 2000 and 31st July 2001. The later date was chosen because the Sexual reproductive health needs assessment revealed that most maternal deaths had occurred after January 2001, which was intended to be the closing date. The MDR model that involves twelve steps was adapted for conducting the maternal mortality review in the country. The working group was made of four teams of data collectors from the four regions. A team from one region was assigned to another region to avoid bias. A total of 43 maternal deaths were identified in the four regional hospitals. Out of 43 deaths, 16 occurred between 1st January 2000 and 31st December 2000. During this period, 16898 live births occurred in the four regional hospitals. This gives a combined hospital based maternal mortality a ratio of 94.7 for the four regional hospitals. Direct causes of maternal deaths accounted for 48.8 percent of all the deaths. The leading direct cause of maternal death was puerperal sepsis in 25.6 percent of the cases followed by haemorrhage in 9.5 percent. Complications of abortion and eclampsia accounted for 7.1 percent of the total maternal deaths each. Indirect causes accounted for 51.2 percent of the total deaths in that period. Medicals diseases accounted for 19 percent of the total deaths but 38.1 percent of the indirect causes. These included cerebral brain tumour, acute renal failure with severe bronchopneumonia, cardiac diseases, and hypertension, failure of intubation, failure to wake up from anaesthesia, and tuberculosis. The deaths due to pulmonary tuberculosis and severe pneumonia considered together as HIV related deaths, HIV would account for 23.3 percent of maternal deaths. The parity distribution of maternal deaths mirrors the parity distribution of sero-positive antenatal care clients in the country. This suggests that the epidemiology of maternal deaths is bound to change due to the HIV/AIDS pandemic. The proportion of women in the high-risk category was 29.3 percent made up of 14.6 percent adolescents, 14.7 percent women above 35 years. When comparing age distribution of women in the maternal death review and that of women from the Swaziland population census it is evident that maternal deaths were under represented in the ages 19 and below and over represented in the age group between 20 and 34 years.

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Report on maternal mortality review in the Kingdom of Swaziland 2001 According to the Swaziland population census, the age specific maternal mortality ratio would be 256 giving a standardized maternal mortality ratio of 86 per 100 000 live births. The currently quoted figure of 229/100 000 was derived using the sisterhood method while the figure in this review is both standardized and hospital based. This makes it impossible to determine is there has been any reduction in maternal mortality. Classification of gestational age at death revealed that 32.6 percent of total deaths were abortions, 18.6 percent were preterm while 37.2 percent were term. The parity of the women ranged from 0 to 10 with a majority (62.8 percent) between 1 and 4, Twenty three percent were primigravidae women while 14.0 were grande multiparous women. The analysis of the maternal deaths review was undertaken following the “model of the three delays” that define the “path the women took to death”. The delay in seeking medical care accounted for 76.3 percent. This delay is influenced by illiteracy or low education of women and poverty manifested by the lack of skilled employment activities, household amenities and inappropriate meanings attached to clinical phenomenal/causation and thus inappropriate health seeking behaviour. Delay to reach health facility is influenced by lack of transport to reach health facility including the ambulance, long distances contributed in a few cases. Delay in receiving appropriate treatment accounted for 39.4 percent. This delay is influenced by delay in being attended at health facility, in receiving adequate care, inadequate services, lack of supplies and treatment including blood, lack of qualified staff and incompetence of staff. There is need for advocacy to politicians, policy makers and other stakeholders about the problem of maternal mortality. This problem requires a multisectoral interventions and action involving all government ministries. There is also a need to establish a committee on standards and audit cycles for management of obstetric emergencies and to set up a committee for confidential enquiry into maternal deaths for periodic confidential enquiries, in-service training for staff and revision and adapting of management treatment norms.

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Report on maternal mortality review in the Kingdom of Swaziland 2001

I.

INTRODUCTION

1 Background and justification A. Demographic situation Swaziland is a landlocked independent Kingdom located in South-Eastern Africa between the Republic of South Africa and Mozambique. It has a total land area of 17,364 square kilometres. The country is divided into four distinct topographical regions, namely: the Highveld, Middleveld, Lowveld and the Lubombo plateau. With a common language, culture and tradition, Swaziland is one of the few ethnically homogeneous countries in Africa. The country has four administrative regions: Hhohho, Manzini, Shiselweni, and Lubombo. Each region has an Administrator who is a political appointee and reports to the Deputy Prime Minister. In addition, the country is further sub-divided into 55 administrative centres (Tinkhundla), under which there are about 200 chieftaincies. The legal system comprises a mixture of Roman-Dutch Common Law and the English Common Law on the one hand, and the Swaziland Law and Custom on the other. According to the Central Statistics Office (CSO) estimates of the population of Swaziland is about 980 722 in 1997 (Provisional census data) increasing from the census figures of 374 697 in 1966, 494 534 in 1976 and 681 059 in 1986. These figures translate into an inter-census (1976 – 1997) growth rate of 2.7 percent as compared to a figure of 3.2 percent during the 1976 – 86 inter-census period. This implies a population doubling time of about 25 years. The country’s population is relatively young with about 45 percent of the population under 15 years of age, 60 percent aged less than 21 years and only about 3 percent being 65 and older and with 76 percent of the population living in rural areas. Youth are defined in Swaziland as person aged 15 to 29 years, and make up about 28 percent of the population, while women of reproductive age (WRA) represent 25 percent of the population. The medium age of the population is about 16 years. The total fertility rate (TFR) of 6.9 lifetime birth per women recorded in 1976, dropped to 6.4 in 1986 and 5.6 percent in 1991, 4.5 in 1997 (CSO, 1997).

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Report on maternal mortality review in the Kingdom of Swaziland 2001 Table 1: Projected Population Growth for Swaziland

Total Population Crude Birth Rate/1000 Crude Death Rate/1000 Rate of Natural Increase p.a. Total Births (Estimates)

1986 668 124 49.1 12.6 3.65 33 402

1996 937 747 42.8 10.1 3.27 40 766

2001 1 095 094 37.7 8.7 2.9 44 633

B. Safe Motherhood The probability of life being at risk every time a Swazi woman becomes pregnant is estimated to be 1 in 69. This is unacceptably too high when compared with only 1 in 5,100 in U.K. or 1:3,500 in USA. The risk in Swaziland is despite the fact that nearly 98 % of pregnant women attend antenatal care at least once; some two thirds make 5 or more visits; 80 % of the population is within an hour of walking distant to a health facility; Tetanus Toxoid 2 coverage rate is reasonably high at about 75 %. Despite the high attendance rate the quality of antenatal care is said to be unsatisfactory. The majority of mothers (more than two-thirds) book late in the second and third trimesters. This may be too late to prevent or treat certain conditions. With syphilis being able to affect the foetus as early as the ninth week of pregnancy, abortions and stillbirths are thus to be anticipated among women who book late and miss the opportunity for early detection and appropriate treatment. Only 56 percent of all projected maternity cases actually deliver at health facilities. Nearly 44% of mothers deliver at home, with a significant percentage assisted by Traditional Birth Attendants (TBAs). The overall maternal mortality rate in Swaziland has remained high at about 229/100,000 live births as against

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